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Rationale for Future Education Preparation of Nutrition and Dietetics Practitioners February, 2015 Updated: July, 2015 Updated: August, 2015 Updated: January, 2017 Updated: March, 2017 Copyright ©2015 Accreditation Council for Education in Nutrition and Dietetics Table of Contents EXECUTIVE SUMMARY .................................................................................................................................... 3 BACKGROUND ON ACEND® ............................................................................................................................. 6 PROPOSED MODEL FOR EDUCATION IN NUTRITION AND DIETETICS ........................................................... 10 ENVIRONMENTAL SCAN ................................................................................................................................ 13 STAKEHOLDER INPUT .................................................................................................................................... 40 STAKEHOLDER INTERVIEWS AND ANALYSIS .............................................................................................. 41 STAKEHOLDER SURVEY DATA COLLECTION AND ANALYSIS ...................................................................... 42 EMPLOYER DATA COLLECTION AND ANALYSIS.......................................................................................... 56 COMPETENCY GAP ANALYSIS .................................................................................................................... 67 STAKEHOLDER INPUT ON FUTURE MODEL RECOMMENDATIONS ............................................................ 69 ADDITIONAL INFORMATION GATHERED IN THE DEVELOPMENT OF THE FUTURE EDUCATION MODEL STANDARDS AND COMPETENCIES ................................................................................................................ 78 ASSOCIATE DEGREE NUTRITION HEALTH WORKER .................................................................................. 79 ASSESSMENT OF THE 2012 ACEND® ACCREDITATION STANDARDS ......................................................... 84 DEVELOPMENT OF THE FUTURE EDUCATION MODEL COMPETENCIES & PERFORMANCE INDICATORS .... 89 PUBLIC COMMENTS ON THE FIRST DRAFT OF THE FUTURE EDUCTION MODEL ACCREDITATION STANDARDS FOR ASSOCIATE, BACHELOR AND MASTER DEGREE PROGRAMS .......................................... 146 REFERENCES APPENDIXES (Separate File) Appendix A Background Report Appendix B State Scope of Practice Appendix C Stakeholder Questionnaire Appendix D Employer Questionnaire Appendix E Frequently Asked Questions Appendix F Stakeholder Input on Future Model Questionnaire Appendix G 2012 Standards Survey Appendix H Associate Degree Competency Questionnaire Appendix I Bachelor Degree Competency Questionnaire Appendix J Master Degree Competency Questionnaire Appendix K Public Comment Questionnaire Fall 2016 i EXECUTIVE SUMMARY INTRODUCTION AND PURPOSE OF REPORT The Accreditation Council for Education in Nutrition and Dietetics (ACEND®) serves the public by establishing and enforcing standards for the educational preparation of nutrition and dietetics practitioners and by recognizing nutrition and dietetics education programs that meet these standards. The educational preparation of dietitian nutritionists and nutrition and dietetics technicians includes didactic and supervised practice components completed through ACEND-accredited programs. The educational preparation of nutrition and dietetics technicians is at the associate degree level and the preparation of dietitian nutritionists is typically at the bachelor degree level, combined with or followed by a supervised practice experience. Some master and doctoral level programs also exist. In 2012, ACEND began discussions on future education needs and the potential of developing degree based standards. Also in 2012, the Academy of Nutrition and Dietetics’ Council on Future Practice released a visioning document recommending that the level of educational preparation for dietitians be elevated to a graduate level to provide a greater depth of knowledge and skills needed for future practice in the profession. In 2013, ACEND began work with a visioning group to explore future practice and the education required to prepare students for this practice. ACEND collected data from key stakeholders and conducted a thorough environmental scan to inform its review of the current standards for nutrition and dietetics education and is recommending a new model of education that includes moving the educational preparation of entry level generalist dietitian nutritionists to the master degree level, moving the educational preparation of entry level nutrition and dietetics technicians to the bachelor degree level and creating a new program preparing nutrition health associates at the associate degree level. The purpose of this report is to summarize data collected in multiple projects conducted with stakeholders, share information collected and recommend a model for future education of nutrition and dietetics practitioners. UPDATES TO RATIONALE DOCUMENT ACEND updates this Rationale Document as new information becomes available and new decisions are made about the recommended future education model in nutrition and dietetics. Updates that have been added to the document include: February, 2015 Release of the original Rationale Document July, 2015 Summary of stakeholder comments on the recommended model section added Title of associate’s degree practitioner changed to Nutrition Health Worker August, 2015 Additional data collection about Nutrition Health Associate section added January 2017 Evaluation of the 2012 Accreditation Standards Development of competencies and performance indicators March 2017 Summary of public comments on the draft Future Education Model Accreditation Standards for Associate, Bachelor and Master Degree Programs in Nutrition and Dietetics 1 ENVIRONMENTAL SCAN The environmental scan included review of more than 100 relevant articles detailing research data, industry trends and the changing health care and business environments. Data collected revealed an emergence of many non-traditional practice settings for the field of nutrition and dietetics and an expanding scope of practice for those working in the profession. There is an increased focus on disease prevention and integrative healthcare and the need for more knowledge in emerging areas such as nutritional genomics, telehealth, nutritional pharmacology, case management, behavioral counseling, prescriptive authority, coding and reimbursement, evidence-based practice and informatics. There is a growing importance for health care professionals to be educated to work more interprofessionally. A graduate degree represents the entry level professional practice degree for most of the health professions and all of the health professions require supervised practice (or its equivalent) as part of their overall training and education. STAKEHOLDER INPUT ON FUTURE PRACTICE IN NUTRITION AND DIETETICS Four different data collection projects were completed to gather information from stakeholder groups (employers, practitioners, educators, administrators, professionals working with nutrition and dietetics practitioners and students) about future practice in nutrition and dietetics. A total of 10 structured interviews were held with representative stakeholders to elicit their views for future practice. Stakeholders interviewed indicated that communication skills, the ability to understand and work with patients in their cultural ecosystem and patient assessment skills are under developed or lacking in current graduates. They stated that graduates of the future will need to be able to effectively work in interprofessional and interdisciplinary teams, interpret and apply scientific knowledge and have strong organizational leadership and project management skills. Stakeholders voiced that bachelor degree graduates are needed in positions of health and wellness, management and marketing. They viewed the master’s degree as the ideal minimum for dietitian nutritionists. Two questionnaires were developed to collect data on skills in six skill set categories: professional research and practice skills; teamwork and communication skills; clinical client care skills; community and population health skills; leadership, management and organization skills; and food and foodservice systems. These categories were developed based on input collected in the stakeholder interviews and skills were identified within each category. One questionnaire was designed to collect data from a broad base of stakeholders (practitioners, employers, educators, administrators, students and professionals working with RDNs and NDTRs) that requested respondent opinions on the importance of 79 skills for future practice in nutrition and dietetics on a four-point importance scale; 9,477 stakeholders responded. Results indicated most (89%) of the 79 individual skills were important (i.e. mean score > 3 on a four-point scale) for future practice in nutrition and dietetics; 40% of the skills were rated greater than 3.5 suggesting they were very important. All six skill set categories were scored as important for future practice with teamwork and communication skills receiving the highest mean score (M=3.64) and leadership, management and organizational skills the lowest mean score (M=3.15). Differences in means scores were found based on respondent’s work setting, education level and years of work experience. The second questionnaire was designed specifically to collect additional information from employers on how essential 69 different skills were for employability in nutrition and dietetics practice in the future on a four-point essential scale; 300 employers provided their perceptions. Results indicated most (86%) of the individual skills were essential (i.e. mean score >3 on a fourpoint scale) for employability in future nutrition and dietetics practice. All six skill category sets were scored essential for future employability in nutrition and dietetics practice with teamwork and communication skills receiving the highest mean score (M=3.52) and community and population health skills the lowest mean score (M=3.03). Few differences were found in mean scores based on respondent’s demographic information. Focus groups were held with four groups of educators, practitioners, preceptors and employers (27 total participants) to explore gaps in the current competencies in the ACEND 2012 Accreditation Standards. Several themes emerged from the focus group discussions: Master degree education for RDNs was well supported; more time was needed for application of knowledge and demonstration of skills (practical experience) in the programs; inconsistency existed in the program and internship expectations; undergraduate programs must include transferable skills for other professional direction (e.g. leadership, business, management); graduate level could offer specialization; and need for an increase number of RDNs teaching the programs. Gaps were identified in the current competencies in areas of research, communication, leadership/management skills, cultural care, interprofessional work, basic food and culinary preparation and sustainability. RECOMMENDATIONS FOR FUTURE EDUCATION The environmental scan, stakeholder and employer interviews, focus groups, and survey data documented the need for increased knowledge, more complex decision making, and a broader array of skills for future practice in nutrition and dietetics. As a result, ACEND is recommending: Master’s degree preparation for entry level, generalist, registered dietitian nutritionists. Bachelor’s degree preparation for entry level food and nutrition practitioners eligible to take the registration examination to become nutrition and dietetics technicians, registered. Associate’s degree preparation for nutrition health associates. Each degree level has competencies identified. Experiential learning integrated into each degree program. Each degree level prepares graduates for employment. Completing one part of the educational model would not be a requirement to enter a program at a higher degree level in the model, but each degree level would build on the preceding degree level knowledge and competence. Future exploration of high school and doctoral level programs. ACEND plans to develop new standards for the associate, bachelor and master’s degree level programs and release them for multiple rounds of public comment in 2016. Once revisions are made and the new standards and competencies are finalized, ACEND plans to release them in 2017 for voluntary adoption by demonstration programs. Outcomes data on graduates of these demonstration programs will be collected and analyzed before ACEND makes a decision about implementation of the recommended future model for all programs. ACEND will work with the Commission on Dietetic Registration to define credentialing options for those completing these new degree programs. Additional information is available at www.eatrightpro.org/acend. These recommendations will not change the current ACEND accreditation standards. Currently accredited programs will continue to be accredited under the 2017 Accreditation Standards. Programs will be given the opportunity to choose whether to voluntarily adopt the new Future Education Model Standards when these standards are released in the future. STAKEHOLDER INPUT ON RECOMMENDATIONS ACEND collected opinions from stakeholders about the recommended future model for education through an online survey, reviewed survey results collected by other educators, and attended area meetings of the Nutrition and Dietetics Educators and Preceptors. Themes of benefits and concerns were identified through qualitative analysis of responses. Informational materials and webinars were developed to help address questions and concerns raised about the recommended future education model. ADDITIONAL INFORMATION ON NUTRITION HEALTH ASSOCIATE After the release of the Rationale Document, many questions were raised about the role of the associate’s degree prepared practitioner in the community setting. To better understand this potential future role, ACEND hired a consultant to conduct focus groups with RDNs who work in community and public health practice and in depth interviews with leaders in community support worker programs. Results of the data collection confirmed the role for a community worker who could provide support for compliance, acceptance and management of nutritional, physical and mental health concerns in community settings. The role and the training for this practitioner currently is not standardized and can range from a high school diploma (for the most part) to a certificate or AA in a health related field. ASSESSMENT OF THE 2012 ACEND® ACCREDITATION STANDARDS ACEND worked with a consultant to gather information from various stakeholders to determine potential changes that might be made to improve on the 2012 ACEND Accreditation Standards for Programs in Nutrition and Dietetics. A total of 407 individuals responded to the survey about the 2012 Standards; most were nutrition and dietetics program directors (53%) or educators (22%). Based on a review of the quantitative and qualitative comments, several changes were recommended including: publish the standards alone in one document; publish a separate document for the guidance material; differentiate what is the standard and what is supporting material; use term “evaluation” for the measurement of program objectives and “assessment” for the measurement of the attainment of student learning outcomes and combine and streamline the standards. DEVELOPMENT OF COMPETENCIES AND PERFORMANCE INDICATORS ACEND contracted with a consultant to conduct a multi-round Delphi study to gather input from a broad base of stakeholders to gain consensus on professional and clinical competencies for future entry-level nutrition and dietetics professionals. Entry-level competencies (knowledge, skill and judgment) needed upon graduation from an accredited nutrition and dietetics education program for early years of practice were identified. The first round involved a group of 15 experts termed subject matter experts (SME). The SMEs determined a competency framework, developed a competency outline, determined desired complexity of competency topics for each academic degree and wrote competencies and performance indicators for future practitioners prepared at the associate, bachelor and master degree levels. The second step of the Delphi process was a first line review by a group of educators and practitioners who participated in online focus groups. A total of 98 individuals participated in one of 10 focus group sessions to review the draft competencies and performance indicators and offer suggested changes to content and assigned academic level. A third step in the process involved completion of an online questionnaire. More than 1,000 nutrition and dietetics practitioners, educators, employers and professionals from outside the field of nutrition and dietetics rated importance to future practice for the competencies and performance indicators. A consensus panel reviewed the Delphi study findings and reached consensus on the final competency and performance indicator statements. Decisions were made on the wording and inclusion of each competency and performance indicator based on the input received. As a result, the total numbers of competencies and performance indicators included in the draft Future Education Model Standards were 20 competencies and 121 performance indicators for the associate degree, 38 competencies and 216 performance indicators for the bachelor degree and 41 competencies and 278 performance indicators for the master degree. PUBLIC COMMENTS ON THE DRAFT FUTURE EDUCATION MODEL STANDARDS ACEND finalized the first draft Future Education Model Standards for Associate, Bachelor and Master Degree Programs and released them for public comment. Input on the draft standards was received from more than 1,200 individuals who provided input to an online survey, more than 200 provided input at the Educator Roundtables at FNCE and nine organizations provided written and telephone input on behalf of their groups. Responses were received from program directors, faculty members, preceptors, practitioners, employers, students/interns and some from outside the profession. There were a wide array of opinions, often conflicting opinions, which were received. ACEND made several major changes in the draft standards as a result. BACKGROUND ON ACEND® AND CURRENT MODEL FOR EDUCATION OF NUTRITION AND DIETETICS PRACTITIONERS 2012 MODEL FOR EDUCATION IN NUTRITION AND DIETETICS Accreditation Council for Education in Nutrition and Dietetics The Accreditation Council for Education in Nutrition and Dietetics (ACEND®), the accrediting agency for the Academy of Nutrition and Dietetics (Academy), serves the public by establishing and enforcing standards for the educational preparation of nutrition and dietetics practitioners and by recognizing nutrition and dietetics education programs that meet these standards. The mission of ACEND is to ensure the quality of nutrition and dietetics education to advance the practice of the profession and its strategic goals include: assuring the quality of dietetics education through a peer review process, effectively communicating the accreditation process and expectations and fostering innovation in nutrition and dietetics education. As shown in Table 1, in 2015, there were more than 570 active US-based and international accredited programs. Table 1: Number of accredited dietetic programs Total Number of Active US-Based ACEND Programs 572 US Dietetic Technician Programs US Coordinated Programs US Didactic Programs US Dietetic Internships US Programs Seeking Candidate Status International Programs Seeking Candidate Status International Coordinated Programs 42 55 223 252 10 1 4 Nutrition and Dietetics Education The educational preparation of dietitian nutritionists and dietetic technicians includes didactic and supervised practice components completed through ACEND-accredited programs. Figure 1 includes the current model of dietetics education based on the 2012 Standards and depicts the multiple ways that students can complete the didactic and supervised practice components for the education to become a dietetic practitioner. The educational preparation of dietetic technicians is at the associate’s level and the preparation of dietitian nutritionists is typically at the bachelor’s level, combined with or followed by a supervised practice experience. Some master’s and doctoral level programs also exist. The most common route has the required core knowledge for practice being included in didactic programs in dietetics (DPD) and the competencies in dietetic internships (DI) or individualized supervised practice pathways (ISPP). Coordinated programs include both the required knowledge and competencies in one program. Standards, which include the required core knowledge and competencies, have been developed for each type of dietetics program. These standards can be found on the ACEND website at www.eatright.org/acend. 7 1 All programs, regardless of degree level, meet the same ACEND didactic knowledge and/or supervised practice requirements 2 Requires acceptance through application process 3 Only available to students are not matched with a dietetic internship 4 Program may or may not require completion of the graduate (master’s, doctoral) degree Figure 1. 2012 ACEND accreditation standards model of dietetics education 8 ACEND has developed two types of standards for oversees programs: International Dietitian Education (IDE) and Foreign Dietitian Education (FDE) programs. Students in a program accredited under IDE standards are required to meet the same competency and supervised practice requirements as US students, including the requirement to complete supervised practice hours in the US, its territories or protectorates and are eligible to sit for the Commission on Dietetic Registration credentialing exam for dietitians. Students in programs accredited under FDE standards are prepared for nutrition and dietetics practice in their country. ACEND also has developed Advanced Practice Residency Program Guidelines. These Guidelines provide information for advanced practice residency programs across the spectrum of dietetics practice. ACEND Review and Revision of Standards ACEND is required by the United States Department of Education to review and revise if needed, its educational standards at least once every five years. The ACEND Standards Committee is charged with undertaking this review and recommending any needed standards revisions to the ACEND Board. In 2006, an American Dietetic Association Education Task Force recommended a review of the educational competencies to allow more opportunity to meet future practice needs through a graduate degree. In 2012, the Academy’s Council on Future Practice released a visioning document recommending that the level of educational preparation for dietitians be elevated to a graduate level to provide a greater depth of knowledge and skills needed for future practice in the profession. In response, ACEND began conducting a thorough review of the current standards for nutrition and dietetics education. An expanded standards workgroup was formed to develop recommendations for the ACEND board related to future education standards. The group elicited input from a visioning group during the process. Expanded Standards Workgroup Members Elaine Molaison, PhD, RD, Chair Maxine McElligott, MA, RD, LMNT, CDE, Co-chair, graduate level Pascale Jean, MPH, RD, LD/N, Co-Chair, bachelor’s level Sue Abbe, PhD, RN Wanda Eastman, PhD, RD, LD Jamie Erskine, PhD, RD Amelia Larkin, MS, DTR Joan Straumanis, PhD Visioning Workgroup Members (Area of Representation) Carol Turner, PhD, RD, LD (public health) E.C. Henley, PhD, RD, LD (business and industry) Kaylene Coffey, MAEd, RD, LD (clinical nutrition/foodservice management) Janet Bezner, PT, PhD (physical therapy) Joel Kopple, MD (medicine- renal research and practice) This document offers recommendations for the future education of nutrition and dietetics practitioners and provides rationale for those recommendations. ACEND believes the education model being presented meets the needs of the public, protects the public, prepares competent practitioners, is based on evidence and is feasible to implement. 9 PROPOSED MODEL FOR EDUCATION IN NUTRITION AND DIETETICS 10 PROPOSED MODEL FOR FUTURE EDUCATION IN NUTRITION AND DIETETICS The environmental scan and additional data collected by ACEND revealed an emergence of many non-traditional practice settings for the field of nutrition and dietetics and an expanding scope of practice for those working in the profession. There is an increased focus on disease prevention and integrative healthcare and the need for more knowledge in emerging areas such as genomics, telehealth, behavioral counseling, diet order writing and informatics. This work requires that health care professionals work more interprofessionally. Employers indicated the need for improved communication skills in nutrition and dietetics practitioners and an improved ability to understand the patient’s community and cultural ecosystem. Practitioners need to be able to read and apply scientific knowledge and interpret this knowledge for the public. Employers also expressed a desire for stronger organizational leadership, project management, communication, patient assessment and practice skills. Many of the stakeholders identified gaps in current competencies in areas of research, communication, leadership/management skills, cultural care, interprofessional work, basic food and culinary preparation and sustainability. Employers indicated that more time might be needed in the preparation of future nutrition and dietetics practitioners to assure application of knowledge and demonstration of skills needed for effective practice. Stakeholders identified the importance of associate and bachelor level prepared graduates for roles in community health, wellness and management. Employers identified the need for preparing undergraduates with transferable skills in leadership, business and management and expressed the need for faculty prepared at the doctoral level. As a result, ACEND is recommending the development of new graduate level standards to prepare generalist and specialist dietitians for these future roles. The recommended new model also includes new associate and bachelor level standards to better prepare graduates for emerging roles in community nutrition and health, wellness, business and industry and management. Figure 2 depicts the recommended future model for education in nutrition and dietetics. Education at the high school and associate’s degree levels focus on the development of skills to work in community nutrition, health and wellness settings. The bachelor’s level preparation is recommended to include a science base and courses core to nutrition and dietetics practice, elevate preparation of dietetic technicians and may provide prerequisite preparation for graduate study. Preparation for practice as a dietitian nutritionist is recommended to move to the graduate level with generalist preparation occurring at the master’s level and specialized preparation at the doctoral level. Core knowledge and competencies will be identified for each degree level and experiential learning would be integrated into each degree program. Each degree level would build on the knowledge base of previous degrees and prepare students for employment. ACEND’s initial focus will be to develop standards, which will include the required core knowledge and competencies, for the associate, bachelor and master level programs. Once the new standards and competencies are finalized, ACEND will release them for voluntary adoption by demonstration programs. Outcomes data on graduates of these programs will be collected and analyzed before ACEND makes a decision about implementation of the recommended future model for all programs. 11 Figure 2. Proposed model for future education in nutrition and dietetics 12 ENVIRONMENTAL SCAN ENVIRONMENTAL SCAN By Anne M. Davis, PhD, RD and Sandra G. Affenito, PhD, RD, CD-N In February 2014, an ACEND® appointed Expanded Standards Workgroup began exploration of degreebased standards and competencies for nutrition and dietetics practitioners. The initial work by the group was to assess existing research and environmental scan data and collect additional stakeholder and market-place data, if needed, to identify the roles of future practitioners, the education level required and the needs of the marketplace. In July, 2014 a Background Report (Appendix A) was released that provided a summarized overview of the forthcoming evidence-based Rationale Document for the future educational requirements of bachelor’s and graduate level prepared nutrition and dietetics practitioners. Three themes emerged from the environmental scan: 1. Continuous high-speed advancements in healthcare, technology, medicine and food systems warrant additional information and a higher level of education may better prepare nutrition and dietetics practitioners to meet the needs of the public. 2. There is a broadening and increased complexity in public health nutrition, food safety, disease prevention, food production and health promotion that may impact the practice of nutrition and dietetics. 3. Many health professions have identified differing skills levels needed by their practitioners in the marketplace and as a result many accrediting agencies have differentiated knowledge and skill requirements at bachelor’s and graduate levels. These themes were explored further. Research data, industry trends and the changing health care environment were explored and results summarized in this document. ACADEMY OF NUTRITION AND DIETETICS DATA Workforce Demand Study The Dietetics Workforce Demand Study Task Force was an appointed collaboration with 14 thought leaders by the Commission on Dietetic Registration (CDR) in 20121. The Task Force was charged to conduct an extensive literature review, future scanning with expert opinion, public policy examination, and analysis of numerous research surveys; and to offer viewpoints on the future of nutrition and dietetics practice from 2012 to 2022. The goal of this systematic approach was to identify and analyze change in nutrition and dietetics practice since the last workforce study was conducted greater than 30 years earlier. The Task Force report indicated that employers wanted to hire leaders “who can innovate, solve problems and organize diverse individuals into results-oriented teams2.” Employers valued adaptability, interdisciplinary perspective and leadership qualities. Demand for nutrition and dietetics services was predicted to increase due to health care reform and the expansion of health care services to an additional 30 million people. The report suggested that approximately 75% of the demand for dietetics services would be met by the 2020 supply of dietetics workforce which left 25% as an unmet need. 14 Credentialed dietetics practitioners’ characteristics in 2010 included an average age of 44 years, 96% were women and about 55% worked in clinical dietetics. The net supply of CDR credentialed dietetics practitioners was projected to grow by 1.1% annually. The report indicated that the public will have more options for nutritional advice from the rise in homeopathy and other sources of alternative (natural) medicine. Therefore, without an adequate supply of nutrition and dietetics professionals, the competitive space for registered dietitian nutritionists (RDN) may be challenged. The report identified the aging population, health care reform, increasing prevalence of certain conditions (including obesity) and growth in the food industry as key factors affecting the demand for nutrition and dietetics practitioners3. This excess demand will provide opportunities for non registered nutrition practitioners (e.g., naturopathic physicians, athletic trainers, nurses and other health professionals) to provide dietitian services. The task force study authors recommended proactive interventions that included: increasing the supply of RDNs by increasing the number of dietetics internship positions, marketing new employment opportunities to potential nutrition and dietetic students and creating professional growth opportunities. Dietetics Practice Audits The National Commission for Certifying Agencies requires that CDR periodically conduct practice audits to delineate performance areas and duties associated with knowledge and/or skills and examination content/item specifications used for certification. CDR uses audit data to develop RDN and dietetic technicians, registered (DTR) examination content. ACEND also uses audit findings to develop and revise educational standards and competencies. 2010 Entry Level Practice Audit. CDR conducted this audit to better understand the level and frequency of involvement and perceived risk associated with nutrition and dietetics activity statements of entry- level (EL) RDNs and DTRs in the first 3 years of practice4. An expert panel of RDNs and DTRs, representing multiple and diverse areas of dietetics practice, developed and categorized 166 activity statements for the mixed mode survey instrument. A total of 2,556 surveys were sent out and a 74% response rate was achieved. The results identified that 95% of the EL RDNs held a bachelor’s, 39% a master’s and 1% a doctorate degree. Current positions held by the EL RDNs varied with 31% in clinical, 10% long-term care, 8% Special Supplemental Nutrition Program for Women, Infants and Children, 4% private practice and 3% each for pediatric/neonatal, nutrition support and general outpatient positions. The survey activity categories that were most frequently done by the EL RDNs included providing nutrition care community/clinical general, providing nutrition care to individuals and managing food and other material resources 4. The EL RDNs were asked to rate the most high risk activities and their categories. Several of the high risk-rated activity statements were also core activity statements. The survey results indicated that the majority EL RDNs performed activities related to nutrition care delivered to individuals and groups, mostly patients (not populations), significantly more than management or research activities. Most of the EL RDNs were employed in clinical dietetics and they did not identify core activities in research, human resource management or other management areas. Dissimilarly, EL DTRs performed a broader scope of food and other material resource management activities and a smaller number of nutrition care–related activities to individuals and groups. 15 2013 DPD Practice Audit. The purpose of this audit was to delineate the practice of bachelor’s prepared EL non-RDN practitioners5. The sample consisted of current Pathway III DTRs (Bachelor’s degree graduates and completion of an ACEND DPD) (PIII DTR); PIII DTR eligible; and recent DPD graduates. A questionnaire was sent to 3,789 graduates and 1,784 responded (47%). The survey instrument used was similar to the one used in the 2010 audit and the questions described demographics, education, career experience and trajectories and current employment in nutrition and dietetics. The demographic data suggested respondents were a median age of 27 years; 90% were female and 8% male; 71% reported to be Caucasian, 8% Hispanic, 5% African American and 9% Asian. Career directions included 47% of the Non-RDN BS/DPD Grads had unsuccessfully applied for an internship. One third (34%) reported that they intended to apply for admission within the next 12 months and 29% stated that they might apply for admission later; 18% reported that they had no plans to pursue an internship. The most common employment positions identified were in clinical and community settings with the primary areas of practice being nutrition care and counseling, education and food service. Results suggested few differences in the nutrition and dietetics practice for Non-RDN BS/DPD Graduates and EL DTRs previously measured by the 2010 DTR Practice Audit Committee5. Council on Future Practice Visioning Report In 2006, an American Dietetic Association Education Task Force noted that basic educational requirements, consisting of a bachelor’s degree and supervised practice, have not changed since 1927 and recommended a review of the educational competencies to allow more opportunity to meet future practice needs through all degree levels6. The Council on Future Practice (CFP) was created and has worked collaboratively with the CDR and ACEND to project and plan for the future practice needs of the profession of nutrition and dietetics. In 2012, the Academy of Nutrition and Dietetics (Academy) CFP released a visioning document recommending that the level of educational preparation for dietitians be elevated to a graduate level to provide a greater depth of knowledge and skills needed for future practice in the profession. The document made the following nine recommendations to support and advance future dietetics practice and keep the Academy and its members at the forefront of food, nutrition and dietetics6. 1. Elevate the educational preparation for the future entry level RDN to a minimum of a graduate degree from an ACEND-accredited program. 2. Recommend that ACEND require an ACEND-accredited graduate degree program and/or consortium that integrates both the academic coursework and supervised practice components into a seamless (1-step) program as a requirement to obtain the future entry level RDN credential. Create an educational system for the future entry level RDN based on core competencies, which provides greater depth in knowledge and skills that build on the undergraduate curriculum and includes an emphasis area (clinical, management, community/public health). 3. Support the development and implementation of a new credential and examination for bachelor’s degree graduates who have met DPD requirements. The competencies, skills and educational standards should clearly differentiate between the practice roles of individuals with the new credential and current/future graduate degree–prepared RDNs and provide minimal overlap between the two. Additionally, legislative and regulatory issues (state and federal) will concurrently 16 be examined and a strategy will be designed to address potential unintended consequences of developing a new credential for licensure and Centers for Medicare and Medicaid Services (CMS) reimbursement. 4. Currently-credentialed DTR practitioners will continue to be supported and recertified; DT education programs will continue to exist to meet the needs of the workforce in their local communities and encourage transfer options with four-year institutions. A plan will be created for all existing Dietetics Technician (DT) education programs and DTRs to promote the positive impact of this transition for increasing workforce growth and opportunities. 5. Recommend that ACEND revise the undergraduate curriculum for dietetics education programs to include requirements for practicum and diverse learning experiences outside of the classroom. Develop students’ critical thinking, leadership, communication and management skills by providing opportunities to experience them in the context of professional work settings. 6. Continue to support development of board certified specialist credentials in focus areas where there is a reasonable pool of practitioners to justify the cost of development and maintenance of the credential and develop a system to recognize RDNs practicing in focus areas where numbers are too small to justify the financial investment. 7. Support continuing development of advanced practice credentials for the nutrition and dietetics profession, based on objective evidence and continue to encourage and develop advanced practice educational experiences and opportunities. 8. Conduct a well–funded, comprehensive marketing, branding and strategic communications campaign related to all of the recommended changes targeting both internal and external stakeholders. 9. Support a RDN credential name change that will be reflective of the changes outlined previously and align with the name change of the Academy. The current RDN credential will remain intact and the terminology used for the new credential titles for the RDN and the new credential for the bachelor’s degree graduate who has met DPD requirements will be complementary and coordinated to provide clarity in distinctions between the two credentials. Legislative and regulatory issues (state and federal) will be examined concurrently and a strategy will be designed to address potential unintended consequences of changing the name of the RDN credential for licensure and CMS reimbursement. 17 SCOPE OF NUTRITION AND DIETETICS PRACTICE RDN and DTR Scope of Practice Scope of practice refers to a range of roles, activities and regulations within the nutrition and dietetics performance arena7, 8. The concept of the dietetics scope of practice encompasses practice standards, credentials, education, practice resources and practice management and advancement. A 2005 Federation of State Medical Boards report defined scope of practice as the “definition of the rules, the regulations and the boundaries within which a fully qualified practitioner with substantial and appropriate training, knowledge and experience may practice in a field of medicine or surgery, or other specifically defined field. Such practice is also governed by requirements for continuing education and professional accountability9.” Scope of practice should require licensees to demonstrate that they have the requisite training and competence to provide a service9. The scope of practice for the RDN7 focuses on “food and nutrition and related services developed, directed and provided by RDNs to protect the public, community and populations; enhance the health and wellbeing of patients/clients; and deliver quality products, programs and services, including Medical Nutrition Therapy (MNT), across all focus areas. Focus areas include, but are not limited to, oncology, pediatrics, diabetes, nephrology, sports, nutrition support, extended care, corrections, weight management and obesity, wellness and prevention, behavioral health, eating disorders and disordered eating, intellectual and developmental disabilities, mental illness, addictions, integrative and functional medicine, food and culinary and supermarkets, sustainable resilient healthy food and water systems, communities and public health, education and management.” RDNs perform their roles in a variety of practice settings including acute, ambulatory/outpatient, home care and extended health care; business and communications; community and public health; entrepreneurial and private practice; foodservice systems; integrative and functional medicine; management and leadership; military service; nutrition informatics; preventive care, wellness and weight management; research; school nutrition; sports nutrition; sustainable resilient healthy food and water systems, U.S. public health service and universities and other academic settings. The scope of practice for the DTR8 focuses on “food and nutrition and related services provided by DTRs who work under the supervision of an RDN when in direct patient/client nutrition care and who may work independently in providing general nutrition education to healthy populations, consulting to foodservice business and industry, conducting nutrient analysis, data collection and research and managing food and nutrition services in a variety of settings.” DTRs perform their roles in a variety of practice settings including acute, ambulatory/outpatient and extended health care; business and communications; community and public health; entrepreneurial and private practice; foodservice systems; management and leadership; nutrition informatics; preventive care, wellness and weight management; research; school nutrition; sports nutrition; sustainable resilient healthy food and water systems and universities and other academic settings. More recently health promotion and disease prevention and public policy and advocacy have been highlighted for future growth and focus10-14. The world population is expected to be greater than nine billion by the year 2050. Concentrated attention is on sustainability and protection of natural resources to ensure safe and healthy food and water. This new practice area for future nutrition and dietetics professionals will require focused knowledge, skills, systems thinking and experience in policy, system and environmental change strategies addressing quality, quantity and safety on human, environmental, 18 economic and social health10. Regulation of Scope of Practice The purpose of scope of practice regulation is for public protection and safety which should be evaluated as most important in scope of practice decisions, rather than professional self-interest. Changes in scope of practice are inherent in a changing health care system. Accrediting and regulatory bodies routinely assess if the current scope of practice accurately reflects nutrition and dietetics professionals’ current activities, functions, roles and responsibilities. The Institute of Medicine (IOM) Center for Health Workforce Scope of Practice and the Future of Team Based Care has recommended that future changes in scope of practice will need to first have a foundational basis within four areas: an established history of the practice scope within the profession, education and training, supportive evidence and appropriate regulatory environment15. State dietetics licensing boards are the groups responsible for developing and implementing individual state statutes and regulations. Each state defines their RDN practitioner’s scope of practice from educational preparation to restriction of performance. For the 46 states that require RDN licensing, the majority of states declare a minimum of the following statutes in their scope of practice: specifications of educational preparation; practice of medical nutrition therapy including nutrition assessment, establishment of nutritional care plans and development of nutritional related priorities, goals and objectives; and provision of nutrition counseling or education as components of preventive and restorative health care (see Appendix B). Expanding Scope of RDN Practice Expanding Scope of Practice in U.S.. As a result of a 2014 Centers of Medicare and Medicaid Services ruling, RDNs may write diet orders for modified diets and medical nutrition therapy including vitamin and mineral supplementation, enteral nutrition and parenteral nutrition and can order nutritional laboratory tests16. The complex knowledge of pharmacotherapy is needed to carefully select and time medical nutrition therapy in patients also receiving medication therapy. Martin and Lipman estimated by the year 2050 33% of the U.S. population will have diabetes mellitus17. Due to the predicted increase in diabetes and the changing health care models, RDNs will be increasingly called upon to provide services as a level 3 educator (uncertified educator of Diabetes Self-Management Education Provider - Four Levels) and DTRs will serve as level 2 educators. The emergence of nontraditional settings will require nutrition and dietetics positions to work in community health centers, faithbased institutions, public libraries, retail pharmacy clinics, congregate housing for the elderly, nephrology clinics, bariatric surgery practices, patient-centered medical homes, nurse-managed health centers, community nursing centers, telehealth, worksites, schools and diabetes-related companies. Concurrently, the U.S. Bureau of Labor Statistics (2010) has projected a significant growth in demand for diabetes educators due to an expansion of federally qualified health centers and other community health centers from the Patient Protection and Affordable Care Act. Little work has been done at present on state licensure of diabetes educators and they are classified as ‘health educators’ because there is no standard job classification by the U.S. government17. Expanding Scope of Practice in Canada. An example of proposed significant changes in RDN scope of practice can be seen from The College of Dietitians of Ontario and Dietitians of Canada 2008 Application 19 for Review of the Scope of Practice of Dietetics in Ontario18. The document proposed many changes to the scope of practice for dietitians including the ability to prescribe and manage therapeutic diets and enteral and parenteral nutrition; make adjustments to the dose of existing insulin or oral hypoglycemic medications that have been prescribed by a physician or authorized health care practitioner; order specified tests as prescribed in the regulation, within their scope of practice and limited to those of particular relevance to managing nutrition therapy; perform skin pricks for the purpose of monitoring capillary blood levels; and act as an “evaluator” for the purpose of determining capacity for admission to a long term care (LTC) facility. FUTURE NEEDS IN HEALTH CARE EDUCATION The Institute of Medicine (IOM) Core Competencies. After releasing two IOM reports on safety and quality19, 20, the IOM sponsored a second summit on health professions education. Attendees at the summit identified five competencies central to the education of all health professions for the future. The IOM then recommended these as core competencies for all health care professionals; they include: provide patient-centered care, work in interdisciplinary teams; provide evidence-based practice; apply quality improvement; and utilize informatics21. The IOM stressed that these core competencies would create an outcome-based education system that better prepares practitioners to meet the needs of patients and the requirements of a changing health care system. Aims of Care. The IOM Crossing the Quality Chasm22, discussed concerns that health care harms too often and more often than not is unsuccessful in delivering its potential benefits. The reports highlighted numerous changes that are affecting health care delivery and suggest a shift from acute to chronic care. The report stressed the need to integrate a continually expanding evidence base and technological innovations, provide more clinical practice occurring in teams, prepare practitioners to work in complex delivery arrangements and change patient–clinician relationships. The report suggested six ‘aims’ of care: Safe Care by avoiding injuries to patients, Effective Care by providing care based on scientific knowledge, Patient-centered care by providing respectful and responsive care that ensures that patient values guide clinical decisions, Timely care by reducing waits for both recipients and providers of care, Efficient care by avoiding waste and Equitable care by ensuring that the quality of care does not vary because of characteristics such as gender, ethnicity, socioeconomic status or geographic location22. Global Forum on Innovation in Health Professional Education. A 2012 IOM initiative activity, The Global Forum on Innovation in Health Professional Education23 brought together stakeholders from multiple countries and professors to discuss within health professional education. Three publications resulted from the forum, Interprofessional Education for Collaboration: Learning How to Improve Health from Interprofessional Models across the Continuum of Education to Practice – Workshop Summary24, Establishing Transdisciplinary Professionalism for Improving Health Outcomes - Workshop Summary25 and Assessing Health Professional Education – A Bridge to Quality21. The third report highlights the importance of matching professional competency appropriately with the health care task to obtain a maximum return on investment and patient safety. The health care workforce has produced systems of higher education in the U.S. and elsewhere that has not been adequately aligned with the mix of professionals required to reach comprehensive health care goals effectively. This lack of alignment in workforce planning partly 20 stems from historic reasons (political and bureaucratic), partly from hardened attitudes regarding professional roles and from vested interests that resist change. Health care reform in all health systems requires progression towards the most efficient and collaborative staffing models. There is a great deal of merit in fostering this progress in a coordinated and efficient manner to achieve desirable levels of standardization. The eight IOM reports emphasized the growing need for leadership and teamwork competencies, skill sets that are relevant to all high, middle and low-income countries19-25. Interprofessional Education. Interprofessional education (IPE) is increasingly viewed as an important strategy to address health workforce reform and safety and quality issues26, 27. According to the World Health Organization (WHO), IPE is an experience that “occurs when students from two or more professions learn about, from and with each other”28. The IOM’s Future Practice Educational Recommendations21 suggest that learning experiences need to provide students the opportunity to design and measure care such as structure, process and outcomes. Academic and supervised learning experiences need to increase student understanding of improving quality as a vital core value of all health professions19. Learning in groups is not the same as learning interprofessionally. According to the IOM27, more IPE education is needed than IPE courses and continuing professional development. Interprofessional Practicebased (IPP) learning experiences are crucial for enhancing collaborative competencies 27. Students adopt interprofessional theories and values through experiential learning with well-functioning teams. Additionally, IPE helps students appreciate other professionals, avoid developing negative stereotypes, prevent working in silos and ultimately improve patient care. The provision of coordinated care through an interdisciplinary health care team has been shown to deliver safer, more cost-effective, more efficient and higher benefit to patient/client treatment than individual professionals28. Well-functioning teams share qualities such as understanding of the team’s goals and his or her role within the team, mutual trust among team members. In order for health care professionals to work interprofessionally, they must be educated interprofessionally28. Lancet Commission The Lancet Commission’s Health Professionals for a New Century: Transforming Education to Strengthen Health Systems in an Interdependent World29 was written by the Lancet Commission, which included 20 professional and academic leaders from a multitude of countries who assembled to develop a common strategy for postsecondary education in medicine, nursing and public health. One of the aims of the commission was to develop a shared vision that was not restricted by borders or the silos (constraints) of individual health professions. The Commission reported that current gaps and inequities in health and health care continue both within and between countries and demonstrate the failure to deliver health advances equitably. Health professional education has not kept up or been able to meet these challenges, largely because of fragmented, outdated and static curricula that produce unprepared graduates. The identified problems were systemic and included29 a mismatch of professional competencies to patient and population priorities because of fragmentary, outdated and static curricula producing ill-equipped graduates from underfinanced institutions. In almost all countries, the education of health professionals has failed to overcome dysfunctional and inequitable health systems because of curricula rigidities, professional silos, static pedagogy, insufficient modification to local conditions and commercialism in the professions. For example, there is a predominant hospital emphasis at the sacrifice of primary care, in both 21 poor and rich countries and failure to share the dramatic health advances equitably. The Commission’s goal was for “all health professionals in all countries needing to be educated to mobilize knowledge and to engage in critical reasoning and ethical conduct so that they are competent to participate in patient and population-centered health systems as members of locally responsive and globally connected teams”29. The Commission emphasized that instructional and institutional modifications are needed with the following two outcomes in mind: transformative learning and positive interdependence in education. Informative learning is about acquiring knowledge and skills in order to produce experts. Formative learning is about socializing students around values with its function to produce professionals. Transformative learning is about developing leadership attributes; its purpose is to produce enlightened change agents. Positive interdependence is when team members need each other to succeed via learning goals, product goals, rewards, resources, tasks or roles. Positive independence occurs with face-to-face affirmative interactions between group members. Effective education builds each level upon the previous one. As a valued outcome, transformative learning involves three fundamental shifts: from fact memorization to searching, analysis and synthesis of information for decision making; from seeking professional credentials to achieving core competencies for effective teamwork in health systems; and from non-critical adoption of educational models to creative adaptation of global resources to address local priorities. Transformative learning is the proposed outcome of instructional reforms; interdependence in education should result from institutional reforms30. Specific recommendations by the Commission to improve systems performance were divided into instructional reforms and institutional reforms. The Commission report recommended instructional and institutional improvements in education in order to produce the desired outcomes of transformative learning and interdependence. The instructional improvements included: adopt competency-driven approaches to instructional design; adapt these competencies to rapidly changing local conditions drawing on global resources; promote interprofessional and transprofessional education that breaks down professional silos while enhancing collaborative and nonhierarchical relationships in effective teams; exploit the power of information technology for learning; strengthen educational resources, with special emphasis on faculty development; and promote a new professionalism that uses competencies as objective criteria for classification of health professionals and that develops a common set of values around social accountability 32. The Commission’s recommendations for institutional improvements included: establish in every country, a joint education and health planning mechanism that take into account crucial dimensions of the health workforce, such as social origin, age distribution and gender composition; expand academic centers to academic systems encompassing networks of hospitals and primary care units; link together through global networks, alliances and consortia; and nurture a culture of critical inquiry32. 22 Integrative Health Care and Integrative Medicine Integrative health care, often referred to as interprofessional health care, is an approach characterized by a high degree of collaboration and communication among health professionals26. The sharing of information among team members related to patient care and the establishment of a comprehensive treatment plan to address the biological, psychological and social needs of the patient is what makes integrated health care unique. As interest in integrative health care and the use of complementary and alternative therapies by the public continues to grow, concern has increased as to whether health professionals are sufficiently educated about integrative health so that they can safely and effectively care for patients. Integrative health topics recommended include relationship-based care, whole person care (i.e., mind, body and spirit), complementary and alternative medicine (CAM) and self-care. As a result, the 2005 IOM Committee on CAM recommended that all conventional health professions training programs incorporate sufficient information about CAM into the standard curriculum to enable licensed professionals to competently advise their patients about CAM30. The Bravewell Collaborative, a philanthropic organization that works to improve health care, defined integrative medicine as “an approach to care that puts the patient at the center and addresses the full range of physical, emotional, mental, social, spiritual and environmental influences that affect a person’s health. 31” The Bravewell Collaborative identified integrative medicine as having the following characteristics31: the patient and practitioner are partners in the healing process; all factors that influence health, wellness and disease are taken into consideration; the care addresses the whole person, including body, mind and spirit in the context of community; practitioners use all appropriate healing sciences to facilitate the body’s innate healing response; effective interventions that are natural and less invasive are used whenever possible; because good medicine is based in good science, integrative medicine is inquiry driven and open to new models of care; alongside the concept of treatment, the broader concepts of health promotion and the prevention of illness are paramount; care is individualized to best address the person’s unique conditions, needs and circumstances; practitioners of integrative medicine exemplify its principles and commit themselves to self-exploration and self- development. The Consortium of Academic Health Centers for Integrative Medicine uses the following definition: “Integrative medicine is the practice of medicine that reaffirms the importance of the relationship between practitioner and patient, focuses on the whole person, is informed by evidence and makes use of all appropriate therapeutic approaches, health care professionals and disciplines to achieve optimal health and healing”32. Suggestion content on integrative medicine in health professional education includes: patient-centered and whole person care; personal responsibility for health and wellness; lifestyle choices, behaviors and outcomes including but not limited to diet, exercise and stress reduction; health promotion and disease prevention; and knowledge, principles, practices and processes that facilitate the integration of conventional biomedical care with CAM30-33. 23 New U.S. Population Concern - Young Adults The needs of young adults and the challenges they face, do not receive a great deal of systematic attention in policy and research. Accordingly, the Health Resources and Services Administration asked the Institute of Medicine (IOM) to convene a committee to examine, analyze and synthesize information and knowledge on the health, safety and well-being of young adults34. Young adults (18-26 years of age) today compared to decades ago live in a more global and networked world, marked by increased knowledge and information transfer, heightened risks, low social mobility and greater economic inequality. Young adults are trapped between the exorbitant cost of college (many students have difficulty financing the investment or repaying the debt they incur) and low prospects for well-paying jobs with only a high school diploma. Young college graduates increasingly find it hard to find entry level jobs with an associate’s degree or bachelor’s degree and more and more jobs have become part-time which does not help to pay back school loans. Many companies do not provide health insurance or other non-salary benefits. Jobs that pay higher wages require additional knowledge, skills and experience. One key finding of the IOM committee’s work was that young adults were unhealthy in terms of diet and physical activity; they pay less attention to health maintenance and mental/behavioral health and partake in risky behaviors. The health status of young adults included a 23% obesity rate, 25% hypertension, 7% diabetes and 27% with impaired glucose tolerance34. Examination of health indicators from Health People 2010 revealed a surprising pattern of declining health, seen most clearly in health behaviors and related health statuses. As these individuals entered their early and mid-20s, they were less likely to exercise, eat breakfast and get regular physical checkups and dental checkups and they were more likely to eat fast food, contract sexually transmitted diseases, smoke cigarettes, binge drink and use marijuana and hard drugs34. This committee cautioned that this poor young adult health status will negatively affect workforce productivity, public safety, national security and the ability of the workforce to compete on a global level. For example, 12% of all age-eligible men and 35% of all age- eligible women were unable to meet U.S. Army standards for weight-to-height ratio and percent body fat in 2007-200834. The Department of Defense reported that, between 2006 and 2011, 62,000 individuals who arrived for military training failed their entrance physical because of their weight. The IOM committee recommendations focused in three common themes: current policies and programs addressing education and employment, civic engagement and national service, public health, health care systems and government programs are fragmented and uncoordinated; current policies and programs are not focused on specific developmental needs of this population; and there is limited evidence-based data for young adults on effective interventions, policies, programs and service designs34. Knowledge of the use and delivery of preventive services for young adults is limited by the lack of attention to this age group in clinical delivery systems and health services research, programs and education. Coordination is needed between the private and public sector to bring forward public awareness and effort towards prevention. Nutrition and dietetics curricula will need to increase content and skill development in prevention and treatment services for young adults. 24 EXTERNAL FORCES IMPACTING HEALTH CARE EDUCATION Education Accreditation The role of accreditation is to assure quality, provide access to federal funds, generate public confidence in higher education and ease transfer of credit. Accreditation in the United States is undergoing a major change as governmental regulatory authority to judge quality in higher education expands, eclipsing accreditation’s collegial model of quality review. The enormous growth of public and private money in higher education, the commitment to universal access and the accompanying calls for greater public accountability, the growing nationalization of public policy and the impact of electronic technology have all contributed to this change. From the 2011 IOM report on Scope of Practice and Future Team Based Care, accreditors will continue to influence proactive quality improvement (QI) and act as change agents15. Accreditors will be required to work more closely with the U.S. Department of Education (USDE) (www.ed.gov) due to increased public demand for accountability and student performance. Accrediting organizations are required to meet ten recognition standards that are in federal law. These standards cover student achievement, curriculum, faculty, student support services and financial and administrative capacity. Accrediting organizations are also expected to comply with a broad collection of rules and regulations that accompany the standards such as: Rule 602.16: Accreditation agency standards must address the quality of institutions or programs in multiple areas including “success with respect to student achievement in relation to the institution’s mission, including an appropriate consideration of course completion, state licensing examination and job placement rates.” Rule 602.21 requires that a recognized accreditation agency “maintain a systematic program of review that demonstrates that its standards are adequate to evaluate the quality of the education or training provided by the institution and program it accredits and is relevant to the education or training needs of students.” Based upon the recommendations from the 2014 IOM report for Assessing Health Professional Education, nutrition and dietetics students may be required by the nutrition and dietetics accrediting body to receive novice and advanced education in IPE in order to develop competencies and skills needed to function as a valued member of the health care team17. Part of the educational requirements likely will include IPP learning experiences24. Degree Qualifications Profiles Accreditors may be required to implement degree qualification profiles (DQP) which are delineations of knowledge and skills between degrees such as IPE differences for bachelor’s and master’s prepared students35. The DQP attempts to establish specific learning expectations for graduates receiving a particular degree. The Profile proposes sets of competencies in five areas of student learning: specialized knowledge, broad integrative knowledge, intellectual skills, applied learning and civic learning and addresses three degree levels: associate, bachelor and master’s. At each degree level, the competencies themselves are described in terms of “action verbs” that portray what a student at that level can actually do. For example, competencies at the associate’s level may require students to “describe” or “present” a topic, at the bachelor’s level to “construct” or “explain” something and at the master’s level to “create” or “assess” something. A degree qualifications profile is a set of requirements of what students should be 25 expected to know and be able to do as a benchmark for the associate, bachelor’s or master’s degree through specific learning outcomes35. Degree profiles are especially important today because jobs are rapidly changing and use technologies that are still emerging and increasing in complexity and graduates work with colleagues from (and often in) all parts of the globe. The resulting product, a degree profile, includes defined competencies which highlight cumulative integration of learning from a multitude of resources and application of learning from a variety of settings35. Professional Maturation The medical and educational landscapes have changed greatly and continue to change. Over that time, the practice of medicine has become increasingly complex in three main areas: new knowledge (e.g., genetics and implications for therapy, bioterrorism); new skills (e.g., use of information and medical technology, review and analysis of the medical literature and application of the findings to practice; and professional attitudes, which are taking on greater importance in ensuring public trust in medical professionals. These increasing complexities have mandated curriculum reform and the development of objective assessment tools to measure student knowledge, skills and attitudes, as well as the need to prepare students to be self-directed critical thinkers who can adapt to changes in the field. The analytical and critical thinking skills required to negotiate this new medical landscape are traditionally associated with a graduate level of education. Health professions that have recently increased degree requirements include Audiology (Doctorate), Occupational Therapy (Master’s), Pharmacy (Doctorate), Physical Therapy (Master’s/Doctorate) and Physician Assistant (Master’s) 36-39. Still other health professions are considering increased degree requirements, such as Dental Hygiene40. Professional degree maturation requires examination of the incentive for advancing the entry level degree requirement. The necessity should stem from a mixture of data to demonstrate the demands for increased educational and skill requirements of the profession, patient and public safety as well as increased access for patients and increased recognition of the profession. When evaluating higher education for entry level practice it should consist of a review of data and evidence to support increased educational levels, assess educational preparation and performance abilities and requirements, assess job demands and requirements as prescribed by health care facilities, determine demographic characteristics of health professionals at various degree levels, consider career pathways and expanded functions gained through educational and practical experience such as transitional degrees41. Careful consideration should be taken when evaluating the impact and success of implementing a new advanced degree requirement. Potential negative impacts from a degree creep could be exacerbation of workforce shortages, lack of capacity in colleges in universities (faculty, facilities, funds, clinical sites), lack of credentialed faculty to deliver instruction, decrease in workforce diversity as inaccessible to minorities and economically disadvantaged, increase in tuition, increase in time in college and access to health care limited in rural areas. Another concern to mitigate may be the creation of a decline in job satisfaction and morale if advanced skills and knowledge are underutilized42. 26 External Drivers of Safety and Quality As nutrition regulations and legislation change, RDNs and the dietetics education and training process will need to adapt and requirements of external accrediting bodies will need to reassess proficiency and educational requirements. The changing focus of many government agencies is enhancing the practice of dietetics in many areas. Health Care Accreditation. The Joint Commission health care accreditation, certification and standards manuals for organizations such as hospital, behavior health, long-term care/assisted living demonstrate the paradigm shift from department policies and procedures to an organizational focus on patient safety goals and elements of performance and moving from survey ready to continuous standard compliance. The Provision of Care, Treatment and Services standards are collaborative and interdisciplinary and require RDNs to take a proactive leadership role on committees and focus on improving the safety and quality of care provided (www.jointcommission.org). Like The Joint Commission, DNV-GL Health Care is a Center of Medicare and Medicaid Services (CMS) authorized accrediting organization for acute care hospitals. The purpose of these organizations is to manage risk and improve patient safety, quality and overall health care delivery. United States Department of Health and Human Services (DHHS). The DHHS Strategic Plan includes strategic goals and associated objectives, strategies for FY 2014-2018 to include: strengthen health care; advance the health, safety and well-being of the American people; and ensure efficiency, transparency, accountability and effectiveness of HHS programs43. Nutrition and dietetics practitioners will be involved in the strategic initiatives by promoting a high value, safe and effective health care practice, implementing a 21st century food safety system, promotion of prevention and wellness across the lifespan, achieving and maintaining healthy weight for Americans and fostering a 21st century health workforce. Cooperative Extension System. The Nation’s Cooperative Extension System created a program focus in health and wellness, which is aligned with the U.S. Department of Health & Human Services’ National Prevention Strategy: Strategic Directions and the National Prevention Strategy. The Cooperative Extension program brings a multitude of assets to the partners (university system, health professionals, education, private and public sectors, engaged communities, community organizations and clinical and community preventative services). Additionally, Cooperative Extension has developed core themes to guide the Extension Health Task Force Recommendations that include: strengthen organizational functioning; enhance leadership and professional development; increase strategic marketing and communications; and build partnerships and acquire resources for health44. Nutrition and dietetics practitioners will be able to both serve the strategy initiatives and benefit from core theme developments. U.S. Preventive Services Task Force. The U.S. Preventive Services Task Force (USPSTF) recommendations to Promote a Healthy Diet and Physical Activity for Cardiovascular Disease (CVD) Prevention in Adults with Known Risk Factors- Behavioral Counseling are to provide screening at the primary, secondary and tertiary levels of health care on all at-risk adults for obesity and provide comprehensive weight loss and behavior management by qualified professionals naming the primary care provider and the RDN12-14. National Prevention Strategy. The National Prevention Strategy is supported by the Affordable Care Act. It represents a shift in health care from problem-based medicine to prevention and wellness endorsed by the U.S. legislature and the Surgeon General. The National Prevention Strategy’s vision is to improve the 27 health and quality of life for individuals, families and communities by moving the nation from a focus on sickness and disease to one based on prevention and wellness45. The healthy eating and active living strategic priorities involve and need leadership from nutrition and dietetics practitioners. Healthy eating includes increasing access to healthy and affordable foods in communities; implementing organizational and programmatic nutrition standards and policies; improving nutritional quality of the food supply; helping people recognize and make healthy food and beverage choices; supporting policies and programs that promote breastfeeding; and enhancing food safety. Active living comprises RDN involvement in conducting physical activity assessments, providing counseling and referring patients to allied health care or health and fitness professionals; offering low or no-cost physical activity programs; developing and instituting policies and joint use agreements that address liability concerns and encouraging shared use of physical activity facilities (e.g., school gymnasiums and community recreation centers); and offering opportunities for physical activity across the lifespan. Centers of Medicare and Medicaid Services. Medical nutrition therapy (MNT) services may be provided under Medicare Part B (Medical Insurance)46, 47. A registered dietitian or nutrition professional who meets certain requirements can provide these services, which may include nutritional assessment, one- on-one counseling and therapy services through an interactive telecommunications system. Coverage is provided for patients/clients with diabetes, renal disease, on dialysis, who have had a renal transplant within the last 36 months and other physician/health care provider referrals. As the Affordable Care Act continues to unfold and its emphasis on preventative services and management of chronic diseases the number of CMS covered services is expected to continue to grow. As part of a large recent ruling (July 2014) by CMS, qualified dietitians or qualified nutrition professionals will be explicitly permitted to become privileged by the hospital staff to order patient diets, order lab tests to monitor the effectiveness of dietary plans and orders and make subsequent modifications to those diets based on the lab tests, if in accordance with state laws including scope of practice laws48. In order for patients to have access to the timely nutritional care that can be provided by RDNs, a hospital must have the regulatory flexibility either to appoint RDNs to the medical staff and grant them specific nutritional ordering privileges or to authorize the ordering privileges without appointment to the medical staff47. The rule is a first step toward positioning RDNs in the care coordination environment to ensure nutrition is an essential component of client/patient/customer transitions of care49, 50. Physician Compare is a CMS website that helps participants find and choose physicians and other health care professionals enrolled in Medicare as part of the Affordable Care Act51. In the future as the ‘over 65’ population increases and health care shifts to keep seniors at home, RDNs may increase the volume of home visits to provide their patients’ nutritional care. Changes are occurring in our health care payment systems that will directly impact MNT, nutrition services and the business of dietetics across practice settings52. Transformations in the payment systems include bundled payments or global payments, pay-for-performance, value-based purchasing, hospital readmissions reduction programs and hospital-acquired conditions (HAC). "Pay-for-performance" is an umbrella term for initiatives aimed at improving the quality, efficiency and overall value of health care53. These arrangements provide financial incentives to hospitals, physicians and other health care providers in the private and public sectors to carry out such improvements and achieve optimal outcomes for patients. The Affordable Care Act expands the use of pay-for-performance approaches in Medicare and encourages 28 research to identify designs and programs that are most effective. The typical pay-for- performance program provides a bonus to health care providers if they meet or exceed agreed-upon quality or performance measures, such as reductions in hemoglobin A1c in diabetic patients. The programs may also reward improvement in performance over time, such as year-to-year decreases in the rate of avoidable hospital readmissions. Pay-for-performance programs can also impose financial penalties on providers that fail to achieve specified goals or cost savings. For example, the Medicare program no longer pays hospitals to treat patients who acquire certain preventable conditions during their hospital stay. RDNs have the expertise and skill set to establish improvement in specific health care quality issues. The challenge will be to demonstrate evidence-based MNT outcomes and cost- effectiveness on a broad scale. 29 KNOWLEDGE AND SKILLS NEEDED FOR FUTURE NUTRITION AND DIETETIC PRACTICE There is a need to fill the gap relating to health promotion, heath coaching, wellness, and public health nutrition. These skills will be beneficial as RDNs address issues related to client/patient compliance with MNT and health promoting lifestyle behaviors. Motivational interviewing to influence and sustain behavior change skills is critical in practice and research in the area of behavior change skills is needed. Nutritional Genomics The advancement of genomics is progressing at a swift pace. Nutritional genomics is a component of genomics and includes nutrigenomics, nutrigenetics and nutritional epigenomics. ‘Personalized nutrition’ has been earmarked by the Academy as future opportunities for RDN, however, specialized knowledge and training will be required4. RDNs using nutritional genomics in clinical practice will demand a full understanding, interpretation and communication of complex genetic testing results as a tool to assess the risk of a disease54. Currently RDNs are not trained in clinical genetics and molecular testing. RDNs surveyed in the U.S., Canada and the U.K. over the past ten years have consistently revealed that RDNs are not confident in their knowledge of translating genomic science into clinical practice and limited ability to communicate probability and risk of disease from genetic testing54-58. Behavioral Counseling, Coaching, Coordination of Care and Program Planning and Evaluation The U.S. Preventive Services Task Force (USPSTF) has recommended intensive, behavioral dietary counseling for adult patients with hyperlipidemia and other known risk factors for cardiovascular and dietrelated chronic disease11-14. Intensive counseling can be delivered by nutrition and dietetics practitioners. Expansion of scope of nutrition and dietetics practice into behavioral counseling suggests a need for increased skills in the areas of coaching, motivational interviewing, coordination of care and program planning and evaluation. RDNs will positively impact the prevention and treatment of co- morbid conditions and chronic diseases. Besides changing practice, health care settings for counseling, coaching and care coordination are changing shown by the increase in home care and in the evolution of the patient-centered medical home. RDNs will need to adapt to these changes and forge the frontier to be successful59-63. Changes affecting health care delivery are occurring, including a shift from acute to chronic care, the need to integrate a continually expanding evidence base and technological innovations, more clinical practice occurring in teams, complex delivery arrangements and changing patient–clinician relationships59-63. Informatics The Academy recently outlined informatics Skills Specific to Levels of Dietetics Practice64. The term informatics is used to describe how humans find, store, analyze and manage information. For entry level competence, minimum basic computer and information literacy skills should be: demonstrate principles of computer file organization including information storage, data protection (backing up data) and basic computer skills; demonstrate basic proficiency with use of selected operating systems (e.g., Mac OS, Windows, Linux); use basic software applications to create documents, spreadsheets and presentations; access and use a web browser to find information; demonstrate proper use of email, including sending, receiving, forwarding, storing and attachments and proper use of email etiquette; quickly identify, evaluate and disseminate accurate information to consumers and other health care professionals; manage user security to protect patient/client information; retrieve a reasonable number of relevant documents 30 using PubMed to search the Medline database; find and evaluate online information sources using appropriate search engines; understand appropriate use of social media tools; and be familiar with basic functions of clinical information systems (e.g., computerized provider order entry, results reporting, documentation and report generation) 64. Telenutrition According to the IOM’s 2012 Workshop summary on The Role of Telehealth in an Evolving Health Care Environment, social media and social networking are the most prevalent online activities, have increased in the elderly since 2010 and participation of all ages are expected to continue to grow65. These technologies are already being used in health care for numerous functions. The entry level RDN will need to keep abreast of the new technologies as well as keep up with their professional, personal, legal and ethical responsibilities related to providing telehealth. Responsibilities include digital competence, regulatory requirements and privacy laws to name a few66. Teledietetics encompasses telephone consultation through dietitian call centers as well as the use of other electronic modalities, such as interactive website tools that support knowledge and behavior change (e.g. dietary assessment tools), social networking, video-based applications (e.g. online learning modules/classrooms/webcast, educational videos), smartphone texting and applications and e-mail messaging. Teledietetics services may involve client-professional (e.g. individual consultations, group education) or professional-professional contact (e.g. support to health professionals)66. A variety of nutritional care and health promotion activities may be provided through teledietetics communication, including interventions (such as education, advice and reminders) and monitoring of interventions. The Health Resources and Services Administration (HRSA) has asked the IOM to focus on the potential for telehealth to serve geographically isolated individuals and extend the reach of scarce resources while also emphasizing the quality and value in the delivery of health care services65. In the health care continuum, it is proposed that telehealth be used for health promotion and disease prevention, for acute care and for chronic disease management. Behavioral patterns and lifestyle choices have some of the largest impacts on health and premature death. Most health care is self-care and the individual patient is the biggest untapped resource in health care. However, the current system does not activate individuals to change their behaviors. The IOM report states that as the baby boomers begin to retire and attempt to maintain independent living in affordable and possibly more rural areas, telehealth will only continue to grow65. One such model includes TREAT (Telemedicine for Reach, Education, Access and Treatment) which uses telemedicine provided by an endocrinologist from an urban setting and a diabetes educator in a rural area working with patients and their primary care providers67. Currently, the RDN is named as a ‘Distance Site Practitioner’ under the Center for Medicare and Medicaid Services69. The Medicare Part B program allows several services provided by RDNs and nutrition professionals to be offered via telehealth68, 69. However, according to a 2009 Medicare claim review, growth in adoption of telehealth among providers has been modest despite increases in Medicare payment rates for telehealth services, expansions of covered services, reductions in provider requirements and provisions of federal grants to encourage telehealth. There were no RDN-submitted claims for this cross-sectional review70. 31 Systems Thinking Knowledge and Experience Systems thinking refers to the understanding of and ability to plan, implement, evaluate and develop policy for health care systems involving food and/or nutrition and food systems and their global impact on local and national issues. Systems thinking includes processes, sets of skills and technologies. The systems thinking process applies a scientific method-based approach to building, communicating and applying understanding to leadership decisions that cause many complex and unforeseen cascade of reactions. It is vital for strategic planning. An example of a systems thinking learning experience includes the Sustainable Food Lab which is a partnership among governments, NGOs and private sector organizations responsible for the production and distribution of food around the globe. Their efforts are program-focused (e.g., coffee supply chain) and while working on any program, participants learn and apply systems thinking concepts to develop deeper understanding of why the systems behave in ways they wish to change and where leverage points are for improving that behavior71. Skills included are: skillful learning within complex economic, social and environmental systems; acting effectively in change processes involving multiple stakeholders with diverse goals and needs; and understanding webs of system’s interdependence. According to Thornton, Peltier and Perreault, systems thinking is the ability to understand (and sometimes predict) interactions and relationships in complex, dynamic systems use such concepts as continuous incremental improvement, organizational learning and feedback loops72. Systems thinking assumes: systems cause most of their problems; solutions lie within the systems; and systems cannot blame outside circumstances for problems. Examples of systems thinking include: sustainable improvement in health care; sustainable healthy eating environment to prevent obesity; systems thinking regarding obesity, health care, food industry, marketing, economics and disability; and management of systems. Systems thinking has also been applied to many other areas, such as sustainability, ecoliteracy, interdisciplinary learning and obesity prevention and decision making72. Management and Leadership Management. Management in dietetics practice has been a ‘mega’ issue for the Academy for a number of years73. RDNs in management positions continue to decrease and be the minority type of RDN jobs. According to the 2013 Compensation and Benefits Survey, 24% of RDNs worked in inpatient acute-care facilities, 12% in ambulatory/outpatient care facilities and 10% of RDNs worked in long-term, extended care or assisted living facilities. These top three job settings employed approximately 50% of practicing RDNs74. Twelve percent of practicing RDNs indicated their area of practice as food and nutrition management. Supervisory responsibility has been found to be strongly associated with wage gains; those with direct and/or indirect supervision of 100 or more employees had a median hourly wage 50% greater than the typical RDN. Budgetary responsibility is also strongly correlated with hourly wages. Educational competencies need to be revisited to promote management as a fundamental part of dietetics curriculum and professional practice. The Academy has identified management competencies for dietitians that work in food and nutrition services in health care. The following core competencies that directly reflect food management and preparation are those competencies that a professional must be able to master75, 76: manage change and transition; develop menus and foodservices that exceed customer expectations; identify, develop and evaluate new business opportunities; lead teams of culturally diverse members; incorporate new information technologies; ensure service of safe food to customers through focus on Hazard Analysis Critical Control Points (HACCP); analyze and improve production and service 32 processes through the application of appropriate operations management quantitative business analysis techniques; measure customer satisfaction; accurately interpret data; make appropriate operational changes; and lead in a constantly changing environment. Management skills related to competencies for the role of a hospital foodservice director are specifically needed in financial management, project management, strategic planning, marketing and human resource management77-79. These same management skills are also vital in most other areas of dietetics. Critical thinking, problem solving, strategic planning and emotional intelligence may be due to an inadequate or a complete lack of experiential learning in undergraduate curricula21. Management is a group of skills, a science, an art that is interconnected to every facet of nutrition and dietetics80. Management is needed to be successful in research to plan the research budget and apply for grant funding; in private practice to plan for income to offset expenses and non-reimbursement; for interdisciplinary team function to use emotional intelligence and persuasion skills, in public health nutrition and community nutrition to plan and evaluate programs; and in academics to establish return on investment for the university to approve new curriculums to name a few81. The 2006 Employer Qualitative Research Study surveyed the views of 140 employers of RDNs and DTRs specifically on entry‐level practitioners. Employers mainly identified management skills as a weakness for entry level RDNs (unpublished data). Employers emphasized the need for RDNs who are able to look at the big picture and think strategically, run and justify programs, understand health care as a business, add value and who are entrepreneurial. Employers wanted RDNs with the following skills and abilities: work in a team; work across levels/departments in the organization (patients, doctors, nurses, technicians, administrators, cooks); supervise and delegate; coach/mentor and negotiate. Skills were also needed in accounting and finance; budget and cost control; inventory control; quality assurance and performance improvement; marketing/selling; revenue generation; reimbursement and sales; research and grant writing; forecasting future needs; problem solving and decision making; effective communications, meeting management, strategic planning; marketing, human resources, and technology. According to the most recent standards of performance for generalist and advanced RDNs in food and nutrition systems82, RDNs must be able to demonstrate basic competencies in the following areas: environmental protection rules; the political environment; marketing and customer satisfaction; continuous quality improvement; work redesign and productivity; innovative cost-containing measures; food consumption patterns; food and equipment technology; human resources trends; food and water safety; disaster and emergency planning; project and process management; and cultural diversity in the workplace82. Leadership. Often RDNs are perceived as assisting in instead of leading the nutrition care process; a perception which can hinder career advancement83. The profession must prepare for continued change in the future by defining, recognizing and supporting multiple levels of practice in a variety of practice areas to meet marketplace demands and to encounter ongoing constant change6. Specific leadership skills needed in RDNs to be successful include collaboration via networking and the sharing of knowledge; communication and mentoring; authentic leadership with emotional intelligence and feedback; vision including keeping abreast of future trends; and innovation such as taking a risk and being creative83-86. The changing landscape of the health care community further emphasizes that leadership skills are essential 33 for RDN accomplishments and viability as well to spread nutrition messages, build brands and businesses, communicate more effectively with employees and stakeholders, enhance the ‘bottom line’ and ultimately improve nutrition service. Case Management The effectiveness of use of an RDN as a case manager was demonstrated in a randomized controlled trial that compared usual medical care to usual care-plus-lifestyle case management provided by an RDN over a one year period. The case-managed group showed substantially greater weight loss, reduced A1c values, decreased prescription use and increased health-related quality of life87. Case management participants had fewer inpatient admissions, which substantially lowered medical care costs. Providing medical nutrition therapy to high-risk patients with type 2 diabetes and obesity decreased health plan costs by 34 percent88. Coding, Coverage and Reimbursement for Nutrition Services The results of the Academy’s 2013 Coding Survey indicated that respondents mainly used two of the five MNT CPT codes (97802, 97803, 97804, G0270 and G0271)89. Those respondents not using any codes (n=759 of the 3,182 respondent providers of outpatient MNT) cited reasons as they did not bill insurance plans or some other group determined billing code. Regarding establishment of usual and customary fee for nutrition services delivery, only 32% (n=1,006) answered they had and 44.5% (n=1,402) specified that they did not know89. The authors concluded that RDNs have a limited knowledge of basic practice and management concepts. Additional education is needed in order to improve third party payment for nutrition services through provider training on coding, billing, documentation of initial and sustained efficacy from nutrition services and skills to market efficacy outcomes to private payers to justify and expand coverage of MNT services. One of the concerns in the survey observed by the authors was the increasing trend in the number of RDNs who reported not billing insurance plans and using “self-pay only89.” This type of practice limits access to the underserved population. As noted earlier, few RDNs participate in the Medicare Physician Quality Reporting System program which becomes problematic in 2015 when Medicare fee for service providers will have their payments reduced if they do not meet satisfactory reporting requirements90. Evidence-based Medicine and Practice Evidence-based medicine (EBM) is defined as “… the conscientious, explicit and judicious use of current best substantiated data in making decisions about the health care of individual patients91”. The term is now expanded to “evidence-based practice” (EBP) to include all health professional disciplines. EBP is the integration of best research with clinical expertise, patient values and available resources92. EBP, a decision making process, involves the selection and use of the current best available research evidence, clinical circumstances and the consideration of patient values93. Irrespective of the health field, it is common to see gaps between research and clinical practice and EBP is used to bridge the gap94. A total of 342 U.S. credentialed RDNs in clinical practice completed an online survey in a 2011 pilot study evaluating their perceptions, attitudes, knowledge, clinical practice and clinical use of EBP95. EBP is a requirement for entry level dietetics education however, the study RDNs responded to using evidencebased resources occasionally even though they had adequate access to the resources. Prior surveys have reported lack of time as a barrier to the use of EBP. RDNs perception and attitude scores were more 34 positive than knowledge scores. Awareness of databases, knowledge of EBP terms, formal training and access to research mentors were reported to be lacking. Additionally, evidence-based practice training of health students appears in the literature for medicine and most health programs but little information is available for nutrition and dietetics curricula94. EBP is and will continue to be essential to demonstrate cost savings, effectiveness of outcomes and ultimately justify the impact of the RDN. In 2014, the Institute of Medicine held a roundtable on value and science-driven health care with the vision for the development of a continuously learning health system in which science, informatics, incentives and culture are aligned for continuous improvement and innovation96. The goal is by the year 2020, 90 percent of clinical decisions will be supported by accurate, timely and up-to-date clinical information and will reflect the best available evidence. Research The dietetics profession relies on research to advance practice. In 2006, a cross-sectional, descriptive study surveyed 258 randomly selected RDNs from Clinical Nutrition Management, Diabetes in Care and Education, Dietitians in General Clinical Practice, Dietitians in Nutrition Support, Nutrition Educators of Health Professionals, Renal Dietitians and Research dietetics practice groups were surveyed97. Key variables reported to predict the level of research skills included perceptions, attitudes, knowledge of evidence-based practice score, level of education, having taken a research course and how recent research was read97. Some of the research scores of individual faculty members were comparable to the clinical RDNs97. This finding may be related to the lower number of food and nutrition research mentors available. The results from this study imply that current entry level RDNs may have lower research scores. In 2011, Readex Research, Inc. conducted a survey on Member Research Activities, Needs and Perceptions98 for the American Dietetic Association on the gaps in dietetics-related research. The most common gap noted by the respondents was limited undergraduate education related to the research process and the paucity of research examining the cost effectiveness of nutrition intervention and outcomes. RDNs were strongly interested in public health research on methods to promote behavior change and maintenance, long-term and sustained community-based health promotion and disease prevention and research on specific populations such as Hispanics and the elderly. The most commonly cited barriers to RDN research were lack of research skills, lack of time and/or lack of staff and funding99, 100. Determinants to RDN involvement in research have been associated with education and knowledge100. The perpetuation and advancement of the nutrition and dietetics profession depends on evidence-based practice and research furnishes the basis for the development of the data. All RDNs will be expected to conduct nutrition research or collaborate in nutrition research as part of their work activity to establish nutrition outcomes recommendations for individuals and populations. Evidencebased practice is an important tool that includes complicated and cognizant decision making based on the highest quality of research available and substantiation on patient or client or program or system characteristics, conditions and subjectivities. Sixteen years ago an article appeared in the Journal of the American Dietetic Association titled, A Model for Making Outcomes Research Standard Practice in Clinical Dietetics101. Stakeholders and employers need to value and assign RDNs’ time for research. One model presented included clinical RDNs collaborating with academic RDNs since the responsibility of academic dietetics training programs in the integration of research and clinical practice. When academic RDNs are not as skilled in research, collaboration with allied health faculty colleagues or industry RDNs may help 35 supplement training programs. Research skills will be vital to the excellence and advancement of the profession. Nutritional Pharmacology Earlier nutrition and medication communications and the study of medical nutrition therapy focused primarily on drug-nutrient interaction. However, parallel to advances seen in medical nutrition therapy and technology, nutritional pharmacology has evolved into a multitude of relationships between nutrition and medication and the effect of nutritional status on drug metabolism, distribution and effectiveness102, 103 . Polypharmacy increasingly complicates pharmacology. Pharmacology encompasses pharmacodynamics, pharmacokinetics and phase 1 and 2 of drug metabolism (oxidation reduction reactions and water-soluble formation, respectively). More information has been learned about the impact of individual micronutrients on drug pharmacokinetics and pharmacodynamics. Pharmacokinetics refers to the study of the time course of drug absorption, distribution, metabolism and excretion (known as ADME). Due to the advances seen in these two clinical areas, RDN education requires an expanded curriculum to include nutritional pharmacotherapy. Knowledge and research on phytochemicals has progressed. For example, Chemopreventive and angiopreventive properties in epigallocatechin (green tea), triterpenoids (citrus juices), resveratrol (red wine), xanthohumol (beer), procyanidin (chocolate) and caffeine (coffee) have been associated with risk reduction of cardiovascular diseases, type 2 diabetes, neurodegenerative diseases and some cancers104. Therefore, nutrition and dietetics practitioners will need to stay at the forefront of on ongoing research results to translate into practice. Health Care Practice Setting There is a shift in health care occurring from new health care legislation (HR 3590) where the emphasis in acute nutrition care is now moving towards community and public health nutrition evaluation and intervention. This is predicted to significantly elevate health promotion and disease prevention practice. The Center for Health Workforce Studies (CWS), with the IOM, conducted an allied health workshop in 2011 on Scope of Practice (SOP) and the Future of Team Based Care15. These thought leaders defined scope of practice as governance “based in state licensing laws and rules which sets legal framework for service delivery by a specific health profession in a state, defines parameters of practice for a profession, limits practice to people who successfully complete specified education and/or training, restricts use of title and/or credential to license holders in the profession and is designed to provide consumer protection”14, 15. This shift will include an increasing use of teams in health care delivery, patient-centered medical homes and will use interprofessional teams in the provision of health care services. Evolving practice settings, besides the patient-centered medical home, include accountable care organizations, health homes for chronically ill, primary care case management and managed care or coordinated care organization (MCO/CCO). Care will be coordinated among multiple providers and team configurations will vary depending on patient needs. Team members will actively communicate and collaborate with each in the delivery of patient care. Robust team cohesiveness will be associated with higher levels of clinical outcomes. There are emerging models of care that emphasize team based approaches. The success of these models will require a commitment to team-based education and training and there will be a greater 36 need for regulatory flexibility related to SOP. It will be important to develop impact measures of SOP changes on efficiency, cost quality and access15. Increased Medical Complexity and Acuity Considering the aging population, home-based and hospital patients with multiple chronic diseases will increase. RDNs will need to be proficient in determining and prioritizing nutritional care while understanding the significance of multiple diseases and their conflicting pathology105. As a part of designing nutritional care, RDNs will be writing diet orders and other increasing scope of practice functions which will impact outcomes, safety, timeliness of care and readmission rates. Therefore, important areas of RDN’s knowledge include acid-base balance and compensatory mechanisms, electrolyte abnormalities, fluid shifts and edema, acute changes in liver, renal, cardiac, respiratory function, multi-system organ failure and nutritional pharmacology to name a few106. Concurrently, RDNs will continue to be faced with demonstrating the benefits of treatment by the RDN for patients with multiple medical conditions107. Public Health The health care shifts from acute care to chronic disease care and prevention public health will greatly change public health nutrition. On one end of the spectrum, public health will become more integrated with nutrition and on the other end there will be an increased demand for RDNs to have enhanced clinical nutrition skills due to the increasing severity of illness in the community108. The National Prevention, Health Promotion and Public Health Council from the Office of the Surgeon General advocates for a National Prevention Strategy: America’s Plan for Better Health and Wellness19, 43. Two of the seven priorities require nutrition expertise (Healthy Eating and Active Living). The upcoming 2015 Dietary Guidelines for America (DGA) will include nutrition and lifestyle recommendations and anticipatory guidance for pregnant and lactating women, as well as, infants and toddlers, which are new additions to the DGA. The new additions result from the solid evidence of epigenetic effects of nutrition imprinting and from the multitude of studies demonstrating rapid infant weight gain in the first three months of life on later development of obesity. Branding and Marketing RDNs, in general, do not market themselves or communicate their roles as food and nutrition experts to non-dietetics groups109. The vast public interest in nutrition continues to grow and there is often confusing, and sometimes conflicting, research reports and advice in the popular media. Therefore, RDNs, individually and as an organization, will need to promote the RDN brand. Besides confusion around nutrition in the popular media, there is public uncertainty around identifying qualified nutrition professionals. RDN’s active participation in the profession’s and its practitioners’ ‘branding’ process will be instrumental in demonstrating RDN’s superior nutritional expertise compared to competitors. In 2011, on behalf of the Academy, Polaris Marketing Research conducted a qualitative survey followed by a quantitative evaluation of the RDN brand110. The purpose of the survey was to understand perceptions of the RDN in the marketplace. The survey population consisted of member and non-member RDNs, physicians, nurses and consumers (n=1,558). The results indicated a strong RDN brand with the exception of low awareness of RDNs among consumers. There was a segment of consumers that believed that RDNs prescribe an inflexible diet without considering the consumer’s preferences or lifestyle. As the public becomes increasingly interested in nutrition, competition from other nutrition and health professionals is also increasing. The RDN brand must become stronger with distinct and pervasive messaging in the 37 marketplace to differentiate RDNs from other nutrition and health professionals. This will be accomplished by implementing RDN communication and services aimed at focused consumer groups. Industry Knowledge and Skills RDNs working in business and industry are trained and exposed to new and different knowledge and skills, not otherwise included in the nutrition and dietetics curriculum. Some examples include, but are not limited to, product development, which requires knowledge and expertise in good manufacturing practice, industrial food production, sensory testing, writing specifications, disassembling, primary and secondary processing. RDNs who work in regulatory affairs are individuals who ensure regulatory compliance and prepare submissions, as well as those whose main job function is clinical affairs or quality assurance and are all considered regulatory professionals. Regulatory professionals can be employed in industry, government and academia and are involved with a wide range of products, including: pharmaceuticals, medical devices, in vitro diagnostics, biologics and biotechnology, nutritional products, cosmetics and veterinary products. Regulatory professionals come from diverse backgrounds. Most regulatory professionals have earned a bachelor's degree and more than half have an advanced degree, most often in a scientific or technical field. Valuable skills include project management and organization, negotiation and communication and the ability to learn from the experience of others, both inside and outside the organization. Nutrition-industry prospective clinical trials (NICTs) are often developed to show either safety/tolerance or efficacy, or both in many cases for a new nutrition product111. NICTs may also be initiated to support a marketing claim based on either a novel ingredient (e.g. docosahexaenoic acid-DHA) or new application (e.g. liquid versus powder). Types of NICTs include drugs (investigational new drug - IND), infant formula, medical food, biologics and medical devices. RDNs are part of the ‘pipeline’ where they organize and run focus groups and advisory boards with key opinion leaders to generate product ideas and develop multicenter research protocols. NICTs are run to the same standards as pharmaceutical drug trials and infant formula results must be approved by the FDA. Industry RDNs are trained in a multitude of valuable skills such as project management, leadership, study monitoring and product production, packaging, labeling and distribution, adverse event reporting and coding, post-market product surveillance and monitoring, medical writing and statistics. SUMMARY The environmental scan represents an extensive examination and comparison of the current and future states of the rapidly growing and increasingly complex health care system. It examines stakeholder needs, findings in global and national reports, advances in medical science and technology, preparation and roles of other health professionals and the professional preparation of nutrition and dietetics practitioners. As noted by IOM and the Lancet Commission, the global health care systems are fractured and health professional education is old and disconnected. Five competencies recommended by the IOM for all health professionals include: patient-centered care, interdisciplinary teams and research, evidence-based practice, continuous quality improvement and informatics. There areas further demonstrate opportunities to gentrify the educational preparation of nutrition and dietetics professionals to meet today’s and tomorrow’s health care system demands. Educational levels and changes observed in other health professions provides timely guidance for RDN 38 educational programs. Namely, the majority of health professions have established multiple degree levels. A graduate degree, often doctoral degree, represents the entry level professional practice degree for most of the health professions. All of the health professions require a significant number of hours in supervised practice (or its equivalent) as part of their overall training and education. Therefore, the success and advancement of the nutrition and dietetics practitioner may require a progressed academic preparation that includes interdisciplinary education, informatics, telehealth, skills thinking, nutritional genomics, nutritional pharmacology, case management, coding and reimbursement, evidence-based practice and outcomes research, behavioral counseling and multi-disease clinical care to meet the growing demands of advancing knowledge, skills and new practice settings. 39 STAKEHOLDER INPUT Stakeholder Interviews and Analysis Stakeholder Survey Data Collection and Analysis Employer Survey Data Collection and Analysis Competency Gap Analysis Stakeholder Input on Future Model Recommendations STAKEHOLDER INTERVIEWS AND ANALYSIS PURPOSE The purpose of this project was to gather information from various stakeholders to determine the additional knowledge and skills needed at various levels of employment for future practitioners. METHODOLOGY ACEND® contracted with Dr. Barry Dornfeld and the Center for Applied Research (CFAR) Consulting Group to conduct structured interviews with representative stakeholders to help inform the development of a questionnaire to gather information from stakeholders about skills needed in future practice in nutrition and dietetics. A total of 10 interviews were conducted with stakeholders representing healthcare administration (pharmacy, nursing), deans of allied health colleges, employers of less traditional roles (communications, marketing and management), physicians, educators in allied health graduate programs and researchers. RESULTS Several themes emerged from the interviews: Communication skills are an essential and under-developed focus in dietetics training at the entry level. It is critical for dietitians to understand the health of the patient in context with the patient’s community and cultural ecosystem. Entry level dietitians will be expected to participate in interprofessional and interdisciplinary teams. Training programs need to incorporate teams as a critical component of education. Healthcare practitioners expect bachelor’s-trained dietitians to be able to provide health and wellness counseling. The ability to read, interpret and apply scientific knowledge is an increasingly essential component of nutrition and dietetics practice at the bachelor’s level, but many are not adequately prepared. Clinical experience is highly valued by employers. However, patient-assessment skills are lacking at all levels of nutrition and dietetics practice. Supervised practice experience is of high value. But the accessibility and quality of experiences is inconsistent, frustrating employers of nutrition and dietetics practitioners. Credible advanced practice credentials remain important in raising the competency level of dietitians and to address the increasing rate of chronic and complex diseases. A master’s degree is viewed as the ideal, at a minimum, by many private sector and healthcare employers, but expectations vary widely based on degree level Employers expect strong organizational leadership and project management skills especially at higher education levels, however, the expectations vary. Nutrition and dietetics is becoming increasingly globalized. 41 STAKEHOLDER SURVEY DATA COLLECTION AND ANALYSIS PURPOSE The purpose of this project was to gather information from various stakeholders on the importance of specific skills for future practice in nutrition and dietetics. METHODOLOGY Using data gathered from the environmental scan and structured interviews with stakeholders, ACEND® worked with Dr. Barry Dornfeld and the CFAR Consulting Group to develop an online questionnaire in Survey Monkey® that included two major sections: one for collecting demographic information about respondents and the other for collecting respondent ratings on the importance of 79 skills for future practice in nutrition and dietetics (see Appendix A). The skills were organized into six skill sets: professional research and practice skills (7 items), teamwork and communication skills (7 items), clinical client care skills (26 items), community and population health skills (11 items), leadership, management and organization skills (18 items) and food and foodservice systems (10 items). These skill set categories were developed based on input collected in the stakeholder interviews. CFAR and the Expanded Standards group identified specific skills within each category. Respondents were asked to rate the importance of each skill for future practice in nutrition and dietetics using a four-point scale ranging from 1, not important to 4, very important. An option of “unable to answer” also was included. Respondents were given the opportunity in open-ended questions to describe any additional skills that might be needed by nutrition and dietetics professionals in the future. A cover letter with a link to the questionnaire was emailed to all of the individuals in the Academy of Nutrition and Dietetics database. A follow-up reminder email was sent two weeks later. Individuals were asked to complete the survey themselves and to forward the request to employers of nutrition and dietetics practitioners and professionals who worked with nutrition and dietetics professionals. Emails were also sent to Academy of Nutrition and Dietetics and dietetic practice group leadership asking their assistance in encouraging response. ACEND worked with Dr. J.T. Johnson, a statistician and director of the Center for Research at the University of Southern Mississippi, to analyze and interpret data. Descriptive statistics were run for all variables and inferential statistics were used to compare ratings by demographic variables. RESULTS Because of the snowball distribution process, the number of possible respondents is not known. A total of 9,477 stakeholders participated in the survey. Demographic Information As presented in Table 2, the most common practice setting noted by participants was healthcare (52.7%) followed by education (17.5%). The setting with the smallest number of participants was communications and media (1.2%). Direct patient care was the most frequently mentioned role (55.3%) followed by education (24.4%). Students or interns comprised 10.1% of the participants. Education level of participants was fairly evenly split between a bachelor’s (43.7%) and master’s (45.2%) degree. Most (94.9%) of the respondents held the RDN credential; 3.8% held the DTR credential. Most (72.2%) responded to the questionnaire from the perspective of the RDN; the remaining responses were split from the perspective of 42 students/interns (8.8%), educators (5.5%), professionals who work with RDNs/DTRs (3.6%) and employers who hire RDNs/DTRs (3.4%). More than one-third of the participants (36.6%) had > 20 years of experience, followed by those with 10-20 years (20.0%). All regions of the country were represented and responses were received from all states. Importance of Future Skills Respondents rated all of the future skills on a four-point scale with 4 being very important. Most (89%) of the individual skills had mean ratings greater than three suggesting that skills were important for future practice; 40% were rated greater than 3.5 suggesting they were very important (see Table 3). The importance ratings for individual skills within a skill category were averaged to give an overall mean score for each skill set category (see Table 4). All of the skill set categories had strong coefficient alpha reliability indicators (alpha .80 or higher) suggesting good internal consistency among the skills included in that category. Results suggested that all six skill set categories (professional research and practice skills; teamwork and communication skills; clinical client care skills; community and population health skills; leadership, management and organization skills; and food and foodservice systems) were important for future practice with teamwork and communication skills receiving the highest mean score (M=3.64) and leadership, management and organizational skills the lowest mean score (M=3.15). Analysis of Variance was used to explore differences in skill set scores based on demographic variables of the respondents. Statistical differences (p<.05) were found among the skill set mean scores based on respondent setting, level of education, years of experience and perspective from which they answered the questionnaire; however, the practical significance of the differences may be of less importance as all mean ratings differed by less than .3 on a 4 point scale (see Table 5). Differences Based on Setting: Professional Research and Practice: Those in the healthcare setting had a lower mean importance score for the professional research and practice skill set than those in education (P<.001) and corporate (P<.001) settings and those with no work experience (P=.002). Those in education had a higher mean importance score than those in government (P=.007), wellness (P=.018) and community settings. Those in wellness and government settings and those who were self-employed all had higher mean importance scores in the professional research and practice skill set than those in the corporate setting (P=.007, .002, .002 and .013, respectively). Teamwork and Communication: There was no difference found in the mean importance scores based on setting for the teamwork and communication skill set. Clinical Client Care: Those in the healthcare setting had a higher mean importance score for the clinical client care skill set than those in community (P=.034) and government (P=.002) settings and those with no work experience (P=.025). Those with no work experience had a higher mean importance score than those in education (P<.001), community (P<.001), corporate (P=.004) and government (P<.001) settings. Those that were self-employed had a lower mean importance score for the clinical client care skill set than those in the community (P=.017) and government (P=.008) settings. 43 Differences Based on Setting (cont.): Community and Population Health: Those in the healthcare setting had a lower mean importance score for the community and population health skill set than several other settings, including education (P<.001), community (P<.001), government (P<.001), and wellness (P=.006) settings and those with no work experience (P<.001). Those that were self-employed had a lower mean importance score for the community and population health skill set than those in the government (P=.032) and community (P=.028) settings. Leadership, Management and Organizational: Those in the healthcare setting had a lower mean importance score for the leadership, management and organizational skill set than those in education (P=.001) and government (P=.043) settings. Food and Food Systems: Those in the healthcare setting had a lower mean importance score for the food and food systems skill set than those in the education (P<.001) setting and those with no work experience (P<.001). Differences Based on Highest Level of Education: Professional Research and Practice: Those with at high school degree as their highest level of education (assumed to be students) had a higher mean importance score for the professional research and practice skill set than did those with an associate’s degree (P=.009), bachelor’s degree (P<.001) and master’s degree (P=.028). Those with a master’s degree or doctorate, had a mean importance score that was significantly higher than those with a bachelor’s degree (P<.001 for both). Teamwork and Communication: Those with a master’s degree had a higher mean importance score for the teamwork and communication skill set than did those with a bachelor’s degree (P=.002). Clinical Client Care: Those with a high school degree had a higher mean importance score for the clinical client care skill set than those with an associate’s degree (P=.057), bachelor’s degree (P<.001), master’s degree (P<.001) or a doctorate (P<.001). Community and Population Health: High School graduates had a higher mean importance score for the community and population health skill set than those with an associate’s degree (P=.044) but a lower score than those with a bachelor’s degree (P=.001). Those with bachelor’s degree had a lower mean importance score for the community and population health skill set than did those with a master’s degree (P<.001) or a doctorate (P=.001). Leadership, Management and Organizational: There were no differences found in the mean score for the leadership, management and organizational skill set based on highest level of education. Food and Food Systems: High school graduates had a higher mean importance score for the food and foodservice systems skill set than those with a bachelor’s degree (P=.001), master’s degree (P=.001) or a doctorate (P=.001). 44 Differences Based on Credential: No significant differences were found in the mean scores for any of the skill set scores based on the respondent’s credentials. Differences Based on Years of Work Experience: Professional Research and Practice: Respondents with no work experience (assumed to be students and interns) had a higher mean importance score for the professional research and practice skill set than all other years of work experience groups, including < 3 years (P<.001), 4-10 years (P<.001), 1020 years (P<.001) and > 20 years (P<.001). Teamwork and Communication: There was no difference found in the mean scores for the teamwork and communication skill set based on years of work experience. Clinical Client Care: Respondents with no work experience had a higher mean importance score for the clinical client care skill set than did all other work experience groups, including < 3 years (P<.001), 4-10 years (P<.001), 10-20 years (P<.001) and > 20 years (P<.001). Those with < 3 years of work experience had a higher mean importance score than those with 10-20 years of work experience (P=.015) and those with > 20 years of experience (P<.001). Those with 4-9 years of experience had a higher mean importance score than those with > 20 years of work experience (P=.001). Community and Population Health: Those with no work experience had a higher mean importance score for the community and population health skill set than all other work experience groups, including < 3 years (P<.001), 4-10 years (P<.001), 10-20 years (P<.001) and > 20 years (P<.001). Those with < 3 years of experience also had a higher mean importance score than those with 10-20 years (P<.001) and > 20 years (P<.001) of work experience. Respondents with 4-9 years of work experience had a higher mean importance score than those with >20 years of experience (P=.008). Leadership, Management and Organizational: Those with > 20 years of work experience had a lower importance score for the leadership, management, and organizational skill set than did those with < 3 years of experience (P<.001), 4-9 years of experience (P<.001) and 10-20 years of work experience (P<.001). Food and Food Systems: Those with no experience had a higher mean importance score in the food and foodservice systems skill set than did those with < 3 years (P=.003), 4-10 years (P<.001), 10-20 years (P<.001) and > 20 years (P=.001) of work experience. Those with 10-20 years of work experience had a lower mean importance score than those with <3 years (P=.030) and with > 20 years (P=.011) of work experience. Differences Based on Perspective for Answering the Questionnaire: Professional Research and Practice: Those who reported their perspective as DTRs had a lower mean importance score for the professional research and practice skill set as compared to those reporting their perspective as employer (P=.024), professionals who work with RDNs and DTRs (P<.001), educators (P=.002), students (P<.001) and interns (P<.001). The mean importance score of RDNs was lower than scores for professionals who work with RDNs and DTRs (P=.010), students (P<.001) and interns (P<.001). 45 Differences Based on Perspective for Answering the Questionnaire (cont.): Teamwork and Communication: There were no difference found in the mean importance scores for the teamwork and communication skill set based on perspective for answering the questionnaire. Clinical Client Care: Those reporting their perspective as student had a higher mean importance score for the clinical client care skill set than those reporting their perspective as RDNs (P<.001), DTRs (P<.001), employers (P<.001), professionals who work with RDNs and DTRs (P<.001) and educators (P<.001). Similarly, those reporting their perspective as interns also had a higher mean importance score than those reporting as RDNs (P<.001), DTRs (P<.001), employers (P<.001), professionals who work with RDNs and DTRs (P<.001) and educators (P=.002). Community and Population Health: Those reporting their perspective as educators had a higher mean importance score for the community and population health skill set than those reporting as RDNs (P<.001), DTRs (P=.006), employers (P<.001) and professionals who work with RDNs and DTRs (P=.013). Those reporting as students or interns had higher mean importance scores than RDNs (P<.001), DTRs (P<.001), employers (P<.001) and professionals who work with RDNs and DTRs (P<.001). Leadership, Management and Organizational: Those reporting their perspective as employers had a higher mean importance score for the leadership, management and organizational skill set than those reporting as RDNs (P<.001) and professionals who work with RDNs and DTRs (P<.001). Those reporting their perspective as educators had higher mean importance scores than RDNs (=.033) and professionals who work with RDNs and DTRs (P=.031). Food and Food Systems: Those reporting their perspective as students had a higher mean importance score for the food and food systems skill set than those reporting as RDNs (P<.001), employers (P<.001) and professionals who work with RDNs and DTRs (P=.002). Those reporting their perspective as Interns also had a higher mean importance score than those reporting as RDNs (P<.001) and professionals who work with RDNs and DTRs (P=.020). 46 Table 2: Demographic characteristics of stakeholders Characteristics %a n Work Setting Healthcare (hospital, long term care, physician network) 4698 52.7% Educational setting (primary, secondary, university) 1558 17.5% Government (federal, city, state, or local) public health 1126 12.6% Self-employed consultation or private practice 867 9.7% Community nonprofit 724 8.1% Wellness programs (workplace, health club, fitness centers) 622 7.0% Corporate/industry settings (R&D, marketing, sales, etc.) 365 4.1% Behavioral care clinics (rehabilitation, mental illness, etc.) 308 3.5% Communications and media 110 1.2% Not currently working 761 8.5% Direct patient care (physician, nurse, pharmacy, dietitian) 4929 55.3% Education 2178 24.4% Administration/management 1721 19.3% Community/population health 1557 17.5% Foodservice 1111 12.5% Student/intern 904 10.1% Research (basic science and medical) 507 5.7% Policy expert/advocate 262 2.9% Research (product R&D) 89 1.0% High School 203 2.2% Associate 264 2.8% Bachelor’s 4107 43.7% Master’s 4244 45.2% Doctorate 605 6.4% 7928 94.9% DTR or NDTR 317 3.8% RN 118 1.4% MD 28 0.3% PharmD 11 0.1% Role Highest Degree Held Credentials Held RD or RDN a In some cases, total n is greater than total number of responses and percentages total more than 100% as respondents were allowed to ‘select all that apply’ 47 Table 2: cont. Characteristics n %a Perspective Responding to the Questionnaire As a registered dietitian 6844 72.2% As a dietetic technician, registered 283 3.0% As an employer who hires registered dietitians or dietetic technicians 321 3.4% As a professional who works with registered dietitians or dietetic technicians 342 3.6% As a dietetics educator 519 5.5% As a dietetics student 496 5.2% As a dietetic intern 339 3.6% No experience 574 6.1% 3 years or less 1781 18.8% 4 to 9 years 1674 17.7% 10 to 20 years 1899 20.0% More than 20 years 3472 36.6% Region 1 (AK, CA, HI, ID, MT, OR, WA, WY) 1427 15.6% Region 2 (IA, MI, MN, MO, NE, ND, SD, WI) 1372 15.0% Region 3 (AL, AR, FL, GA, LA, MS, PR, SC) 1247 13.6% Region 4 (AZ, CO, KS, NM, NV, OK, TX, UT) 1269 13.9% Region 5 (IL, IN, KY, OH, TN, WV) 1481 16.1% Region 6 (DE, DC, MD, NC, PA, VA) 1084 11.8% Region 7 (CT, ME, MA, NH, NJ, NY, RI, VT) 1279 14.0% Years of Work Experience Region of the Country 48 Table 3. Stakeholder ratings of importance of skills for future practice in nutrition and dietetics Skill n Mean a Std. Dev Professional Research and Practice Skills Collect and interpret data for use in decision making and evaluation 8009 3.57 .654 Engage in quality assurance and performance improvement activities 8009 3.48 .679 Analyze, evaluate and critique scientific studies 8009 3.48 .717 Use data collected to make operational decisions 8009 3.47 .704 Lead efforts in health, food and nutrition policy development, implementation and evaluation 8009 3.44 .748 Perform data analysis 8009 3.21 .811 Design, conduct, analyze and disseminate basic science, clinical and/or translational research 8009 3.14 .847 Teamwork and Communication Skills Accurately communicate evidence-based information 8313 3.86 .387 Translate dietetics vocabulary across disciplines and in laymen terms 8313 3.76 .508 Participate in team decision making 8313 3.75 .492 Use cross cultural skills effectively in communication 8313 3.66 .550 Develops and uses a variety of media and technologies to communicate messages and education 8313 3.54 .639 Lead transdiscplinary, interprofessional and/or interdisciplinary teams 8313 3.50 .661 Employ strategies and facilitate team building 8313 3.43 .682 Assess nutrition status in clients with a variety of diseases and medical conditions 6267 3.86 .414 Develop, monitor and evaluate nutrition interventions in clients with a variety of diseases and medical conditions 6267 3.85 .422 Diagnose nutrition problems in clients with a variety of diseases and medical conditions 6267 3.81 .479 Counsel clients with multiple diseases/medical conditions and those who require complex nutrition care using appropriate behavior change theories and techniques 6267 3.78 .505 Interview clients for nutrition risk and diet history 6267 3.76 .517 Prescribe and manage therapeutic diets (renal, cardiac, diabetes, phenylketonuria) 6267 3.75 .562 Clinical Client Care Skills a scale: 1, not important to 4, very important for future practice in nutrition and dietetics 49 Table 3. (cont.) Skill n Mean a Std. Dev Clinical Client Care Skills (cont.) Analyze food intake in clients with a variety of diseases and medical conditions 6267 3.73 .534 Educate clients in health maintenance and disease prevention 6267 3.73 .522 Prescribe and manage enteral and parenteral nutrition 6267 3.69 .646 Provide nutrition care for clients who have multiple diseases/medical conditions and complex nutrition and health needs (e.g. palliative and hospice care, oncology, high risk pregnancy) 6267 3.69 .594 identify sociological, psychological and environmental influences on eating behavior 6267 3.64 .576 Implement designated dietary interventions based on protocol 6267 3.60 .625 Counsel clients affected with disorders that are serious in nature, including eating disorders 6267 3.60 .641 Write nutrition orders for nutrition supplements, vitamins and minerals 6267 3.57 .723 Apply integrative nutrition principles to nutrition care and Medical Nutrition Therapy (MNT), including the use of nutritional genomics, dietary supplements and/or herbal remedies 6267 3.56 .665 Assess individual’s physical, social and cultural needs 6267 3.53 .683 Counsel clients on appropriate ways and methods to increase physical activity 6267 3.48 .688 Order nutrition related laboratory tests 6267 3.45 .743 Perform calculations for risk assessment following protocol 6267 3.43 .733 Conduct nutrition focused physical exams as part of assessment 6267 3.34 .797 Manage nutrition related medication of clients 6267 3.34 .778 Lead client care coordination/case management 6267 3.19 .838 Perform routine tests (e.g. finger stick for blood glucose, urine analysis) to assess and monitor clients’ nutrition and health status 6267 2.79 1.008 Prescribe or dispense adjustment of insulin and oral hypoglycemic regimens 6267 2.87 1.005 Conduct psychotherapy, including cognitive behavioral therapy and solutions focused therapy 6267 2.80 1.020 Insert nasal gastric feeding tubes 6267 2.25 1.048 50 Table 3. (cont.) Skill n Mean a Std. Dev Food and Foodservice Systems Skills Develop menus and standardized recipes for diverse groups for normal and therapeutic diets applying principles of menu planning and knowledge of medical nutrition therapy and therapeutic nutrition 6650 3.56 .673 Complete nutrient analysis of food products, recipes and menus 6650 3.51 .701 Teach others how to prepare healthy foods using knowledge of food science and culinary techniques 6650 3.48 .718 Plan and implement food safety and sanitation programs 6650 3.37 .804 Manage production and service of food that meets nutrition guidelines, cost parameters and health needs 6650 3.36 .795 Conduct operational analyses and streamline operations to reduce costs while ensuring health related goals are not compromised 6650 3.31 .792 Manage food distribution and service ensuring accuracy, quality and portion control 6650 3.25 .838 Evaluate purchasing needs and develop specifications for food and equipment 6650 3.14 .858 Negotiate purchases and contracts for products and services 6650 2.97 .914 Design foodservice systems (layout, equipment) 6650 2.90 .932 Community and Population Health Serve as a nutrition resource for community organizations 7033 3.65 .600 Provide nutrition and life style education to well populations 7033 3.55 .660 Design and implement culturally appropriate nutritional initiatives and programs 7033 3.41 .726 Interpret and use national nutrition surveillance data and population based statistical data 7033 3.33 .742 Interpret basic population based statistical data 7033 3.31 .738 Assess the need to develop and implement a community or population health program and/or intervention considering biological, behavioral, psychological, social, economic, policy and/or environmental factors 7033 3.29 .752 Convene and mobilize community partnerships and coalitions to identify and solve food, nutrition and/or health related issues by building on community assets and focusing on policy, systems and environmental strategies 7033 3.27 .781 Develop and utilize nutrition and health surveillance systems to monitor and identify population and community health and nutrition priorities and problems; communicate results to local, state and national health authorities and policy makers 7033 3.25 .781 51 Table 3. (cont.) Skill n Mean a Std. Dev Community and Population Health (cont.) Conduct culinary demonstrations to teach cooking skills, safe food handling practices and promote consumption of healthy foods 7033 3.25 .805 Develop and evaluate policies, laws and regulations that address and protect health and nutrition for individuals and populations 7033 3.24 .769 Identify and seek funding sources for development and ongoing maintenance of community health programs 7033 3.15 .822 Lead process improvement activities to improve delivery of food and nutrition services 6261 3.38 .742 Advocate for changes in policies to improve access to food and nutrition services for the public 6261 3.35 .780 Lead initiatives to improve use of sustainable practices in food and nutrition services 6261 3.29 .796 Demonstrate conflict resolution and mediation skills 6261 3.27 .804 Develop operational policies, procedures, job descriptions, work schedules and performance standards 6261 3.22 .811 Manage staffing functions such as interviewing, hiring, motivating, supervising, evaluating and terminating employees 6261 3.20 .840 Conduct employee performance evaluations and counsel employees for performance improvement 6261 3.18 .841 Conduct employee orientation and training programs 6261 3.16 .835 Identify opportunities for increasing revenue 6261 3.16 .855 Adjust operations based on financial performance 6261 3.10 .871 Direct strategic planning 6261 3.03 .886 Develop, implement and evaluate marketing plans for new products, programs and services 6261 3.03 .861 Develop operational and capital budgets 6261 3.02 .904 Develop emergency preparedness plans for facilities, patients/clients and/or communities 6261 3.01 .905 Develop business plans to sell ideas and turn ideas into action 6261 2.99 .882 Evaluate and make recommendations for equipment, layout and design or redesign of facilities 6261 2.98 .897 Develop informatics systems in collaboration with programmers 6261 2.87 .890 Leadership, Management and Organizational Skills 52 Table 4. Skill set importance scores and score reliability n Mean a Std. Dev Cronbach’s Alpha Teamwork and Communication Skills 8563 3.64 .384 .798 Clinical Client Care Skills 8014 3.46 .429 .933 Professional Research and Practice Skills 8726 3.40 .510 .819 Community and Population Health Skills 7615 3.33 .574 .929 Food and Foodservice Systems Skills 7105 3.28 .658 .945 Leadership, Management and Organizational Skills 7302 3.15 .649 .962 Skill Set a scale: 1, not important to 4, very important for future practice in nutrition and dietetics 53 Table 5. Comparison of mean importance scores based on demographic data Characteristic Research n Mb ± SD Client Care n Mb ± SD Skill Set Community Teamwork b n M ± SD n Mb ± SD Leadership n Mb ± SD Foodservice n Mb ± SD Setting c Healthcare Behavioral care Education Community Government Wellness Corporate Communications Self Employed Not Working 3338 56 928 338 693 184 210 24 316 615 3.36 ± .519 3.32 ± .550 3.46 ± .459 3.36 ± .526 3.37 ± .538 3.32 ± .591 3.53 ± .405 3.54 ± .378 3.37 ± .552 3.45 ± .474 3126 53 827 303 635 156 183 20 284 542 3.47 ± .384 3.55 ± .374 3.43 ± .468 3.38 ± .556 3.39 ± .499 3.45 ± .448 3.39 ± .494 3.51 ± .372 3.51 ± .389 3.53 ± .409 2910 50 833 296 621 144 181 21 269 502 3.22 ± .621 3.26 ± .749 3.40 ± .494 3.48 ± .495 3.46 ± .515 3.41 ± .544 3.33 ± .523 3.52 ± .409 3.32 ± .587 3.40 ± .531 3276 55 911 333 681 174 208 24 305 603 3.64 ± .385 3.66 ± .344 3.64 ± .371 3.66 ± .414 3.64 ± .390 3.59 ± .444 3.64 ± .384 3.71 ± .330 3.63 ± .409 3.61 ± .394 2803 46 808 278 602 128 173 19 257 471 3.09 ± .676 3.10 ± .689 3.20 ± .601 3.14 ± .635 3.18 ± .624 3.13 ± .704 3.21 ± .583 3.20 ± .536 3.13 ± .699 3.17 ± .614 2751 46 799 269 560 120 165 17 244 464 3.21 ± .688 3.36 ± .589 3.38 ± .584 3.29 ± .688 3.30 ± .674 3.28 ± .711 3.26 ± .628 3.35 ± .630 3.24 ± .654 3.36 ± .576 Level of Education c High School Associate Baccalaureate Master’s Doctorate 158 232 3742 3947 578 3.54 ± .438 3.37 ± .570 3.35 ± .523 3.42 ± .503 3.48 ± .442 133 213 3430 3629 545 3.63 ± .399 3.51 ± .514 3.46 ± .427 3.46 ± .425 3.43 ± .436 123 195 3226 3482 528 3.49 ± .512 3.31 ± .647 3.29 ± .592 3.36 ± .564 3.38 ± .500 151 228 3673 3869 574 3.65 ± .359 3.60 ± .458 3.63 ± .392 3.66 ± .370 3.61 ± .391 121 186 3080 3342 512 3.19 ± .681 3.16 ± .699 3.10 ± .657 3.19 ± .636 3.13 ± .648 113 185 3006 3243 500 3.53 ± .517 3.39 ± .654 3.28 ± .656 3.28 ± .660 3.25 ± .674 7307 281 73 23 8 3.39 ± .512 3.32 ± .598 3.51 ± .420 3.42 ± .429 3.31 ± .326 6742 253 70 22 8 3.45 ± .421 3.38 ± .598 3.45 ± .392 3.33 ± .526 3.37 ± .324 6422 235 66 19 8 3.32 ± .572 3.26 ± .646 3.39 ± .529 3.39 ± .468 3.13 ± .609 7177 281 107 26 10 3.65 ± .378 3.58 ± .445 3.61 ± .463 3.48 ± .486 3.56 ± .346 6176 222 62 18 8 3.15 ± .644 3.15 ± .705 2.97 ± .731 3.01 ± .658 2.78 ± .627 6004 221 60 17 8 3.27 ± .663 3.38 ± .663 3.31 ± .676 3.25 ± .520 2.81 ± .849 Credential RD/RDN DTR/NDTR RN MD PharmD a Skill Sets include: professional research and practice skills; clinical client care skills; community and population health skills; teamwork and communication skills; leadership, management and organization skills; and food and foodservice systems. b Scale: c 1, not important to 4, very important for future practice in nutrition and dietetics practice Differences (p<.05) found among some means; results presented in Rational Document text. 54 Table 5. (cont.) Characteristic Research n Mb ± SD Client Care n Mb ± SD Skill Set Community Teamwork b n M ± SD n Mb ± SD Leadership n Mb ± SD Foodservice n Mb ± SD Years Work Experience c None 3 or less 4-9 10-20 More than 20 483 1618 1531 1768 3268 3.51 ± .429 3.40 ± .504 3.39 ± .516 3.37 ± .529 3.40 ± .510 423 1456 1375 1620 3087 3.64 ± .355 3.49 ± .430 3.48 ± .422 3.45 ± .443 3.43 ± .427 388 1354 1295 1547 2982 5844 238 290 300 461 354 264 3.46 ± .416 3.3801 ± .616 3.3781 ± .462 3.4281 ± .436 3.4721 ± .389 3.65 ± .362 3.6008 ± .365 5541 222 287 289 454 327 247 3.51 ± .464 3.41 ± .555 3.35 ± .581 3.30 ± .593 3.29 ± .575 466 1570 1508 1731 3230 3.67 ± .369 3.64 ± .377 3.62 ± .397 3.62 ± .396 3.66 ± .377 365 1263 1228 1488 2909 6223 258 310 313 484 400 287 3.65 ± .379 3.58 ± .452 3.66 ± .351 3.63 ± .380 3.64 ± .379 3.63 ± .396 3.68 ± .378 6223 258 310 313 484 400 287 3.16 ± .647 3.07 ± .661 3.08 ± .664 3.11 ± .656 3.23 ± .624 355 1245 1194 1426 2838 3.44 ± .534 3.30 ± .657 3.27 ± .656 3.22 ± .683 3.29 ± .656 Perspective Answering c RD/RDN DTR/NDTR Employer Other Professional Educator Student Intern 6346 263 313 316 489 419 292 3.38 ± .518 3.29 ± .623 3.43 ± .439 3.48 ± .468 3.45 ± .480 3.51 ± .448 3.50 ± .433 55 3.31 ± .577 3.27 ± .662 3.25 ± .607 3.30 ± .606 3.44 ± .485 3.50 ± .486 3.53 ± .467 3.13 ± .651 3.15 ± .717 3.30 ± .588 3.07 ± .691 3.23 ± .597 3.18 ± .628 3.14 ± .655 5171 212 267 269 434 295 232 3.26 ± .670 3.38 ± .672 3.26 ± .646 3.24 ± .658 3.35 ± .614 3.46 ± .545 3.44 ± .522 EMPLOYER DATA COLLECTION AND ANALYSIS PURPOSE The purpose of this project was to gather information from employers on how essential specific skills were for future employability of nutrition and dietetics practitioners. METHODOLOGY Using data gathered in the stakeholder survey and review by an expert panel, ACEND® collaborated with Dr. Barry Dornfeld and the CFAR Consulting Group to develop an online questionnaire in Survey Monkey® that included two major sections: one for collecting demographic information about respondents and the other for collecting respondent ratings of how essential each of 69 skills were for future employability in nutrition and dietetics practice (Appendix B). The skills were organized into six skill sets: professional research and practice skills (6 items), teamwork and communication skills (8 items), clinical client care skills (22 items), community and population health skills (9 items), leadership, management and organization skills (14 items) and food and foodservice systems (10 items) based on information collected in the stakeholder interviews. Skills rated as important in the stakeholder survey and those recommended for inclusion by an expert panel were included in the employer survey. Respondents were asked to rate how essential each of skills was for future employability in nutrition and dietetics practice using a four-point scale ranging from 1, not essential to 4, very essential. An option of “unable to answer” also was included. A cover letter with a link to the questionnaire was emailed to a list of 300 employers whose names were obtained from an earlier survey requesting RDNs and DTRs provide contact information for employers. Emails were also sent to Academy of Nutrition and Dietetics dietetic practice group leadership asking their assistance in encouraging member response. A follow-up reminder email was sent two weeks later. Individuals were asked to complete the survey themselves and to forward the request to employers of nutrition and dietetics practitioners. ACEND worked with Dr. J.T. Johnson, a statistician and director of the Center for Research at the University of Southern Mississippi, to analyze and interpret data. Descriptive statistics were run for all variables and inferential statistics were used to compare ratings by demographic variables. RESULTS Because of the snowball distribution process, the number of possible respondents is not known. A total of 300 employers participated in the survey. Demographic Information The most common practice setting noted by participants was Healthcare (75.6%) followed by Community (9.8%) (see Table 6). The settings with the smallest number of participants were Communications and Media (1.0%) and self-employed (1.0%). Administration was the most frequently mentioned role (53.6%) followed by Client Care (16.3%). A master’s degree was the most common (57.4%) education level of participants. Most (96.8%) of the respondents held the RDN credential; 1.1% held the DTR credential. More than half of the participants (55.7%) had more than 20 years of experience, followed by those with 10-20 years (23.6%). Responses were received from all regions in the country. Size of organization was fairly evenly split among organizations of greater than 5000 56 employees (27.9%), 2,001-5,000 employees (21.4%), 501-2000 employees (25.5%) and less than 500 (25.1%). The number of dietitians in the organization varied with greater than 30 (28.1%) and 1-5 (26.4%) being the most common. The number of dietetic technicians was much fewer with 56.4% of organizations not employing any and 22.3% employing 1-5; only 12.4% employing more than five dietetic technicians. Most (90.0%) employers currently require at least a bachelor’s degree and 29.0% currently require a graduate degree for nutrition and dietetics positions in their organization. Responses to whether they would require a degree for future nutrition and dietetics positions was divided – 30.9% indicate yes they would require a graduate degree, 34.6% indicated that they may require a graduate degree and 34.6% indicated they would not require a graduate degree for future positions in nutrition and dietetics. Importance of Future Skills Respondents rated all of the future skills on a four-point scale with 4 being very essential. Most (86%) of the individual skills had mean ratings greater than three suggesting that skills were essential for employability in future nutrition and dietetics practice; 22% were rated greater than 3.5 suggesting they were very essential (see Table 7). The essential ratings for individual skills within a skill category were averaged to give an overall mean score for each skill set category (see Table 8). Results suggested that all six skill category sets (professional research and practice skills; teamwork and communication skills; clinical client care skills; community and population health skills; leadership, management and organization skills; and food and foodservice systems) were essential for future employability in nutrition and dietetics practice (i.e. mean > 3 on 4-point scale) with teamwork and communication skills receiving the highest mean score (M=3.52) and community and population health skills the lowest mean score (M=3.03). Analysis of Variance was used to explore differences in skill set scores based on demographic variables of the respondents (see Table 9). Few statistical differences (p<.05) were found. Those with < 3 years of experience had the highest mean essential score for the community and population health skill set, which was higher (p<.05) than the scores for those with more experience. Those in the healthcare setting had higher (p<.05) essential scores for the clinical client care skill set than those in many other settings. Those with one to five dietitians in their operation had a higher (p<.05) essential score for the food and foodservice systems skill set than those with more dietitians. No significant differences in the essential scores were found based on degree level, role of the employer or number of people employed in the organization. No significant differences in the essential scores were found based whether the organization currently required a bachelor’s or graduate degree or whether they expected to require a graduate degree in the future. 57 Table 6. Demographic characteristics of employers n %a 217 75.6% Community nonprofit 28 9.8% Educational setting (primary, secondary, university) 13 4.5% Government (federal, city, state, or local) public health 13 4.5% Corporate/industry settings (R&D, marketing, sales, etc.) 10 3.5% Communications and media 3 1.0% Self-employed consultation or private practice 3 1.0% Characteristics Work Setting Healthcare (hospital, long term care, physician network) Role Administration/management 148 53.6% Client care 45 16.3% Community/population health 40 14.5% Foodservice 37 13.4% 1 .4% Associate’s 4 1.4% Bachelor’s 111 37.5% Master’s 170 57.4% Doctorate 11 3.7% 268 96.8% DTR or NDTR 3 1.1% RN 4 1.4% MD 2 1.1% 3 years or less 24 8.1% 4 to 9 years 37 12.5% 10 to 20 years 70 23.6% 165 55.7% Research Highest Degree Held Credentials Held RD or RDN Years of Work Experience More than 20 years a In some cases, total n is greater than total number of responses and percentages total more than 100% as respondents were allowed to ‘select all that apply’ 58 Table 6. (cont.) Characteristics %a n Region of the Country Region 1 (AK, CA, HI, ID, MT, OR, WA, WY) 69 23.7% Region 2 (IA, MI, MN, MO, NE, ND, SD, WI) 24 8.2% Region 3 (AL, AR, FL, GA, LA, MS, PR, SC) 65 22.3% Region 4 (AZ, CO, KS, NV, NM, OK, TX, UT) 49 16.8% Region 5 (IL, IN, OH, WV, KY, TN) 39 13.4% Region 6 (DE, DC, MD, ND, PA, VA) 26 8.9% Region 7 (CT, ME, MA, NH, NJ, NY, RI, VT) 19 6.5% Less than 100 employees 23 7.8% 100-500 employees 51 17.3% 501-2,000 employees 75 25.5% 2,001-5,000 employees 63 21.4% More than 5,000 employees 82 27.9% 1 .3% 1-5 78 26.7% 6-10 43 14.7% 11-20 65 22.3% 21-30 22 7.5% More than 30 83 28.4% 167 56.4% 1-5 66 22.3% 6-10 18 6.1% 11-20 9 3.0% 21-30 1 .3% More than 30 9 3.0% 26 8.8% Size of Organization Number of RD/RDNs in Organization None Number of DTRs in Organization None Unknown 59 Table 7. Employer ratings of skills essential for future employment in nutrition and dietetics practice Skill n Mean a Std. Dev Professional Research and Practice Skills Engage in quality assurance and performance improvement activities 260 3.66 .542 Collect and interpret data for use in decision making and evaluation 259 3.46 .692 Lead efforts in health, food and nutrition policy development, implementation and evaluation 258 3.21 .821 Analyze, evaluate and critique scientific studies 260 3.18 .829 Perform data analysis 260 3.00 .854 Design, conduct, analyze and disseminate basic science, clinical and/or translational research 258 2.78 .879 Teamwork and Communication Skills Accurately communicate evidence-based information 259 3.77 .483 Participate in team decision making 258 3.72 .516 Use cross cultural skills effectively in communication 258 3.55 .611 Translate dietetics vocabulary across disciplines and in laymen terms 253 3.53 .614 Develops and uses a variety of media and technologies to communicate messages and education 257 3.49 .638 Lead transdiscplinary, interprofessional and/or interdisciplinary teams 257 3.44 .677 Employ strategies and facilitate team building 257 3.37 .696 Translate research into materials for consumers 257 3.30 .759 Clinical Client Care Skills a Assess nutrition status in clients with a variety of diseases and medical conditions 247 3.81 .442 Develop, monitor and evaluate nutrition interventions in clients with a variety of diseases and medical conditions 247 3.75 .541 Diagnose nutrition problems in clients with a variety of diseases and medical conditions 247 3.75 .541 Counsel clients with multiple diseases/medical conditions and those who require complex nutrition care using appropriate behavior change theories and techniques 247 3.71 .506 Prescribe and manage therapeutic diets (renal, cardiac, diabetes, phenylketonuria) 244 3.71 .559 Prescribe and manage enteral and parenteral nutrition 246 3.69 .641 scale: 1, not essential to 4, very essential for future employability in nutrition and dietetics practice 60 Table 7. (cont.) Skill n Mean a Std. Dev Clinical Client Care Skills (cont.) Interview clients for nutrition risk and diet history 245 3.60 .603 Provide nutrition care for clients who have multiple diseases/medical conditions and complex nutrition and health needs (e.g. palliative and hospice care, oncology, high risk pregnancy) 246 3.60 .575 Analyze food intake in clients with a variety of diseases and medical conditions 247 3.52 .674 Implement designated dietary interventions based on protocol 247 3.49 .680 Educate clients in health maintenance and disease prevention 243 3.48 .632 Assess individual’s physical, social and cultural needs 246 3.46 .697 Perform calculations for risk assessment following protocol 243 3.44 .698 Write nutrition orders for nutrition supplements, vitamins and minerals 245 3.42 .784 Counsel clients affected with disorders that are serious in nature, including eating disorders 246 3.40 .673 Apply integrative nutrition principles to nutrition care and Medical Nutrition Therapy (MNT), including the use of nutritional genomics, dietary supplements and/or herbal remedies 247 3.38 .760 Conduct nutrition focused physical exams as part of assessment 246 3.33 .800 identify sociological, psychological and environmental influences on eating behavior 246 3.32 .733 Order nutrition related laboratory tests 242 3.17 .883 Counsel clients on appropriate ways and methods to increase physical activity 245 3.14 .739 Manage nutrition related medication of clients 243 3.14 .830 Perform routine tests (e.g. finger prick for blood glucose, urine analysis) to assess and monitor clients’ nutrition and health status 242 2.54 .994 Community and Population Health Serve as a nutrition resource for community organizations 245 3.34 .750 Provide nutrition and lifestyle education to well populations 241 3.27 .783 Design and implement culturally appropriate nutritional initiatives and programs 240 3.10 .852 Interpret and use national nutrition surveillance data and population• based statistical data 242 3.05 .790 Interpret basic population based statistical data 239 3.05 .782 61 Table 7. (cont.) Skill n Mean a Std. Dev Community and Population Health (cont.) Convene and mobilize community partnerships and coalitions to identify and solve food, nutrition and/or health related issues by building on community assets and focusing on policy, systems and environmental strategies 237 2.95 .874 Assess the need to develop and implement a community or population health program and/or intervention considering biological, behavioral, psychological, social, economic, policy and/or environmental factors 239 2.94 .868 Develop and evaluate policies, laws and regulations that address and protect health and nutrition for individuals and populations 240 2.85 .882 Conduct culinary demonstrations to teach cooking skills, safe food handling practices and promote consumption of healthy foods 242 2.77 .913 Food and Foodservice Systems Skills Develop menus and standardized recipes for diverse groups for normal and therapeutic diets applying principles of menu planning and knowledge of medical nutrition therapy and therapeutic nutrition 243 3.33 .781 Complete nutrient analysis of food products, recipes and menus 243 3.30 .759 Conduct operational analyses and streamline operations to reduce costs while ensuring health related goals are not compromised 242 3.21 .899 Manage production and service of food that meets nutrition guidelines, cost parameters and health needs 243 3.16 .892 Plan and implement food safety and sanitation programs 240 3.16 .942 Teach others how to prepare healthy foods using knowledge of food science and culinary techniques 241 3.10 .836 Manage food distribution and service ensuring accuracy, quality and portion control 242 3.05 .950 Evaluate purchasing needs and develop specifications for food and equipment 239 2.92 .953 Negotiate purchases and contracts for products and services 240 2.75 1.024 62 Table 7. (cont.) Skill n Mean a Std. Dev Leadership, Management and Organizational Skills Lead process improvement activities to improve delivery of food and nutrition services 245 3.48 .761 Demonstrate conflict resolution and mediation skills 241 3.35 .771 Manage staffing functions such as interviewing, hiring, motivating, supervising, evaluating and terminating employees 243 3.35 .776 Develop operational policies, procedures, job descriptions, work schedules and performance standards 244 3.32 .778 Conduct employee performance evaluations and counsel employees for performance improvement 242 3.27 .805 Adjust operations based on financial performance 243 3.25 .898 Identify opportunities for increasing revenue 242 3.20 .913 Develop emergency preparedness plans for facilities, patients/clients and/or communities 243 3.07 .854 Direct strategic planning 243 3.07 .909 Develop operational and capital budgets 243 3.05 .937 Develop business plans to sell ideas and turn ideas into action 243 3.03 .955 Advocate for changes in policies to improve access to food and nutrition services for the public 242 3.03 .940 Lead initiatives to improve use of sustainable practices in food and nutrition services 242 2.99 .942 Develop, implement and evaluate marketing plans for new products, programs and services 243 2.96 .974 63 Table 8. Skill set essential scores n Mean a Std. Dev Teamwork and Communication Skills 259 3.52 .389 Clinical Client Care Skills 248 3.44 .444 Professional Research and Practice Skills 262 3.25 .465 Leadership, Management and Organizational Skills 246 3.17 .682 Food and Foodservice Systems Skills 243 3.11 .727 Community and Population Health Skills 246 3.03 .661 Skill Set a scale: 1, not essential to 4, very essential for future employability in nutrition and dietetics practice 64 Table 9. Comparison of employer mean essential scores based on demographic data Skill Seta Characteristic Research Client Care Community Teamwork n Mb ± SD n Mb ± SD n Mb ± SD n Mb ± SD Leadership n Mb ± SD Foodservice n Mb ± SD Setting Healthcare Education Community Government Corporate Communications Self Employed 191 12 24 12 10 2 2 3.26 ± .464 3.34 ± .423 3.06 ± .469 3.17 ± .457 3.40 ± .367 3.36 ± .909 3.64 ± .101 182 12 23 12 9 1 2 3.49 ± .381x 3.13 ± .850y 3.39 ± .569xz 3.32 ± .414z 3.21 ± .545z 3.90 3.20 ± .096z 176 12 22 12 10 2 2 2.99 ± .666 3.10 ± .489 3.25 ± .499 3.06 ± .750 3.67 ± .157 3.67 ± .157 3.17 ± .393 188 12 24 12 10 2 2 3.51 ± .384 3.53 ± .413 3.49 ± .443 3.50 ± .392 3.48 ± .337 3.94 ± .008 3.87 ± .177 178 12 21 12 10 2 2 3.18 ± .669 3.32 ± .790 3.02 ± .587 3.11 ± .729 3.12 ± .732 4.00 ± .000 3.79 ± .303 177 11 21 12 9 2 2 3.13 ± .654 3.29 ± .910 3.07 ± .906 2.85 ± 1.10 2.93 ± .752 3.16 ± .403 2.94 ± .550 Level of Education Associate Bachelor’s Master’s Doctorate 4 101 147 10 3.21 ± .247 3.28 ± .433 3.25 ± .476 3.08 ± .676 4 98 136 10 3.58 ± .542 3.44 ± .506 3.45 ± .391 3.35 ± .489 4 94 136 10 3.14 ± 1.01 3.03 ± .649 3.03 ± .670 2.94 ± .620 4 102 143 10 3.28 ± .329 3.52 ± .389 3.54 ± .367 3.26 ± .605 4 95 136 10 3.36 ± .707 3.13 ± .636 3.22 ± .689 2.76 ± .913 4 95 134 9 3.25 ± .618 3.16 ± .751 3.09 ± .702 2.70 ±.870 23 31 63 145 3.30 ± .455 3.25 ± .432 3.19 ± .508 3.27 ± .456 23 26 57 142 3.58 ± .636 3.42 ± .477 3.37 ± .493 3.46 ± .374 23 29 55 137 3.38 ± .556y 3.10 ± .670z 3.02 ± .602z 2.96 ± .686z 23 30 63 143 3.62 ± .335 3.47 ± .435 3.42 ± .421 3.55 ± .366 22 29 56 138 3.38 ± .492 2.99 ± .593 3.06 ± .725 3.22 ± .698 22 28 55 137 3.42 ± .636x 2.86 ± .759y 3.04 ± .815z 3.14 ± .683z 2.98 ± .633 3.13 ± .735 3.04 ± .696 3.20 ± .600 2.89 ± .385 132 38 31 35 4 3.53 ± .369 3.56 ± .384 3.54 ± .399 3.47 ± .456 3.22 ± .524 124 37 29 32 4 3.15 ± .670 3.27 ± .711 3.36 ± .574 2.96 ± .672 3.14 ± .883 122 37 29 32 3 3.11 ± .679 3.30 ± .612 3.28 ± .620 2.86 ± .982 3.00 ± .667 Years of Work Experience 3 or less 4-9 10-20 More than 20 Position Administration Client Care Foodservice Community Education 133 40 31 35 4 3.26 ± .450 3.25 ± .490 3.42 ± .419 3.09 ± .493 3.07 ± .429 126 37 29 33 4 3.46 ± .406 3.55 ± .333 3.44 ± .576 3.44 ± .576 3.48 ± .422 124 37 28 33 4 a Skill Sets include: professional research and practice skills; clinical client care skills; community and population health skills; teamwork and communication skills; leadership, management and organization skills; and food and foodservice systems. b Scale: 1, not essential to 4, very essential; values within a characteristic column grouping with dissimilar superscript letters (x,y,z) differ significantly (p<.05). 65 Table 9. (cont.) Characteristic Research n Ma ± SD Client Care n Ma ± SD Skill Seta Community Teamwork a n M ± SD n Ma ± SD Leadership n Ma ± SD Foodservice n Ma ± SD Organization Size <100 employees 100-500 501-2,000 2,001-5,000 >5,000 18 44 67 58 73 3.34 ± .432 3.24 ± .459 3.16 ± .462 3.31 ± .446 3.27 ± .498 16 39 66 54 71 3.39 ± .356 3.41 ± .537 3.38 ± .523 3.53 ± .336 3.48 ± .394 17 40 63 53 69 3.18 ± .676 3.26 ± .590 3.38 ± .523 3.53 ± .336 3.48 ± .394 19 42 67 56 73 3.56 ± .315 3.51 ± 3425 3.50 ± .419 3.55 ± .358 3.50 ± .385 17 39 64 53 70 3.21 ± .626 3.28 ±.702 3.15 ± .694 3.15 ± .692 3.12 ± .676 16 39 64 53 69 3.06 ± .539 3.31 ± .679 3.12 ± .840 3.04 ± .720 3.05 ± .686 Number of RDNs 1-5 6-10 11-20 21-30 >30 69 38 60 16 74 3.27 ± .463 3.18 ± .395 3.33 ± .533 3.35 ± .430 3.19 ± .441 63 36 56 15 73 3.47 ± .476 3.36 ± .438 3.50 ± .361 3.53 ± .377 3.42 ± .486 63 35 56 14 71 3.19 ± .387 2.87 ± .582 3.04 ± .683 2.85 ± .594 3.00 ± .670 69 36 59 16 74 3.49 ± .395 3.51 ± .323 3.55 ± .435 3.53 ± .321 3.53 ± .377 65 35 55 15 71 3.33 ± .693 2.90 ± .713 3.17 ± .722 3.10 ± .621 3.15 ± .621 64 35 55 15 69 3.33 ± .664x 2.89 ± .820y 3.15 ± .640y 2.93 ± .739y 3.01 ± .752y Currently Require Bachelor Degree Yes No 220 24 3.27 ± .465 3.24 ± .429 218 25 3.46 ± .412 3.37 ± .582 218 25 3.02 ± 0674 3.13 ± .571 219 26 3.51 ± .399 3.58 ± .318 221 25 3.16 ± .689 3.29 ± .618 219 24 3.09 ± .739 3.25 ± .594 Currently Require Graduate Degree Yes No 70 173 3.24 ± .495 3.27 ± .446 70 172 3.45 ± .457 3.45 ± .423 71 171 2.99 ± .712 3.05 ± .645 70 173 3.52 ± .461 3.51 ± .361 71 174 3.16 ± .721 3.18 ± .669 71 171 3.04 ± .720 3.13 ± .730 Expect to Require Graduate Degree Yes No 75 82 3.34 ± .490 3.23 ± .439 73 83 3.52 ± .406 3.46 ± .419 75 81 3.16 ± .619 3.04 ± .687 73 84 3.59 ± .429 3.48 ± .372 75 84 3.20 ± .763 3.17 ± .682 72 84 3.05 ± .759 3.17 ± .761 66 COMPETENCY GAP ANALYSIS By Leanne Worsfold, RN, iComp Consulting PURPOSE The purpose of this project was to gather information from educators, preceptors, practitioners and employers and determine whether there were gaps in the competencies required in the current 2012 ACEND® program accreditation standards for each program type (didactic program in dietetics, dietetic internship program, coordinated programs in dietetics and dietetic technician program). METHODOLOGY Open-ended and probing questions were used to gather feedback from participants in four focus groups regarding the identified gaps and required enhancement to the competencies in an effort to determine the minimum expectation of the student entering current and future practice in nutrition and dietetics. RESULTS A total of 12 educators, 9 practitioners (several of whom were employers) and 6 preceptors participated in the two hour long focus groups. Several themes emerged from the discussions: Master’s level education for RDNs was well supported; a need for more time for application of knowledge and demonstration of skills (practical experience) in the programs; inconsistency in the programs and internship expectation; undergraduate program must include transferable skills for other professional direction (e.g. leadership, business, management); graduate level could offer specialization and the need for an increased number of RDNs teaching the programs; and concerns with students obtaining internship placements and inconsistency with internship expectations. The findings addressing specific gaps in competencies are detailed in Table 10. 67 Table 10. Gaps in competencies in 2012 ACEND Accreditation Standards Domain Perceived Gaps in Competencies Scientific and Evidence Base of Practice: integration of scientific • • • • • • • Interpretation of research and basic terms Syntheses and analysis of information Critically evaluate research Interdisciplinary research focus Communications skills related to knowledge transfer Use of technology (database) Submission of Institutional Review Board forms – graduate level • • • • • Cultural communications Written and verbal communication skills Determinates of health and diversity Health law – add application of applicable legislation Motivational interviewing • • • • • • • • • Knowledge of medical terminology Critical thinking and decision-making Cultural care Industry/business competencies Food preparation and culinary skills Population health focus – graduate level Supply chain management (more than just procurement) Sustainability, recycling and waste (aeroculture and globalization) Medical Nutrition Therapy – intervention/treatment • • • • • • • • Psychology Anatomy Epidemiology - graduate level General management and business principles (e.g. economics) Ethics – health related Math skills Critical thinking Food preparation indicators (move to another unit) information and research into practice Professional Practice Expectations: beliefs, values, attitudes and behaviors for the professional dietitian level of practice. Clinical and Customer Services: development and delivery of information, products and services to individuals, groups and populations. Support Knowledge: knowledge underlying the requirements specified above. 68 STAKEHOLDER INPUT ON FUTURE MODEL RECOMMENDATIONS By Christopher Buonincontri, MA EXECUTIVE SUMMARY Findings from the content analysis of the ACEND Education Model Feedback Survey are presented. Resultant themes varied widely, though more concerns were expressed than benefits. The most common perceived benefits of the proposed model were increased prestige among dietitians, elevation of the field to match the requirements of peer professions, increased knowledge and skill, and new career pathways. Prime concerns included compensation issues, job and internship availability, lack of justification for new requirements, cost to students and institutions, blurred delineation between levels, and adverse impact. Considerations and limitations based on the nature of the data are briefly discussed. A Frequently Asked Questions (FAQ) document to address questions and concerns in included in Appendix E PURPOSE The purpose of this project was to gather information from various stakeholders to determine reactions to the recommended future education model. METHODOLOGY ACEND® conducted an online survey to gather stakeholder comments related the recommended future model for an associate’s degree program for community nutrition and health assistants, a bachelor’s degree program for nutrition and dietetics technicians, and a master’s degree for dietitian nutritionists. A copy of the questionnaire is included in Appendix F. A total of 7,366 comments were reviewed; 3,671 from (50%) nutrition and dietetics practitioners, 2,150 (30%) from educators, 688 (9%) from students/interns, 460 (6%) employers, and 397 (5%) education or healthcare administrators. Responses were assigned codes and grouped together, listed under either Benefits or Concerns within one of four topics: the Master’s Degree for Dietitian Nutritionist, the Bachelor’s Degree for Nutrition and Dietetics Technician, the Associate’s Degree for Community Nutrition and Health Assistant (now termed Nutrition Health Worker), or the entire model. Major and minor themes were identified, with “major” defined as 25 or more weighted responses, and “minor” as between 5 and 25 responses. General “perceived strengths,” “concerns,” and “additional comments” were coded distinctly at first but later grouped in with the first three topics, as all significant themes identified under them were redundant with those previously listed. Groupings were re-analyzed and subdivided or consolidated as more and more data was reviewed (deductive and inductive analysis). Given that the overall response rate was much higher among the “Educator of Nutrition and Dietetics Practitioner” and “Nutrition and Dietetics Practitioner” groups, it was necessary to include weighted adjustments when comparing response prevalence per theme. Despite this, the small sample sizes of the “Healthcare Administrator” and “Education Administrator” groups all but precluded identification of any themes. Additionally, it is difficult to say whether themes associated with Educators and Practitioners are truly specific to those groups or would otherwise have been emphasized by other groups as well. 69 Sample bias may have colored the results obtained from this survey. Many of the responses were emphatic and polarized, indicating that only those with strong opinions participated—a large number of others who may have been pleased or unconcerned with the proposed changes may simply have not bothered to complete the survey. Other unknown factors may also have limited the sample of respondents, though this is impossible to ascertain without additional information. Additional biases may have affected results, including response bias stemming from elements or cues within the preceding webinar. Some respondents also expressed confusion and misunderstanding of the material presented. RESULTS Overview of Findings The responses analyzed were thoroughly mixed in terms of opinion, level of detail, and enthusiasm. The majority included concerns instead of benefits, and many focused on the master’s degree prepared dietitian nutritionist rather than the bachelor’s degree prepared nutrition and dietetics technician or the associate’s degree prepared community nutrition and health assistant (now termed nutrition health worker), positions. Concerns were generally lengthier and expressed in more detail than perceived benefits. The most popular themes were often counterbalanced by less popular, complementarily opposing ones (e.g. predictions that salaries would increase versus others predicting they would not). The most salient theme by far was concern for compensation levels, and the negative impact (or lack of positive change) the model would have in this regard. This was part of a larger monetary concern including cost of education; increased costs without future return on investment was predicted to lead to loss of talent and fewer dietitian nutritionists overall, raising additional concerns over adverse impact (the field would be limited to “affluent white women”). Respondents also suggested that current low levels of job and internship availability would be exacerbated by implementation of the model. The most cited benefit of the new master’s requirement was increased respect by other allied healthcare professions. Many alluded to these other fields as having set a necessary precedent, and encouraged dietetics to follow suit. The anticipated education requirements were viewed as a benefit to many, elevating the expertise throughout the field; others claimed they are unnecessary, and that experience is more valuable than time in the classroom. Some stated that master’s level practitioners should be specialized instead of “generalists,” and a few suggested doctoral degree prepared as specialists in addition to the proposed model. Educators expressed concern over implementation at their institutions, referencing high cost and a dearth of qualified instructors. Competition among the three new roles was a recurring concern, related to employer (and public) confusion as to what the different skill sets and requirements of each would be. Lack of clarity raised the issue of job creation/availability, and employment of newly available under-qualified individuals (which would cost employers less) instead of Registered Dietitian Nutritionists (RDN). Respondents called for increased marketing efforts in an effort to solve this problem. Critics predicted dilution of the field and reliance on inadequate expertise. Some saw the overall model as beneficial, providing new roles that would fill identified needs and job 70 demand, as well as a logical career pathway. More, however, doubted that this would be the case, predicting competition between roles, friction between professionals with the same position but different levels of education and experience, and many of the issues previously mentioned. Difference in response prevalence among stakeholders is noted below each description. Master’s Degree for Dietitian Nutritionist Benefits (Major Themes) Respect, Credibility, Prestige. The most prevalent benefit noted was the increased credibility gained by a master’s degree requirement. Respondents indicated that other healthcare professions do not respect them as experts in the field, and that elevating the profession by mandating higher education would rectify this. Emphasized by all groups, especially Students. Comparison with Other Fields. Highly related to the theme above, many respondents cited effectiveness of similar models in other healthcare professions, particularly nurses and physical therapists. Emphasized by Educators, Employers and Practitioners. Increased Knowledge. Respondents indicated that a broader level of knowledge would be a beneficial product of the new degree requirement. Emphasized across all groups. Specific Graduate Degree Skills. Responses included certain skills that graduates would gain from a master’s level education. Most commonly mentioned were research skills, followed by critical thinking skills, management skills, and communication skills. Emphasized by Educators and Practitioners. Increased Salaries. A significant number of respondents anticipated higher salaries following the master’s requirement. It should be noted that more responses indicated doubts that this would be the case. Emphasized by Practitioners, Students and Educators. Benefits (Minor Themes) Reduce Crowded Field. Some respondents indicated that the new master’s degree requirements would “reduce the influx of RDNs,” regulating some of the high demand for jobs and internships and, in turn, possibly leading to higher salaries in the long run. Interestingly, an almost equal number of responses predicted negative consequences of this outcome. Emphasized by Practitioners. PhD Recommended for Specialists. A portion of participants who applauded the current model recommended that a doctoral degree be required for specialists in the field, following the example of other healthcare professions (e.g. physical therapists). Emphasized by Educators, Practitioners. Concerns (Major Themes) Compensation Issues. The most common theme among concerns of the new model centered on compensation issues: that is, worries about current and future salary levels. Respondents expressed doubts that salaries would increase commensurate with higher qualifications, as well as expressing dissatisfaction with current salary levels. Heavily coinciding with “Cost of Degree,” the two themes combine into an overarching concern for Return on Investment of the degree. Some also cited concern over lack of reimbursement under the current model, which may not improve (or worsen) post-changes. 71 Emphasized across all groups. Cost of Degree. Both the expense and time required for the master’s concerned a large portion of respondents. Emphasized across all groups. Adverse Impact. Concerns that higher education requirements would prevent minorities from entering the field were most common for the master’s degree section. Predictably, these responses highly coincided with concerns over the cost of the degree. The dietetics field was repeatedly cited as being dominated by white women. Concerns that the requirements would deter men from the field were also expressed, though much less common. Emphasized by Educators, Practitioners. Educational Institution Concerns. These concerns centered on problems with implementation of the new master’s program at educational institutions. The most common concerns were availability of qualified instructors at the doctoral level and available funds. Additional concerns included: impact on existing undergraduate programs, institutional buy-in, closure of programs, and time required for implementation. Emphasized almost exclusively by Educators, Educational Administrators. Job Availability. Respondents expressed concern that there would be low demand for the new master’s degree position as described. Many also indicated that, as the new position would demand a higher salary, employers are likely to hire less qualified (i.e. bachelor degree) job candidates instead. Emphasized most by Employers, Practitioners. Diluting the Field. Responses related concern that requiring a generalist master’s degree would both devalue current practitioners at the master’s level, and water down the degree (related to concern that the degree should be specialized instead of general). Institutions would be forced to condense too much material into a two year curriculum. Emphasized most by Educators, and some Practitioners. Internship Availability. Many expressed concern that the already scarce number of internships would be in even higher demand under the new model. Some decried use of distance internships, and worried that widespread use of this would allow unqualified professional into the field. Emphasized most by Educators. 72 Concerns (Major Themes) (cont.) Master’s Unnecessary. The concerns expressed under this category represented a number of interrelated subthemes. Primary among them, respondents indicated that a master’s level professional should specialize in a particular area rather than work as a generalist, which is appropriate for the bachelor’s level. Specialization would make the position more attractive to employers. Some raised concerns that the master’s degree and bachelor’s degree prepared RDNs would essentially be the same. It was noted that the general nutrition master’s degree would be appropriate for those changing careers, though these individuals may be less qualified without the foundation of the bachelor’s degree. Emphasized by Educators, Employers, Practitioners, Students. Another concern regarded the value of experience over education. One respondent put it succinctly: “a Bachelor’s degree with experience is more beneficial than a Master’s degree.” Many cited the internship as more “valuable” than the master’s degree. Some indicated that higher-level education is only needed for some RDN positions and not others; others claimed that needed skills, such as management skills, would not be provided by master’s training. Emphasized by Educators, Employers, Practitioners. Concerns (Minor Themes) Fewer Dietitians. Related to adverse impact, participants expressed concern that the new requirements would reduce the number of practitioners overall, pushing qualified students to pursue other career paths with better return on investment. Emphasized by Educators, Practitioners. Premature Career Choices. Respondents raised concern as to whether it is wise to force students to begin their master’s without having experience in the field first. Many stated that students should not be faced with the decision of what to specialize in straight out of their undergraduate program, as they would be less likely to make informed decisions that early in their career. Some also suggested that it would be better to mandate a master’s degree while working in the field (i.e. within five or ten years), following other professions’ examples. Emphasized by Educators, Practitioners, Students. Title / Branding. Many responses indicated concern that the new title itself would both confuse the public and undermine the value of the position. Emphasized by Educators, Practitioners, Students CUP. Some respondents suggested incorporation of Coordinated Undergraduate Programs, citing their effectiveness. Emphasized by Employers, Practitioners. Degrees in Other Fields. A small but significant number of responses indicated concern with accepting individuals with master’s degrees in unrelated fields into programs, some adding that prerequisites should be mandated. Relatedly, others were confused as to whether such individuals would be accepted under the new model. Emphasized by Employers, Practitioners. Marketing Importance. This was cited with regard to all three roles, and the model in general. Respondents stressed the importance of clearly defining and marketing the roles to employers, affiliates and the public. Emphasized by Educators, Employers, Practitioners. 73 Concerns (Minor Themes) (cont.) Degree Creep. Participants described the current situation using the term “degree creep,” or the practice of requiring higher-level degrees for the same job. This was repeated with regard to the other positions as well. This is related to concerns over increased cost to student, adverse impact and restricting overall number of dietitians in the field. Emphasized by Employers, Healthcare Administrators, Practitioners, Students. Bachelor’s Degree for Nutrition and Dietetics Technician Benefits (Major Themes) Additional Career Options. Respondents cited a wider array of possible career options, due to the new positions, as an important benefit of the new model. The bachelor’s degree nutrition and dietetics technician position would be available to those who either could not or do not want to pursue an internship. Additionally, it would serve as another step in the “career ladder” within the field. Emphasized across all groups. Increased Knowledge. Similar to the theme identified regarding the master’s requirement, participants stated more knowledge and higher general skill level would be a positive move for the profession. Emphasized by all groups. Benefits (Minor Themes) Increased Salaries. Similar to those indicating that the new master’s requirement would correspond to increased salaries, some stated that the new bachelor’s degree would lead to higher compensation. Emphasized across all groups. Bachelor’s Requirement is Appropriate. Respondents indicated that the degree requirement is generally appropriate given the nature of the role. Emphasized by Educators, Practitioners, and especially Students. Better Support for RDNs. Survey participants suggested that bachelor’s degree nutrition and dietetics technician would provide better quality support for dietitians. Emphasized by Employers, Practitioners. Compensation Issues. Responses regarding compensation issues described in the master’s section above were echoed for this position. Some indicated that the bachelor’s degree would make nutrition and dietetics technicians (identified by many as highly similar to current DTRs) overqualified for the low pay they would receive. Emphasized by Educators, Employers, Practitioners, Students. Job Availability, Hiring Issues. Many listed concerns that employer demand for the bachelor’s degree nutrition and dietetics technician would be low for various reasons. Some cited that facilities would not have the budget to include both an NDTR and RDB: thus, either NDTRs will not be hired, or will be brought on to replace RDNs. Emphasized by all groups. 74 Concerns (Major Themes) Competitions Between Roles. Related to the hiring issues noted above, competition among the new roles was a prevalent concern among responses. Apart from competition with RDNs, some were concerned that entry-level nutrition and dietetics technicians would compete with current NDTRs, eventually phasing out the profession altogether. Emphasized across all groups. Name / Branding. Respondents expressed concerns over the name of the new position (“technician” was widely cited as inappropriate for a bachelor’s degree holder). Additionally, the name and defined role were described as potentially confusing to the public and potential employers. This is related to concern over employers hiring lower level positions, who may be more likely to hire less expensive candidates if unclear regarding the expertise and function of the various new roles. Emphasized by all groups. Cost of Degree. Highly related to compensation issues, and thus concern with overall return on investment of degree. Emphasized across all groups. Same as Current DTR. Related to degree creep, many indicated that the bachelor’s level nutrition and dietetics technician position as described would be the same as the current NDTR role. Others stated that a two-year degree was satisfactory preparation for this new role, as it is for the NDTR currently. Generally, there was some confusion regarding the bachelor’s level nutrition and dietetics technician position job description, especially set alongside current RDNs and NDTRs (related to “competition among roles,” above). Emphasized across all groups Concerns (Minor Themes) Independence from RDNs. Concern was expressed as to whether bachelor’s level NDTRs would work independent of RDN supervision. Some thought this should be mandated, though others indicated scope of responsibilities would vary by setting, circumstance, etc. Emphasized by Educators, Practitioners. Supervised Practice Availability. Respondents were concerned with preceptor availability for supervised practice at this level, considering the current shortage. Emphasized by Educators, Practitioners. Degree Creep. Participants described the current situation using the term “degree creep,” or the practice of requiring higher-level degrees for the same job. This was repeated with regard to the other positions as well. This is related to concerns over increased cost to student, adverse impact and restricting overall number of dietitians in the field. Emphasized by Employers, Healthcare Administrators, Practitioners, Students. Diluting the Field. Concern was expressed that bachelor’s degree nutrition and dietetics technicians would replace RDNs in many settings, thus comprehensively lowering the qualifications of the dietetic workforce and weakening the profession. Emphasized by Educators, Practitioners. 75 Associate’s Degree for Community Nutrition and Health Assistant (now termed Nutrition Health Worker) Benefits (Major Themes) New Role in Career Ladder. Respondents stated this would be a beneficial addition to the dietetics career ladder for a number of possible reasons, including creation of more jobs, opportunities for lowerlevel graduates, and a pipeline to bolster the field overall. Emphasized across all groups. Increased Knowledge. Many respondents indicated that the new education requirements are appropriate for the position. Emphasized by Practitioners. Benefits (Minor Themes) Provide Needed Services. Respondents suggested that the new community nutrition and health assistant (CNHA) role would provide much needed services, and thus serve as a beneficial addition to the model. Examples included work in healthcare settings (conducting preliminary health screenings), in food service systems, with WIC, and in schools. Emphasized by Educators, Practitioners. Concerns (Major Themes) Role Clarity. Survey participants expressed concern and confusion as to the definition of this role, in terms of what the job would look like in practice and what skill sets incumbents would have. Emphasized across all groups. Title / Branding. Respondents were concerned that the CNHA title was “degrading.” The term “assistant” is commonly used for those without degrees, and AS degree holders would be appropriately titled “technicians.” Many others cited the title as “confusing” and “cumbersome.” Emphasized by Educators, Practitioners. Diluting the Field. Respondents expressed concern that the role itself was “diluted,” and that inclusion of a professional at this level would have a negative impact on RDNs and “water down the profession.” This is related to scope of practice, and delineation/competition between roles. Emphasized by Educators, Employers, Practitioners. Too Many Levels. Respondents indicated that inclusion of the CNHA position would bring too many levels to the dietetic career structure, confusing the public and employers as well as fostering competition among the newly created roles. Emphasized most by Practitioners. Job Availability. Many participants related concerns that there would be no demand among employers for the new position. Emphasized across all groups (except Healthcare Admins). Compensation Issues. Corresponds to theme described above in the master’s section. Emphasized across all groups, especially Practitioners. 76 Concerns (Minor Themes) Competition Between Roles. Participants expressed concern that positions would compete for scarce jobs: some believed that it would be difficult for CNHAs to compete with bachelor’s degree holders, but most asserted that CNHAs would take the jobs of more qualified professionals as employers tried to cut costs. This is highly related to job availability. Emphasized by Educators, Practitioners, Students. Role Should Require Bachelor’s. Respondents indicated that the CNHA role should require a four-year degree. Sending professionals with lower qualifications into the field to educate the public would serve to disseminate misinformation in an already largely misunderstood field. Others thought it would be better to require certification or licensure instead. Emphasized by Educators, Employers, Practitioners, Students. RDN Supervision. Some concern was noted regarding whether CNHAs would be under RDN supervision, for reasons similar to why others expressed they should need a Bachelor’s degree (see above). 77 ADDITIONAL INFORMATION GATHERED IN THE DEVELOPMENT OF THE FUTURE EDUCATION MODEL STANDARDS AND COMPETENCIES Associate Degree Nutrition Health Worker Assessment of the 2012 ACEND® Accreditation Standards 78 ASSOCIATE DEGREE NUTRITION HEALTH WORKER By Leanne Worsfold PURPOSE In February 2015, ACEND® released recommendations for the future education of nutrition and dietetics practitioners. That model included a recommendation for an associate’s degree prepared practitioner initially titled, community nutrition assistant. After release of the document, many questions were raised about the type of work this practitioner would do. The purpose of this project was to collect additional data to better understand the possible role of an associate’s degree prepared nutrition and dietetics practitioner in a community setting. METHODOLOGY Consultant, Leanne Worsfold, conducted two focus groups with 17 registered dietitian nutritionists (RDN) who worked in community and population health to explore the current role and responsibilities of nutrition and dietetic professionals working in community and population health positions. In addition, she conducted two structured, in-depth interviews with two individuals who have provided leadership to community health initiatives: Carl Rush, MRP, who provides leadership for the Project on Community Health Worker (CHW) Policy and Practice at the University of Texas Institute for Health Policy and Laura Bahena, who is on the American Public Health Association CHW Governing Council and works for the Illinois Department of Public Health Office of Minority Health. The interviews explored the roles and responsibilities of the community support worker (CSW) and discussed the future role and responsibilities of the potential community nutrition assistant. RESULTS Focus Groups Focus group participants discussed distinctions between the community and population health RDN prepared at the baccalaureate and master’s level. Participants described how community support workers are utilized in communities such as Native American and Hispanic communities as peer support workers. The anticipated roles and responsibilities and competence needed were identified. Anticipated Roles and Responsibilities for Community Support Worker Focuses on health promotion and monitoring plan of care Works in collaboration with and under the supervision of RDNs (with Masters level) Demonstrates food preparation skills Provides support for the elderly, older adult, child and maternal health groups Assists with diabetic education programs and school-based education Builds relationships in the community Collects basic assessment data (Hemoglobin, BP, blood glucose level, weight) 79 Skills Needed education principles geriatric and pediatric health communication skills culinary skills knowledge of special diets menu planning physiology and disease states safe food preparation and storage food insecurities Structured Interviews Participants in the structured interviews stressed that the effectiveness of the role of the community worker is based on the community relationship and social and economic balance. These workers were described as being most effective when they resided within the local community and were able to share life experiences. Many individuals in this role see it as a "calling" versus a job or a profession. The main role for the community worker was thought to be providing support for compliance, acceptance and management of nutritional, physical and mental health concerns for health promotion. The role and the training for this practitioner currently is not standardized and can range from a high school diploma (for the most part) to a certificate or AA in a health related field. Anticipated Roles and Responsibilities for Community Support Worker Creates a positive experience and relationship with the client Acts as a patient and community advocate Counsels and assists clients to deal with personal and social problems Keeps the client out of the hospital by supporting regular visits to their primary physician Keeps clients actively engaged with their primary physician Supports the client to ensure pick-up of their prescription medications Proactively engages the client to manage their care Provides client education using predefined and pre-developed learning plans and education materials Supports transitions of care Helps to keep clients compliant with their care plans Partners with care team (community, providers, internal staff) Is knowledgeable and continues learning of community cultures and values Conducts assessments using standardized templates Offers information and resources Supports development of education materials Undertakes activities to enable people to address their own health and well-being needs consistent with the plan of care Facilitate and encourages the development of skills in the following areas: activities of daily living, interpersonal coping, socialization, & community functioning Supports the individual and the family in crisis situations; provides personalized interventions to develop, facilitate, or enhance an individual's ability to make informed and independent decisions 80 Facilitates self-motivational skills Conducts assessments of the environment Monitors plans of care Collects assessment data - weight, BMI, gait assessment, activity level Engages client in motivation interviewing Monitors diabetes management - blood glucose level, education Collects research data Skills Specific to Nutrition and Dietetics very practical skills focused on food and meals versus nutrients and nutrition grocery store tours culinary skills dietary monitoring counseling, coaching and motivation skills informing and enabling outreach label reading recipe sharing Skills Needed advocacy skills health systems and structure/ community agencies cultural influence, values and beliefs behavior change, counseling theories and interviewing skills determines of health and impact on care and the community life-span psychology and developmental problem solving skill professional behaviors and therapeutic relationship communication skills presentation skills learning process mentoring and coaching motivational learning and behavioral change basic dietary needs food labels knowledge of food insecurities and how to access resources (food banks, food stamps, energy assistance programs) physical activity 81 inter-professional care and understanding of the role and responsibilities of axillaries and allied health professions chronic disease management (CHF, diabetes, heart disease) maternal-child health policy development and government legislative structure documentation environmental and basic client assessment Use of Community Health Workers United Kingdom Dietetic Support Workers usually work under the close supervision of a dietitian in either a community or hospital setting. A dietetic support worker working in a hospital may, for example, be involved in assisting patients requiring special diets to choose from the hospital menu, collecting information regarding patients' intake and weight and liaising with the dietitian regarding patients' progress. Within a community setting, dietetic support workers may work with the dietitian to assess the food and health needs of local residents and assist in enabling people to eat a healthier diet to prevent disease. Support workers usually start their career with little formal training or experience. They are required to have a good standard of English and math with excellent communication skills and qualifications could include relevant General Certificate of Secondary Education, National Vocational Qualification or Scottish Vocational Qualification. Many have some experience working in a patient, community or care environment, so for example, in a care home, school or voluntary organization, catering or in a hospital. Assistant Practitioners in Dietetics deliver elements of delegated dietetic care. They are usually educated to Foundation Degree level or equivalent and normally work at a level above dietetic support workers. However, each role varies depending on the post and also the title used to describe posts varies. Canada Community Support Workers interview, counsel, and assist clients to deal with personal and social problems. They may also organize and implement a variety of community programs and services. Individuals in this role may be responsible for preparing intake reports, referring clients to other social services, admitting clients to appropriate programs, and meeting with clients to evaluate treatments/plans and progress. The CSW program provides students with the necessary knowledge and practical skills to provide many types of assistance to people in the community. Areas of study include addictions, psychology, sociology, mental health, Canadian family dynamic, professional skills, counselling and interviewing techniques, development, business communications and report writing. United States of America A variety of terms are used to describe the community worker position in the US including community support worker (CSW), community health worker, and promotoras. There is no set curriculum at this time for the CSW but various groups such as the American Association of Diabetes Educators and US Cooperative Extension System have participated in projects to create curriculum for CSWs. Community Support Worker education program hours range from 20 - 160 hours with practice experiences. The states of Massachusetts, New York, Illinois and Virginia are seeking state licensure and Maine seeking title protection of Community Health Worker. Currently ongoing individual credentialing is not required as risk to public is perceived as being 82 low. Many see the potential to see a large increase demand for CSW from insurance companies due to the Patient Protection and Affordable Healthcare Act. CHANGES TO RECOMMENDED FUTURE MODEL OF EDUCATION IN NUTRITION AND DIETETICS After reviewing results of the data collected, the ACEND Board affirmed its support of the recommendation for an associate’s degree prepared nutrition and dietetics practitioner who would provide support in the community setting. The ACEND Board chose to change the name of the associate’s degree prepared practitioner to the Nutrition Health Worker to make it more consistent with titles used for community support personnel. 83 ASSESSMENT OF THE 2012 ACEND® ACCREDITATION STANDARDS By Martha Smith Sharpe PURPOSE The purpose of this project was to gather information from various stakeholders to determine potential changes that might be made to improve on the 2012 ACEND Accreditation Standards for Programs in Nutrition and Dietetics. METHODOLOGY ACEND® contracted with consultant, Martha Smith Sharpe to examine standards set by other accreditors, review U.S. Department of Education (USDE) requirements and conduct and analyze results of on online stakeholder survey of the 2012 Standards. The first phase of the project involved reviewing work previously conducted by ACEND, evaluating the 2012 Standards relative to requirements for USDE recognition, and assessing the standards’ adequacy in light of common practices within similar specialized/professional fields’ accrediting standards. The second phase of the project involved developing an online questionnaire (Appendix G) in Survey Monkey® that included four major sections: one for collecting demographic information about respondents, a second to determine participant involvement in doing a Program Assessment Report (PAR) using the 2012 Standards, a third section that determined participant involvement in doing a Self-Study/Site Visit using the 2012 Standards and a fourth that involved evaluation of each of the 23 Standards included in the 2012 Standards. For each standard, respondents were asked to rate whether the standard was clear and easy to understand and whether providing evidence for the standard demonstrated program quality using a five-point scale ranging from 1, strongly disagree to 5, strongly agree. An option of “no opinion” also was included. Respondents were provide comment boxes with each standard to provide additional comments or concerns. RESULTS A total of 407 individuals responded to the survey about the 2012 Standards; most were nutrition and dietetics program directors (53%) or educators (22%). Nearly 65% of the respondents indicated having some experience with applying the standards or completing a Program Assessment Report (PAR) or self-study using the report (Table 11). Respondents indicated the 2012 Standards better prepared them to write a self-study as compared to a PAR. Respondents were asked to indicate whether the standards were clear and easy to understand and whether providing evidence for this standards demonstrated quality. As shown in Table 12, there was variation in perceptions of clarity of individual standards. Nearly all standards had 70% or more of responses as agree/strongly agree. Standards focused on policies and procedures, program mission, curriculum length and student complaints had the highest number of agree/strongly agree responses. Standards focused on program improvement and student learning assessment had a somewhat lower number of agree/strongly agree responses. 84 Based on a review of the quantitative and qualitative comments, the following recommendations for changes to future standards documents are offered: Publish the standards alone in one document with no additional information, but reference to separate guidance material Publish a separate document for the guidance material. Differentiate what is the standard and what is supporting material and use terminology “Suggestions for Narrative” rather than “Suggested Discussion” Change from use of Standards and Guidelines to a hierarchical numbering system that retains the ability to individual standards numbers for each standard. Use term “evaluation” for the measurement of program objectives and “assessment” for the measurement of the attainment of student learning outcomes Give explicit recognition in the Standards to the Core knowledge and Competencies Combine and streamline the standards o o o Title Standard 1: Eligibility Standards for Candidate and Accredited Programs Combine 1.1 and 1.2 – call it Program Sponsorship and Location Within its Sponsoring Organization Combine 1.3 and 18 – call it Program Resources Combine 1.4 and 1.5 – call it Criteria and Types of Program Awards Combine 1.6 and 12 – call it Curriculum Length and Supervised Practice Combine 1.7 and 15 – call it Program Director Responsibilities and Credentials Bring Standard 3 into Standard 1 – call it Programs Established Under Consortia Agreements Bring Standard 2 into Standard 1 – leave title same Title Standard 2: Curriculum Create a new standard with the information about the knowledge and competencies from Standard 9 preamble – call it Core Knowledge and Competencies Include Standard 9 – Program Concentrations Include Standard 11 – Learning Activities Include Standard 10 – Curriculum Mapping Title Standard 3: Program Planning Evaluation, Assessment, Review and Improvement Combine Standards 4, 5, 6, and 7 – call it Program Mission, Goals, and Objectives and Their Evaluation Include Standard 13 – Student Learning Outcomes and Assessment Include Standard 14 – Program Review and Improvement 85 o Title Standard 4: Faculty and Preceptors o o Include parts of Standard 6 – call it Student Achievement Measures Include Standards 15 and 16 Title Standard 5: Students and the Public Include Standard 22 Include part of Standard 20 on opportunities to learn, progress and feedback, soliciting input, verifying remote student identity, Include Standard 21 - Student Complaints Title Standard 6: Policies and Procedures Include Standard 23 86 Table 11. Respondents Experience with Applying the 2012 Standards n % Involved as a program educator or preceptor in activities applying the 2012 Standards Involved as a program director in completing a self-study/site visit under the 2012 Standards 87 65 21.4% 16.0% Involved as a program director in completing a PAR under the 2012 Standards 64 15.7% Involved as an ACEND program reviewer, board member or staff member in reviewing program PARs and/or self-studies under the 2012 Standards No involvement in applying the 2012 Standards to a program 40 9.8% 151 37.1% Type of Experience Table 12. Respondents Experience in Preparing the Program Assessment Report or Self Study using the 2012 Standards a na % The 2012 Standards provided the information the program needed to be well prepared for writing the PAR Completing the PAR under the 2012 Standards provided the program the opportunity to demonstrate the quality of the program 30 50.0% 39 65.0% Information provided by ACEND regarding the 2012 Standards was easy to understand and apply in writing the PAR The 2012 Standards made it clear what was acceptable supporting evidence for each standard Preparing the Self-Study 22 36.7% 23 38.3% The 2012 Standards provided the information the program needed to be well prepared for writing the self-study report 48 82.8% The information was easy to understand and apply to writing the self-study report 34 57.5% 30 51.7% Experience Preparing the Program Assessment Report The 2012 Standards made it clear what was acceptable supporting evidence for each standard a respondents who agreed/strongly agreed with the statement 87 Table 13: Respondents Ratings of Standard Clarity and Demonstration of Quality Standard Clear Easy to Interpret na %a na %a 1: Program Characteristics and Finances 155 81.2% 129 72.1% 2: Title IV Compliance for Free-Standing Programs 87 47.7% 70 39.9% 3: Consortia 84 47.9% 66 38.3% 4: Program Mission 154 90.1% 138 80.6% 5: Program Goals 151 86.7% 145 84.3% 6: Program Objectives 137 81.4% 131 77.9% 7: Program Assessment 135 80.7% 133 79.5% 8: On-going Program Improvement 116 72.0% 113 68.1% 9: Program Concentration 112 69.9% 98 61.5% 10: Curriculum Mapping 124 76.5% 123 76.4% 11: Learning Activities 127 78.8% 124 76.9% 12: Curriculum Length 143 89.9% 122 76.1% 13: Learning Assessment 115 72.3% 112 70.8% 14: On-Going Curricular Improvement 126 79.7% 125 78.5% 15: Responsibilities of Program Director 136 85.5% 123 76.8% 16: Facilities and Preceptors 137 85.5% 128 80.4% 17: Continuing Professional Development 141 88.6% 125 78.1% 18: Program Resources 131 83.6% 118 73.7% 19: Supervised Practice Facilities 118 74.1% 116 72.5% 20: Student Progression and Professionalization 129 81.5% 127 79.3% 21: Student Complaints 142 89.7% 129 81.6% 22: Info Prospective Students and Public 139 88.4% 123 77.3% 23: Policies and Procedures respondents who agreed/strongly agreed 144 91.1% 136 84.9% Standard a Demonstrates Program Quality 88 DEVELOPMENT OF THE FUTURE EDUCATION MODEL COMPETENCIES AND PERFORMANCE INDICATORS 89 DEVELOPMENT AND VALIDATION OF ENTRY-LEVEL COMPETENCIES AND PERFORMANCE INDICATORS FOR FUTURE ASSOCIATE, BACHELOR AND MASTER DEGREE PROGRAMS IN NUTRITION AND DIETETICS By Leanne Worsfold PURPOSE The purpose of this project was to develop, verify and gain consensus on professional and clinical competencies and performance indicators for future nutrition and dietetics professionals who graduate, in the year 2025 and beyond, from an associate, bachelors or master’s level program. METHOD ACEND® contracted with consultant, Leanne Worsfold, to conduct a multi-round Delphi study to gather input from a broad base of stakeholders to gain consensus on professional and clinical competencies for future entry-level nutrition and dietetics professionals. Entry-level competencies (knowledge, skill and judgment) needed upon graduation from an accredited nutrition and dietetics education program for early years of practice were identified. These entrylevel competencies could be used to: Inform academic curriculum and program syllabi; Provide measurable education outcomes for the nutrition and dietetics programs (associate, bachelor and master level); Support competency-based learning by outlining student expectation and defining what the student should be able to do upon graduation; Shape future nutrition and dietetics practice; Introduce a new practitioner (associated degree level); Increase patient access to nutrition and dietetics health care services; Assist in defining nutrition and dietetics job roles and responsibilities; Promote legislative changes in scope of practice; and Communicate the role of competence nutrition and dietetic practitioners to internal and external stakeholders (e.g. accreditation bodies and organizations, employers, the public) The multi-round Delphi study was conducted from spring 2015 through summer 2016 with national samples of credentialed Registered Dietitian Nutritionists (RDNs) and Nutrition and Dietetics Technicians, Registered (NDTRs), employers, allied health professionals, educators and community health workers. The goal of the Delphi process was to systematically facilitate communication of information via several stages of the consultant asking questions, undertaking analysis, providing feedback and asking further questions to develop and validate the competency and performance indicator statements. Information was collected on the draft competencies using focus groups (in-person and via webinar) and an online questionnaire to reach group consensus on the final competencies and performance indicators. 90 Throughout each stage of the study, participants were asked to consider the anticipated nutrition and dietetics practice landscape 10-years or more out, considering: the aging patient population; emerging healthcare and wellness needs (e.g. mental health, multi and complex health needs, new diseases, disease prevention) and nutrition trends and issues (e.g. genetically modified foods, nutrigenomics, behavior modification, changing climate, sustainability, global health); advancements in technology; anticipated aging health professional populations and lack of human resources; anticipated workplace needs (e.g. community, health care, business, and rural areas); and community and global health issues and needs. Each round of the Delphi study focused on evaluating the list of draft competencies and performance indicators finalized in the previous round and gaining consensus by the ACEND Standards Committee and Expanded Standards Workgroup before being presented to the ACEND Board for final review and approval. Subject Matter Experts The first step in the competency development process occurred in spring through fall 2015 with a group of 15 individuals termed subject matter experts (SMEs) that included RDNS and NDTRs from across the United States who were working or had worked as educators or practitioners in a broad spectrum of practice areas (inpatient and outpatient clinical nutrition, foodservice management, school foodservice, business, communication, community nutrition, private practice, public health, college teaching, research, quality management and healthcare administration). The SMEs were guided through a multi-step process by consultant Worsfold to determine a competency framework, develop a competency outline, determine desired complexity of competency topics for each academic degree and write competencies and performance indicators for future practitioners prepared at the associate, bachelor and master degree levels. Desired complexity of the identified competency topics was rated by each SME for each degree level as 0, Do not include; 1, Broad knowledge, performs with direct supervision or consultation; 2, Deeper comprehension, uses standardized templates, forms and protocols, seeks referral or guidance when needed or 3, Has extensive knowledge and skill, independently applies critical thinking and professional judgment. The individual ratings were combined and discussed by the SME group to finalize a group rating. The SMEs then developed competency and performance indicator statements for competency topics included in the outlines for the associate, bachelor and master degree programs in nutrition and dietetics. Their work was vetted with the ACEND Standards Committee, Expanded Standards Workgroup, Visioning Group and the ACEND Board at several points during their work. First Line Review The second step of the Delphi process was a first line review by a group of educators and practitioners who participated in online focus groups conducted by consultant Worsfold. A total of 241 individuals were invited to attend one of the 10 focus group sessions to review the draft competencies and performance indicators and offer suggested changes to content and assigned academic level. Based on input received, a revised set of competencies and performance indicators were reviewed by the ACEND Standards Committee, Expanded Standards Workgroup, 91 Visioning Group, Subject Matter Experts, and the ACEND Board before they were shared more widely for input. Online Stakeholder Survey A third step in the process, which involved completion of an online questionnaire (Appendixes HJ), began in April 2016. Random and convenience samples totaling more than 16,000 nutrition and dietetics practitioners, educators, employers and professionals from outside the field of nutrition and dietetics (separate samples for each degree level program) were asked to rate the competencies and the performance indicators. Participants provided ratings on a four-point scale of perceived importance to future practice in the profession (1, Not important to future practice; 2, Minor importance to future practice; 3, Important for future practice; 4, Critical for future practice) for each competency and performance indicator and provided a rating on a four-point scale of the importance to ensuring the public (patient) has access to nutrition and dietetics services (1, Not important; 2, Minor importance, 3, Important; 4, Critically important) for each competency. A traditional scale of frequency performed by the profession was not used, given the competencies were projecting required nutrition and dietetic competence 10 plus-years in the future. Space for comments was included for each competency and its performance indicators. Consensus Panel Meeting In June 2016, a Consensus Panel Meeting was convened, which included the ACEND Standards and Executive Committee members and the Expanded Standards Workgroup to review the Delphi study findings and gain consensus on the final competency and performance indicator statements. Ratings received and comments made about the competencies and performance indicators in the online survey were reviewed by the group in a week-long consensus panel meeting. Decisions were made on the wording and inclusion of each competency and performance indicator based on the input received. The finalized list of competencies and performance indicators were incorporated into the Future Education Model Accreditation Standards and were presented to the ACEND Board for their review and approval to be released for public comment. RESULTS In all rounds of the Delphi process, participants and respondents represented a wide variety of nutrition and dietetics practice settings (clinical care, foodservice, community/public health, government, education) and roles (clinical care, academic, management, foodservice, community) from all regions of the United States. Participants held associate, bachelor, master and/or doctoral degrees and had been in practices from less than three years to more than 20 years. Practitioners from outside the profession (physicians, nurses, allied health practitioners, business and industry executives, community health workers) were used as well to provide input into competencies needed in future nutrition and dietetics practice. 92 Subject Matter Experts Outcomes The SMEs first conducted a functional analysis of several competency frameworks and determined a framework that included competencies and performance indicators grouped within competency units would work best for nutrition and dietetics education (see Figure 3) and decided to use this framework for their competency development work. The SMEs generated an initial list of competency units (Table 14) based on an extensive literature review. Within each competency unit, competency topics were identified. An example of one competency unit and the initial list of competency topics is shown in Table 15. These competency topics were discussed by the group and condensed into a smaller number of topics to reduce overlap and redundancy among topics. The SMEs completed an exercise wherein they individually rated the desired complexity of each competency topic for each academic degree level. The individual ratings were combined and discussed by the SME group to finalize a group rating. An example of group complexity ratings for one competency unit showing the distinction between the bachelor and master prepared graduates is provided in Table 16. These group ratings were vetted with the ACEND Standards Committee, Expanded Standards Workgroup and the ACEND Board before competency statements and performance indicators were written. The SME group then worked for several months developing the first draft of the competencies and performance indicators using the results of the competency complexity ratings and Bloom’s Cognitive Taxonomy to develop competency statements and indicators of performance mapped to the academic degree level (associate, bachelor and master). In total the group developed nearly 100 competency statements and 600 performance indicators (Table 17). An example of one competency unit (Community and Population Health Nutrition) and the proposed competency statements within that unit for bachelor and master prepared graduates is shown in Table 18. Table 19 includes an example of one competency and the performance indicators developed for that competency. First Line Review Outcomes The next round of the competency development Delphi process involved a series of online focus groups to review the draft standards and competencies and offer suggested changes to wording, content and assigned academic level. A total of 98 (41% response) individuals participated in one of the 10 first line review online focus group sessions facilitated by consultant Worsfold. The first line reviewers offered several changes in verbs used in the competency and performance indicator statements to better reflect the degree level of the program. Additional competency statements and performance indicators were suggested for all three degree level programs (Table 20). Online Survey Outcomes An online survey was used to gather input on the draft competencies and performance indicators from a larger group of educators, practitioners and other professionals who work with nutrition 93 and dietetics practitioners; more than 1000 (7% response) responded. Demographic characteristics of the respondents is found in Table 21. A total of 242 individuals provided ratings for the associate degree program competencies and performance indicators, 459 individuals provided ratings for the bachelor degree and 397 provided ratings for the master degree. The overall mean rating, on a 4-point scale (4-being critical for future practice), of importance to future practice in the profession for the competency and performance indicator statements for all three degree levels was 3.41, standard deviation 0.66. The overall mean rating, on a 4-point scale (4-being critical), of importance to ensuring public access to nutrition and dietetics services for the competencies and performance indicators for all three degree levels was 3.27, standard deviation 0.67. Individual ratings on both scales for each competency are included in Tables 22-24. Associate degree The overall mean rating, on a four-point scale (4 being critical for future practice), for importance to the profession of the associate degree competencies and performance indicators was 3.46, standard deviation 0.64. The overall mean rating, on a four-point scale (4 being critical), for importance to public access for the associate degree competencies and performance indicators was 3.26, standard deviation, 0.68. As shown in Table 22, all of the competencies for the associate degree were rated higher than 3 on the 4 point scale suggesting that all of the competencies were perceived as being important to future practice and to the public. The highest rated competencies were “Demonstrates an understanding of the principles of food and nutrition” (µ=3.83±.39; µ=3.54±.53 respectively) and “Demonstrates ethical behaviors becoming of the profession” (µ=3.78±.42; µ=3.66±.51 respectively). The lowest rated competency for importance to future practice in the profession (µ=3.23±.78) and for importance to the public (µ=3.08±.78) was “Advocates for programs and services for individuals and the community.” Bachelor degree The overall mean rating, on a four-point scale (4 being critical for future practice), for importance to the profession of the bachelor degree competencies and performance indicators was 3.44, standard deviation 0.67. The overall mean rating, on a four-point scale (4 being critical), for importance to public access for the bachelor degree competencies and performance indicators was 3.27, standard deviation 0.68. As shown in Table 23, nearly all of the competencies for the bachelor degree were rated higher than 3 on the 4 point scale suggesting that most of the competencies were perceived as being important to future practice and to the public. The highest rated competencies were in the professionalism competency unit: “Demonstrates ethical behaviors becoming to the profession” (µ=3.77±.48) and “Adheres to legislation, regulations and standards of practice” (µ=3.66±.52). The lowest rated items for importance to future practice in the profession for the bachelor degree included: “Demonstrates knowledge of math and statistics” (µ=2.98±.69), “Coordinates the purchasing, receipt and storage of food products and services” (µ=2.98±.76), “Incorporates risk 94 management strategies into practice” (µ=2.94±.77), and “Applies an understanding of agricultural practices, food technology and processes” (µ=2.92±.73). Ratings of importance to the public also were less than 3 for these competencies (µ=2.91±.74; µ=2.94±.79; µ=2.90±.80; µ=2.87±.76, respectively). Master’s degree The overall mean rating, on a four-point scale (4 being critical for future practice), for importance to the profession of the master degree competencies and performance indicators was 3.33, standard deviation 0.68. The overall mean rating, on a four-point scale (4 being critical), for importance to public access for the master degree competencies and performance indicators was 3.27, standard deviation 0.66. As shown in Table 24, nearly all of the competencies for the master degree were rated higher than 3 on the four-point scale suggesting that most of the competencies were perceived as being important to future practice and to the public. The highest rated competencies were: “Demonstrates ethical behaviors becoming to the profession” (µ=3.78±.43), “Performs or coordinates nutritional interventions for all individuals, groups and populations” (µ=3.75±.48) and “Applies current research and evidence-based practice to services” (µ=3.69±.55). The lowest rated items for importance to future practice in the profession for the master degree included: “Develops and implements risk-management strategies and programs” (µ=2.90±.82), “Applies and demonstrates an understanding of agricultural practices, food technology and processes” (µ=2.84±.82) and “Oversees the purchasing, receipt and storage of products used in food production and services” (µ=2.76±.83). Ratings of importance to the public also were less than 3 for these competencies (µ=2.86±.82; µ=2.81±.76; µ=2.79±.78, respectively). Consensus Panel Outcomes The consensus panel reviewed ratings for each of the competencies and performance indicators and all comments made. The group made decisions to modify or delete items as needed. Associate’s degree After review of the ratings and the comments, the consensus panel deleted 11 performance indicators due to noted redundancy or too high in scope of practice and modified nine performance indicators and one competency to adjust the expected competence level or to further clarify expectations based on the participants’ comments. Terminology was adjusted throughout the document to improve consistency in use of terms. As reported in Table 25, the number of competencies for the associate degree remained unchanged at 20, however, the list of performance indicators was reduced from 132 to 121. The panel confirmed, based on the competencies perceived to be important for future practice, that the associate degree prepared nutrition and dietetics worker would support communitybased nutrition and dietetics services to encourage positive patient and community outcomes. 95 Bachelor’s degree After review of the ratings and the comments, the consensus panel deleted 24 performance indicators due to noted redundancy or noted as out-of-scope of practice; and modified 19 performance indicators and two competencies to adjust the expected competence level or to further clarify expectation based on the participant comments. Terminology was adjusted throughout the document to improve consistency in use of terms. As reported in Table 25, the number of competencies for the bachelor degree program remained the same at 38; the list of performance indicators was reduced from 240 to 216 The panel confirmed that based on perceptions of future practice of the bachelor degree practitioner the competencies place a focus on autonomous practice in the area of foodservice management and suggest an expectation for the practitioner to have sufficient nutrition knowledge to provide direct patient care when patient care needs are well established and predictable, and work place resources and support (policies, protocols, standardized templates, registered dietitian nutritionists) are in place. Master’s degree After review of the ratings and the comments, the consensus panel deleted 11 performance indicators due to noted redundancy or noted as out-of-scope of practice; and modified 13 performance indicators and 1 competency to adjust the expected competence level or to further clarify expectations based on the participant comments. Terminology was adjusted throughout the document to improve consistency in use of terms. As reported in Table 25, the number of competencies for the master degree program remained the same at 41; the list of performance indicators was reduced from 289 to 278. The panel confirmed that based on perceptions of future practice the master degree level nutrition and dietetic professional’s competencies places an importance on leadership skills, research, population and global nutrition and managing highly complex patient care needs. Recommended Competencies and Performance Indicators The consensus panel finalized a list of proposed competencies and performance indicators for the Future Education Model associate, bachelor and master degree programs (Tables 26-28). This list was then proposed to the ACEND Board by the Standards Committee. 96 Figure 3: Competency framework used for Future Education Model competency development 97 Table 14: Initial competency units developed by subject matter experts Associate Degree Competency Units Bachelor and Master Degree Competency Units Foundation Knowledge Foundation Knowledge Professionalism Client Services Individual and Community Services Food Systems Management Cultural Competence Community and Population Health Nutrition Communication, Collaboration and Advocacy Leadership, Management and Organization Critical Thinking, Evidence-informed Practice and Research Professionalism Communication, Collaboration and Advocacy Table 15: Example of a competency unit and competency topics within that unit Competency Unit Community and Population Health Nutrition Competency Topics Population-based data collection Data synthesis and analysis Data interpretation Sustainability Funding sources Surveillance of population issues Population health activities Nutrition policy Behavioral health Food assistance Development/evaluation of community nutrition programs Community engagement and partnerships Government reimbursements/leveraging resources Disparities in population health Environmental influences Corporate wellness Food availability/resources/ food insecurity Community advocacy International nutrition /global health Government policy/legislation (local, state, federal, international) 98 Table 16: Example of a competency unit, competency topics and complexity rating Competency Unit Community and Population Health Nutrition a Complexity Level Bachelora 1 Complexity Level Mastera 2, 3 Principles of health promotion and population health 1 2, 3 Prevention, wellness and outreach 1, 2 2, 3 Nutrition care process specific to community and population 1, 2 3 Epidemiology and biostatistics 0 2 Policies, guidelines and standards 1 2, 3 Environmental and system change 0 3 Competency Topics Public health systems Scale: 0, Do not include; 1, Broad knowledge, performs with direct supervision or consultation; 2, Deeper comprehension, uses standardized templates, forms and protocols, seeks referral or guidance when needed or 3, Has extensive knowledge and skill, independently applies critical thinking and professional judgment Table 17. Total number of competency units, competency statements and performance indicators developed by subject matter experts Degree Competency Units Competency Statements Performance Indicators Associate 5 20 120 Bachelor 8 35 205 Master 8 38 269 99 Table 18: Example of a competency unit and competency statements for bachelor and master degree developed by subject matter experts Unit Community and Population Health Nutrition (Applies community and population health theories to address nutrition and global health and wellness) Bachelor Competencies 1. Assesses, plans, implements and evaluates communitybased programs. Master Competencies 1. Assesses, plans, implements and evaluates community-, populationand/or global-based programs to improve the nutritional health of vulnerable populations. 2. Identifies community, population, global environmental and publichealth hazards, and participates in and/or coordinates the management of the situation. 3. Engages in legislative and regulatory activities that address global nutrition health and nutrition policy. 100 Table 19: Example of performance indicator statements developed by subject matter experts for a competency statement for the master degree Unit: Community and Population Health Nutrition (Applies community and population health theories to address nutrition and global health and wellness) Competency: Assesses, plans, implements and evaluates community-, population- and/or globalbased programs to improve the nutritional health of vulnerable populations. Performance Indicators 1. Demonstrates knowledge of public-health, health-promotion and population-health principles. 2. Recognizes how determinates of health (biological, social, cultural, economic and physical) influence the health and well-being of a specific population. 3. Conducts and/or facilitates a community- and/or population-based needs assessment. 4. Engages in consultation activities with partners in addressing public-health issues. 5. Identifies and documents epidemiological findings, health disparities, political interests, impacts of determinates of health, availability of resources, accessibility, and program goals and objectives. 6. Identifies the resources and partners needed for sustainability of the program. 7. Considers the assessment data and potential strengths, benefits constraints, and limitations when developing the program. 8. Implements program plan applying project-management skills and adhering to public-health policies and standards. 9. Collects nutrition surveillance and global health-and-safety data and evaluates the program using measure indicators and outcomes. 10. Engages in research activities to further nutrition knowledge and population-health practice. 11. Initiates legislative and regulatory activities that address global nutrition health and nutrition policy. 12. Communicates evaluation findings, outcomes, recommendations and/or research findings to stakeholders to promote change and substantiate program. Table 20. Total number of competency units, competency statements and performance indicators after first line review focus group discussions Degree Competency Units Competency Statements Performance Indicators Associate 5 20 132 Bachelor 8 38 240 Master 8 41 289 101 Table 21. Demographic characteristics of respondents to online survey Associate Degree Bachelor Degree Characteristics n Work Setting Healthcare (hospital, long term care, physician network) 76 Educational setting (primary, secondary, university) Government (federal, city, state, or local) public health Community nonprofit % Master Degree n % n % 22.6% 254 42.1% 210 40.5% 65 19.4% 127 21.0% 118 22.7% 63 18.9% 67 11.1% 46 8.9% 62 18.5% 39 6.5% 23 4.4% Self-employed, consultant or private practice 22 6.6% 39 6.5% 38 7.3% Wellness programs (workplace, health clubs, fitness centers) 20 5.9% 34 5.6% 22 4.2% Other 27 8.1% 44 7.2% 62 12.0% Management/Leadership 75 21.2% 108 16.2% 100 17.2% Clinical care 59 16.7% 215 32.3% 193 33.2% Community/public health 120 33.9% 107 16.1% 79 13.6% Foodservice 21 5.6% 68 10.2% 42 7.2% Academic/Research 47 13.3% 99 14.9% 101 17.4% Other 32 9.3% 69 10.3% 66 11.4% Role Highest Degree Held Associate’s 19 0.2% 21 5.4% Master’s 59 93 21.6% 26.6% 41.9% 167 216 36.9% 47.7% 104 217 26.8% 55.9% Doctorate 22 9.9% 51 15,2% 46 11.9% 3 years or less 22 9.1% 34 7.5% 29 7.3% 4 to 9 years 10 to 20 years 42 60 17.4% 27.0% 83 109 18.2% 23.8% 84 110 21.3% 27.8% More than 20 years 117 53.5% 231 50.5% 172 43.6% 29 37 12.3% 15.7% 59 47 12.8% 10.2% 53 41 14.0% 10.8% Region 4 (AZ, CO, KS, NV, NM, OK, TX, UT) 22 65 9.4% 27.7% 75 52 16.3% 11.3% 47 68 12.4% 18.0% Region 5 (IL, IN, OH, KY, TN, WV) 36 15.3% 75 16.3% 61 16.1% Region 6 (DE, DC, MD, NC, PA, VA) 17 29 7.2% 12.4% 68 84 14.8% 18.3% 50 58 13.2% 15.5% Bachelor’s 48 Years of Work Experience Region of the Country Region 1 (AK, CA, HI, ID, MT, OR, WA, WY) Region 2 (IA, MI, MN, MO, NE, ND, SD, WI) Region 3 (AL, AR, FL, GA, LA, MS, PR, SC) Region 7 (CT, ME, MA, NH, NJ, NY, RI, VT) 102 Table 22: Ratings of importance for associate degree competencies by participants in an online survey of the draft competencies Importance to Future Practicea Competencies n Mean Importance to Publicb SD n Mean SD Unit 1. Foundational Knowledge 1.1 Demonstrates an understanding of the principles of food and nutrition. 242 3.83 .39 237 3.54 .53 1.2 Integrates knowledge of health determinates into all aspects of care and services. 192 3.54 .56 190 3.44 .63 1.3 Demonstrates knowledge of wellness strategies that contribute to long-term health. 166 3.55 .60 165 3.38 .60 1.4 Applies principles of food safety and sanitation standards specific to culinary skills, food supply and food storage. 163 3.56 .60 163 3.55 .62 1.5 Demonstrates understanding of public health system. 162 3.25 .72 162 3.28 .70 2.1 Demonstrates ethical behaviors becoming of the profession. 156 3.78 .42 154 3.66 .51 2.2 Engages in reflective-practice activities to maintain ongoing competence. 147 3.44 .59 146 3.39 .59 2.3 Adheres to legislation, regulations, standards of practice and organizational policies. 143 3.68 .51 143 3.56 .58 3.1 Screens basic nutrition and health needs of individuals and communities. 138 3.55 .57 138 3.50 .61 3.2 Participates in the development, monitoring and modifications of the client's program. 132 3.41 .64 132 3.39 .60 3.3 Considers the factors that impact food availability in the community (seasonal, accessibility, affordability, geographical location) within the social determinants of health. 131 3.44 .62 131 3.37 .57 3.4 Supports recipe modification and meal planning based on cultural needs and preferences in collaboration with other professionals. 124 3.41 .64 124 3.38 .58 3.5 Organizes community nutrition programs and promotes access to community resources. 122 3.24 .76 121 3.21 .73 Unit 2. Professionalism Unit 3. Individual and Community Services 3.6 Provides information and pre-developed 117 3.27 .69 117 3.32 .72 evidence-informed educational materials to meet the needs of the individual and community. a Scale: Importance to future practice in the profession: 1, Not important to future practice; 2, Minor importance to future practice; 3, Important for future practice; 4, Critical for future practice b Scale: importance to ensuring the public (patient) has access to nutrition and dietetics services: 1, Not important; 2, Minor importance, 3, Important; 4, Critically important 103 Table 22: cont. Importance to Future Practicea Competencies n Mean Importance to Publicb SD n Mean SD Unit 4. Cultural Competence 4.1 Demonstrates an understanding of the principles of cultural competence. 115 3.50 .63 115 3.43 .69 4.2 Identifies and addresses cultural needs of the individual and community. 113 3.39 .74 113 3.35 .69 4.3 Demonstrates knowledge of foods, cultural and religious food traditions, eating patterns and trends in the community. 113 3.50 .57 113 3.42 .62 5.1 Applies effective written and oral communication skills and techniques to achieve desired goals and outcomes. 112 3.69 .49 112 3.63 .48 5.2 Works collaboratively with intra- and interprofessional team members, individuals and the community. 112 3.63 .52 112 3.47 5.7 5.3 Advocates for programs and services for individuals and the community. 112 3.23 .78 112 3.08 .78 Unit 5. Communication, Collaboration and Advocacy 104 Table 23: Ratings of importance for bachelor degree competencies by participants in an online survey of the draft competencies Importance to Future Practicea Competencies n Mean Importance to Publicb SD n Mean SD Unit 1. Foundational Knowledge 1.1 Applies a basic understanding of environmental and genetic factors in the development and management of disease. 459 3.36 .63 457 3.48 .55 1.2 Demonstrates an understanding of anatomy and physiology. 404 3.49 .59 404 3.44 .60 1.3 Demonstrates an understanding of microbiology and food safety. 374 3.41 .57 374 3.51 .56 1.4 Demonstrates knowledge of chemistry and food science as it pertains to food and nutrition. 358 3.14 .64 358 3.10 .68 1.5 Demonstrates and applies knowledge of pathophysiology and biochemical functionality and their relationship to physiology (health and disease). 339 3.47 .66 338 3.55 .58 1.6 Applies knowledge of social, psychological and environmental aspects of eating and food. 315 3.45 .58 315 3.36 .63 1.7 Applies the principles of cultural competence within own practice. 306 3.39 .62 305 3.33 .69 1.8 Demonstrates basic knowledge of nutrition pharmacology, and integrative and functional therapy. 296 3.39 .63 296 3.32 .61 1.9 Demonstrates knowledge of math and statistics. 289 2.98 .69 289 2.91 .74 1.10 Demonstrates knowledge of medical terminology when communicating with individuals. 286 3.59 .56 286 3.44 .64 1.11 Demonstrates knowledge of food preparation and techniques. 282 3.22 .67 292 3.16 .67 1.12 Applies technology in the decision-making process. 273 3.26 .72 273 3.30 .62 1.13 Applies nutrition knowledge in the provision of nutrition care at all stages of the life cycle. 265 3.61 .55 265 3.52 .55 1.14 Applies knowledge of health promotion and prevention for individuals and groups. 256 3.52 .58 256 3.40 .61 a Scale: Importance to future practice in the profession: 1, Not important to future practice; 2, Minor importance to future practice; 3, Important for future practice; 4, Critical for future practice b Scale: importance to ensuring the public (patient) has access to nutrition and dietetics services: 1, Not important; 2, Minor importance, 3, Important; 4, Critically important 105 Table 23: cont. Importance to Future Practicea Competencies n Mean Importance to Publicb SD n Mean SD Unit 2. Client Services 2.1 Applies a framework to assess, develop, implement and evaluate program and services. 239 3.21 .66 239 3.00 .75 2.2 Conducts and interprets nutritional status screening for individuals, groups or targeted population using standardized tools. 230 3.58 .57 230 3.43 .62 2.3 Utilizes the nutrition care process to manage clients/patient s with less complex health needs in a supportive health system. 226 3.40 .71 226 3.45 .66 2.4 Performs nutritional interventions for clients with less complex care needs when environmental supports are in place. 211 3.39 .67 211 3.46 .61 2.5 Considers the patient's use of, and beliefs and values related to nutrition integrative and functional therapy. 199 3.38 .60 199 3.27 .63 3.1 Manages the production, distribution, and service of quantity and quality of food products. 193 3.18 .71 193 3.17 .68 3.2 Coordinates the purchasing, receipt and storage of food products and services. 190 2.98 .76 190 2.94 .79 3.3 Applies principles of food safety and sanitation to the production and service of food. 188 3.44 .70 188 3.29 .72 3.4 Applies an understanding of agricultural practices, food technology and processes. 187 2.92 .73 187 2.87 .76 187 3.11 .73 187 3.05 .73 5.1 Demonstrates leadership skill to guide practice. 186 3.42 .66 186 3.40 .64 5.2 Applies principles of organization management. 186 3.14 .77 186 2.99 .79 5.3 Applies project management principles to achieve project goals and objectives. 183 3.08 .74 182 3.04 .77 5.4 Incorporates quality improvement into practice. 182 3.13 .72 182 3.04 .77 5.5 Incorporates risk management strategies into practice. 182 2.94 .77 182 2.90 .80 Unit 3. Food Systems Management Unit 4. Community and Population Health Nutrition 4.1 Assesses, implements and evaluates community and population-based programs. Unit 5. Leadership, Management and Organization 106 Table 23. cont. Importance to Future Practicea Competencies n Mean Importance to Publicb SD n Mean SD Unit 6. Critical Thinking, Evidence-informed Practice and Research 6.1 Incorporates critical thinking skills in overall practice. 181 3.55 .60 181 3.38 .73 6.2 Identifies and understands the scientific method and research ethics. 180 3.26 .69 180 3.07 .78 6.3 Applies current research and evidence-based practice to services. 179 3.49 .62 179 3.39 .72 7.1 Demonstrates ethical behaviors becoming to the profession. 179 3.77 .48 179 3.68 .56 7.2 Engages in self- reflective practice activities to maintain ongoing competence and professional behaviors. 178 3.47 .65 178 3.29 .65 7.3 Adheres to legislation, regulations and standards of practice. 178 3.66 .52 178 3.63 .57 8.1 Applies effective communication skills and techniques to achieve desired goals and outcomes. 178 3.62 .52 178 3.54 .57 8.2 Works with and facilitates intra- and interprofessional collaboration and teamwork. 178 3.39 .65 178 3.25 .69 8.3 Demonstrates advocacy skills to promote awareness and required change. 178 3.24 .67 178 3.15 .75 Unit 7. Professionalism Unit 8: Communication, Collaboration and Advocacy 107 Table 24: Ratings of importance for master degree competencies by participants in an online survey of the draft competencies Importance to Future Practicea Competencies n Mean Importance to Publicb SD n Mean SD Unit 1. Foundational Knowledge 1.1. Applies an understanding of environmental and genetic factors in the development and management of disease. 397 3.35 .64 388 3.43 .57 1.2. Applies an understanding of anatomy and physiology. 344 3.59 .57 342 3.60 .54 1.3. Applies knowledge of microbiology and food safety. 311 3.38 .58 311 3.36 .64 1.4. Integrates knowledge of chemistry and food science as it pertains to food and nutrition, product development and when making modifications to food. 289 3.10 .70 287 2.98 .71 1.5. Demonstrates and applies knowledge of pathophysiology and biochemical functionality and their relationship to physiology (health and disease). 263 3.57 .60 263 3.57 .55 1.6. Applies knowledge of social, psychological and environmental aspects of eating and food. 248 3.46 .62 247 3.30 .60 1.7. Integrates the principles of cultural competence within own practice and when directing services. 232 3.39 .67 230 2.36 .64 1.8. Applies knowledge of pharmacology, and integrative and functional therapy to recommend, prescribe and administer nutrition related therapy. 222 3.44 .68 223 3.40 .57 1.9. Applies knowledge of math and statistics. 217 2.95 .76 217 2.68 .80 1.10. Applies knowledge of medical terminology when communicating with individuals, groups and other health professionals. 214 3.71 .49 214 3.53 .56 1.11. Demonstrates knowledge of food preparation and techniques. 208 3.25 .73 208 3.13 .74 1.12. Applies technology in the decision-making process. 203 3.37 .67 203 3.28 .65 1.13. Integrates knowledge of nutrition and physical activity in the provision of nutrition care at all stages of the life cycle. 197 3.59 .52 197 3.48 .54 a Scale: Importance to future practice in the profession: 1, Not important to future practice; 2, Minor importance to future practice; 3, Important for future practice; 4, Critical for future practice b Scale: importance to ensuring the public (patient) has access to nutrition and dietetics services: 1, Not important; 2, Minor importance, 3, Important; 4, Critically important 108 Table 24. cont. Importance to Future Practicea Competencies n Mean Importance to Publicb SD n Mean SD Unit 1. Cont. 1.14. Applies knowledge of health promotion and prevention for individuals, groups and populations. 194 3.52 .59 194 3.44 .59 1.15. Gains a foundational knowledge on global health issues and nutritional needs. 192 2.95 .68 191 2.86 .67 2.1. Creates a framework to assess, develop, implement and evaluate products, programs or services. 177 3.07 .72 176 2.94 .72 2.2. Selects, develops or implements nutritional status screening tools for individuals, groups or populations. 174 3.41 .61 174 3.35 .57 2.3. Utilizes the nutrition-care process with individuals, groups or population to manage complex health needs and comprehensive systems in all practice settings. 168 3.60 .58 168 3.58 .56 2.4. Performs or coordinates nutritional interventions for all individuals, groups and populations. 150 3.63 .51 150 3.58 .51 2.5. Prescribes or recommends nutrition-related drugs, supplements, nutrition integrative and functional therapy. 146 3.36 .75 146 3.45 .69 3.1. Oversees the production and distribution of quantity and quality food products. 143 3.01 .74 143 2.97 .72 3.2. Oversees the purchasing, receipt and storage of products used in food production and services 142 2.76 .83 142 2.79 .78 3.3. Applies principles of food safety and sanitation to the production and service of food. 140 3.21 .80 140 3.10 .72 3.4. Applies and demonstrates an understanding of agricultural practices, food technology and processes. 140 2.84 .82 140 2.81 .76 Unit 2. Client Services Unit 3. Food Systems Management 109 Table 24. cont. Importance to Future Practicea Competencies n Mean Importance to Publicb SD n Mean SD Unit 4. Community and Population Health Nutrition 4.1. Assesses, plans, develops, implements and evaluates community, population and global programs to improve the nutritional health of vulnerable populations. 137 3.15 .77 137 3.04 .71 4.2. Identifies community, population, global, environmental and public health hazards, and participates in or coordinates the management of the situation. 136 2.91 .78 136 3.01 .73 4.3. Engages in legislative and regulatory activities that address community, population and global nutrition health and nutrition policy. 136 2.91 .77 136 2.82 .73 5.1. Demonstrates leadership skill to guide practice. 135 3.53 .66 135 3.47 .69 5.2. Applies principles of organization management. 135 3.19 .74 135 3.06 .75 5.3. Applies project management principles to achieve the project goals and objectives. 134 3.15 .74 134 3.00 .77 5.4. Leads quality improvement activities to measure, evaluate and improve a program, services, products and initiatives. 134 3.25 .73 134 3.10 .75 5.5. Develops and implements risk-management strategies and programs. 134 2.90 .82 134 2.86 .82 6.1. Incorporates critical thinking skills in managing more complex situations. 134 3.55 .63 134 3.43 .70 6.2. Applies scientific methods utilizing ethical research practices, when reviewing, evaluating and conducting research. 133 3.44 .67 133 3.30 .70 6.3. Applies current research and evidence-based practice to services. 132 3.69 .55 132 3.58 .58 7.1. Demonstrates ethical behaviors becoming to the profession. 132 3.78 .43 132 3.67 .53 7.2. Engages in self-reflective practice activities to develop and demonstrate social and emotional intelligence to maintain ongoing competence and professional behaviors. 131 3.40 .71 131 3.39 .64 7.3. Adheres to and advocates for legislation, regulations and standards of practice. 131 3.49 .71 131 3.52 .63 Unit 5. Leadership, Management and Organization Unit 6. Critical Thinking, Evidence-informed Practice and Research Unit 7. Professionalism 110 Table 24: cont. Importance to Future Practicea Competencies n Mean Importance to Publicb SD n Mean SD Unit 8: Communication, Collaboration and Advocacy 8.1. Applies effective communication skills and techniques to achieve desired goals and outcomes. 131 3.63 .54 131 3.55 .62 8.2. Works with and facilitates intra- and interprofessional collaboration and teamwork. 131 3.52 .57 131 3.35 .61 8.3. Demonstrates advocacy skills to promote awareness and required change. 131 3.25 .67 131 3.17 .71 Table 25. Total number of competency units, competency statements and performance indicators finalized by the consensus panel Degree Competency Units Competency Statements Performance Indicators Associate 5 20 121 Bachelor 8 38 216 Master 8 41 278 111 Table 26. Proposed competencies and performance indicators for future associate degree programs Unit 1 Foundational Knowledge Applies foundational food and nutrition knowledge to ensure safe, competent and effective services. Competencies Performance Indicators 1.1 Demonstrates an understanding of the principles of food and nutrition. 1.1.1 Considers the impact of food and nutrition on wellness, health promotion and disease throughout stages of the life cycle. 1.1.2 Incorporates basic knowledge of food and nutrition requirements to provide appropriate services throughout stages of the life cycle and across disease states. 1.1.3 Identifies, assesses and manages potential primary nutritional risks that may impact the delivery of safe and effective foodservices. 1.1.4 Investigates and suggests improvements to basic nutritional risk management plans. 1.1.5 Modifies recipes for acceptability and affordability to accommodate cultural diversity and health status in less complex situations and health conditions. 1.1.6 Applies knowledge of food insecurity in the provision of community health services. 1.2 Integrates knowledge of determinants of health into all aspects of nutrition care and services. 1.2.1 Explains to stakeholders how demographic, social and economic factors and ecological issues affect the individual, group and community wellbeing. 1.3 1.3.1 Supports the development and modifications of wellness, exercise and nutrition programs to meet the nutrition needs of the client/patient, community and organization. Demonstrates knowledge of wellness strategies that contribute to long term health. 1.2.2 Takes into consideration demographics, lifestyle risk factors and socioeconomic factors to manage food and nutrition needs. 1.2.3 Identifies key environmental factors that affect services and access to food. 1.3.2 Implements wellness activities for various audiences, utilizing agencyapproved materials. 1.3.3 Promotes nutritional well-being and assists with self-management for the prevention of non-communicable diseases to the community. 1.3.4 Summarizes how society, media, culture, social norms and peer pressures influence wellness. 1.3.5 Defines dimensions of wellness. 1.3.6 Obtains and interprets information relating to the determinants of health. 1.4 Applies principles of food safety and sanitation standards specific to culinary skills, food supply and food storage 1.4.1 Follows food safety and sanitation regulations, policies and procedures. 1.4.2 Educates others on food safety principles. 112 Table 26. cont. Unit 1 cont. Competencies Performance Indicators 1.5 1.5.1 Identifies appropriate services and refers clients to public health and health care systems. Demonstrates understanding of public health system. 1.5.2 Promotes nutrition programs and resources within the community. Unit 2: Professionalism Assumes professional responsibilities to provide safe, ethical and effective nutrition services. 2.1 Demonstrates ethical behaviors becoming of a professional. 2.1.1 Refers individuals for consultation when issues are beyond scope of practice. 2.1.2 Takes accountability for actions and decisions. 2.1.3 Demonstrates honesty and integrity through trustworthy, transparent, respectful and non-judgmental behaviors. 2.1.4 Practices in a manner that respects diversity and avoids prejudicial treatment of an individual, group or the community. 2.1.5 Applies client-centered principles to all activities and services. 2.1.6 Understands the dynamics of the provider-client/patient relationship. 2.1.7 Recognizes, maintains and balances professional boundaries with clients/patients. 2.1.8 Recognizes and manages ethical dilemmas. 2.1.9 Analyzes the impact of one’s own professional behaviors, values, beliefs and actions on others. 2.1.10 Applies principles of the informed consent process prior to engaging a client in services. 2.2 Engages in reflective practice activities to maintain ongoing competence and self-awareness. 2.2.1 Demonstrates continuous self-awareness by critically evaluating one’s own knowledge, skill and judgment to determine the appropriateness of performing the activity and providing the service. 2.2.2 Self-reflects on own experiences and personal opinions. 2.2.3 Self-reflects on own position and relationships in the community and how this impacts the services provided. 2.2.4 Obtains feedback and demonstrates a willingness to consider opinions of others. 2.2.5 Identifies and reviews evidence-informed literature and credible health information sources. 2.2.6 Demonstrates critical thinking to inform decisions and actions. 2.2.7 Reflects on and incorporates own experiences and learning in practice and determines the appropriateness of the situation before proceeding. 2.2.8 Develops own learning goals and objectives and identifies activities to meet goals. 2.2.9 Maintains current knowledge of evidence-informed nutrition and dietetics information. 113 Table 26. cont. Unit 2 cont. Competencies Performance Indicators 2.3 Adheres to legislation, regulations, standards of practice and organizational policies. 2.3.1 Understands governance of nutrition and dietetics practice such as the legislative scope of nutrition and dietetics practice and the Code of Ethics for the nutrition and dietetics profession. 2.3.2 Adheres to confidentiality and privacy legislation, practice standards and organization’s policies. 2.3.3 Demonstrates awareness of all mandatory reporting obligations. 2.3.4 Protects the confidentiality and security of information throughout collection, storage, use, dissemination and destruction process. 2.3.5 Works within the defined role and responsibilities outlined by the employer. Unit 3: Individual and Community Services Applies and integrates client-centered principles supporting access to services, and promotes health and wellness of an individual and community. 3.1 Screens basic nutrition and health needs of individuals and communities. 3.1.1 Uses standardized nutrition screening tools to identify client/patient’s and community’s nutritional risks and needs. 3.1.2 Adheres to guidelines, protocols and policies when performing nutrition screening. 3.1.3 Collects data using interviewing skills, observation and available evidence to inform nutrition screening process. 3.1.4 Collects relevant information about the client/patient’s prior function, abilities, nutritional health and environment. 3.1.5 Identifies internal and external environmental factors that may impact the client/patient’s or community’s nutrition health outcomes. 3.1.6 Identifies and accesses resources that may enhance the nutritional health and wellness of the client/patient and community. 3.1.7 Reports findings to support the development of the nutrition plan and to inform client/patient or community nutrition needs. 3.1.8 Recognizes client/patient’s nutritional health status, symptoms and abilities and refers to others when appropriate. 3.1.9 Determines factors that may influence nutrition intake and nutritional status. 3.1.10 Recognizes nutritional health behaviors and determinants of health attributes that influence food habits and preferences in individuals, groups and communities. 3.2 Participates in the development, monitoring and modifications of the client/patient’s nutrition programs. 3.2.1 Reports nutrition screening data to inform the development of the nutrition plan of care. 3.2.2 Accurately communicates client/patient’s nutritional health status, symptoms and abilities and facilitates appropriate referrals. 3.2.3 Communicates cultural and personal nutrition needs of the client/patient and community to appropriate team members. 114 Table 26. cont. Unit 3 cont. Competencies Performance Indicators 3.2 cont. 3.2.4 Supports the client/patient’s understanding of the nutrition plan of care in his or her cultural context. 3.2.5 Implements the established nutrition program and plan of care in collaboration with the client/patient and other team members. 3.2.6 Monitors and reports a client/patient’s nutritional health status following established protocols and procedures. 3.2.7 Reports changes in nutritional health status, situation, environment and or compliance to appropriate team member. 3.3 Considers the factors that impact food availability in the community within the social determinants of health. 3.4 Supports recipe modification and meal planning based on cultural needs and preferences in collaboration with other professionals. 3.5 Coordinates community nutrition programs and promotes access to community resources. 3.3.1 Uses standardized nutrition educational material templates, forms and protocols in menu planning. 3.3.2 Demonstrates basic meal preparation skills applying culinary skills and knowledge of healthy food choices and disease management. 3.3.3 Reviews a client/patient’s menus considering the nutrition and health needs based on established criteria and nutrition plan of care. 3.3.4 Considers the factors that impact food availability in the community. 3.3.5 Considers client/patient needs, nutritional requirements, and aesthetic characteristics of foods, following established guidelines. 3.4.1 Provides nutrition education using approved materials and protocols for meal planning, recipes, understanding food labels and purchasing. 3.4.2 Applies knowledge of basic food science and food preparation techniques. 3.4.3 Reviews meal plans and recipes and makes recommendations for changes based on established criteria. 3.4.4 Promotes healthful food choices and healthful eating behavior. 3.5.1 Identifies and explains individual, public, private, organizational and government roles and responsibilities. 3.5.2 Maintains current knowledge of community resources available to clients/individuals and the community. 3.5.3 Contributes to a community needs assessment and supports implementation of services. 3.5.4 Engages in stakeholder consultation to support the development and implementation of a program, service and resource. 3.5.5 Takes into consideration sustainability and population disparities when planning for the program, service and resources. 3.5.6 Contributes to the design of the nutrition program, service and resources considering the determinants of health. 3.5.7 Obtains community and organizational support for the implementation of the program, service and resource. 3.5.8 Evaluates services and resources using agency-approved evaluation criteria, tools and methods. 115 Table 26. cont. Unit 3 cont. Competencies Performance Indicators 3.6 3.6.1 Determines the needs of the client/patient or group considering the determinants of health culture and the readiness for change. Provides nutrition information and approved evidenceinformed nutrition educational materials to meet the needs of the individual and community. 3.6.2 Selects appropriate evidence-informed materials to meet the needs of the audience. 3.6.3 Selects the appropriate delivery method to meet the needs of the audience and overall nutrition goals. 3.6.4 Suggests modifications to the materials to ensure cultural acceptance. 3.6.5 Evaluates the effectiveness of the nutrition information and education. Unit 4: Cultural Competence Applies cultural principles to guide services and to positively impact nutrition and health behaviors of individuals and the community. 4.1 4.1.1 Develops an awareness of how cultural differences influence interactions. Demonstrates an understanding of the principles of cultural competence. 4.1.2 Gains a holistic understanding of the client/patient’s and community’s needs considering the determinants of health. 4.1.3 Develops self-awareness of personal beliefs, values and biases to better serve clients/patients from different cultures and backgrounds. 4.1.4 Respects the human rights of clients/patients and the community. 4.1.5 Empowers clients/patients to value cultural identity and well-being. 4.1.6 Takes into consideration the culture of the work setting and the different cultures of the team members. 4.2 Identifies and addresses cultural needs of the individual and community. 4.2.1 Identifies and addresses barriers to implementing culturally competent practices. 4.2.2 Identifies strategies for dealing respectfully with clients/patients whose cultural background or language is different from one’s own. 4.2.3 Recognizes the importance of social and cultural norms, community wishes and challenges with integration into the community. 4.2.4 Modifies services to meet the needs of culturally diverse clients/patients and groups. 4.2.5 Promotes delivery of culturally sensitive nutrition care and resources. 4.3 4.3.1 Identifies client/patient’s and group’s cultural food and eating patterns. Demonstrates knowledge of foods, cultural and religious food traditions, eating patterns and trends in the community. 4.3.2 Recognizes cultural diversity in food preparation and traditions. 4.3.3 Integrates knowledge of cultural foods when practicing culinary skills and when selecting and providing nutrition educational materials. 116 Table 26. cont. Unit 5: Communication, Collaboration and Advocacy Applies effective communication techniques to achieve common nutrition health goals. Competencies Performance Indicators 5.1 5.1.1 Fosters open, honest, clear and ethical communication. Applies effective written and oral communication skills and techniques to achieve desired goals and outcomes. 5.1.2 Communicates clearly and effectively. 5.1.3 Selects appropriate mode of communication for specific messaging to meet the needs of the audience. 5.1.4 Identifies and addresses barriers to communication. 5.1.5 Adapts communication style to meet diverse needs of clients/patients and groups. 5.1.6 Uses effective verbal and written communication skills to deliver information in a respectful thoughtful manner. 5.1.7 Writes clearly, concisely and professionally using correct spelling and grammar. 5.1.8 Uses active listening techniques. 5.1.9 Offers communications in the preferred language of the client/patient and seeks support from a professional interpreter when needed. 5.1.10 Interprets and responds to nonverbal communications. 5.1.11 Utilizes technology competently, ethically and efficiently to support delivery of services. 5.1.12 Documents all client/patient encounters following the standards of the profession and organizational policies. 5.1.13 Confirms information is credible and evidence-informed prior to communications 5.2 5.2.1 Communicates role and responsibilities accurately to others. Works collaboratively with intraprofessional and interprofessional team members, individuals and the community. 5.2.2 Applies networking skills to establish opportunities and to support clients/patients and community services. 5.2.3 Respects the opinions and values of others. 5.2.4 Seeks consultation and refers to other professionals when needed. 5.2.5 Demonstrates conflict management skills. 5.2.6 Understands meeting management principles in order to effectively participate in meetings and small group activities. 5.2.7 Collaborates with community partners and stakeholders in promoting individual, group and community nutritional health. 5.2.8 Consults with others and provides nutrition information within the community using agency-approved nutrition education materials. 5.3 5.3.1 Defines and compares various types of community advocacy. Advocates for nutrition programs and services for individuals and the community. 5.3.2 Participates in activities of an advocacy-based organization. 5.3.3 Networks with internal and community professional groups and organizations. 5.3.4 Identifies and suggests strategies for reaching individuals in populations that do not access available resources in the community. 117 Table 27. Proposed competencies and performance indicators for future bachelor degree programs Unit 1: Foundational Knowledge Applies foundational sciences to food and nutrition knowledge to meet the needs of individuals, groups, and organizations. Competencies Performance Indicators 1.1 1.1.1 Identifies and considers environmental and genetic factors that influence the development of disease. Applies a basic understanding of environmental and genetic factors and food in the development and management of disease. 1.2 Demonstrates an understanding of anatomy and physiology. 1.3 Demonstrates an understanding of microbiology related to food and nutrition and food safety. 1.1.2 Identifies and considers the influence of food consumption on the development of disease. 1.1.3 Identifies the foods needed to treat acute and chronic diseases. 1.2.1 Recognizes anatomical structures and explains the physiological functions of the body. 1.2.2 Describes the physiological processes of humans. 1.2.3 Analyzes the impact of disease state, injury and food on different body systems and functions. 1.3.1 Applies food safety principles across all stages of the life cycle and all stages during the flow of food. 1.4 Demonstrates knowledge of chemistry and food science as it pertains to food and nutrition. 1.4.1 Applies fundamental chemistry and organic chemistry principles to enhance understanding of food. 1.5 1.5.1 Explains ingestion, digestion, absorption, metabolism and excretion of nutrients. Demonstrates and applies knowledge of patho-physiology and biochemical functionality and their relationship to physiology. 1.4.2 Applies nutritional biochemistry principles to the understanding of human nutrition health and metabolism. 1.4.3 Explains the chemical nature of food and the impact on food quality, acceptability and compatibility. 1.5.2 Recognizes nutritional biochemical indicators specific to the disease process. 1.5.3 Explains the effect of diet, fluids, electrolytes and nutritional status on the development and progress of the disease process. 1.5.4 Explains the effects of disease, clinical conditions and treatment on nutritional health status. 118 Table 27. cont. Unit 1: Foundational Knowledge (cont.) Competencies Performance Indicators 1.6 1.6.1 Identifies social and psychological factors affecting intake of food and impacting nutritional status. Applies knowledge of social, psychological and environmental aspects of eating and food. 1.6.2 Demonstrates an understanding of behavioral health as an overall component of health, wellness and nutritional status. 1.6.3 Defines and discusses the practice of sustainability, food and water waste, reusable/biodegradable items, local produce sourcing and access to food. 1.6.4 Identifies key environmental factors that may affect services and/or access to food. 1.7 1.7.1 Demonstrates knowledge of the cultural competence models. Applies the principles of cultural competence within own practice. 1.7.2 Applies knowledge of foods, cultural foods, eating patterns and food trends. 1.7.3 Identifies challenges that arise when different cultures, values, beliefs and experiences exist between clients/patients and nutrition and dietetics professionals. 1.7.4 Identifies and implements strategies to address cultural biases and differences. 1.7.5 Applies culturally sensitive approaches and communication skills. 1.7.6 Develops self-awareness of one’s own personal beliefs, values and biases to better serve clients/patients of different cultures and backgrounds. 1.8 Demonstrates basic knowledge of pharmacology and integrative and functional nutrition. 1.8.1 Identifies the major pharmacological classifications to inform potential drug and food interactions. 1.8.2 Recognizes significant drug and nutrient interactions to inform practice and ensure client/patient safety. 1.8.3 Identifies evidence-based literature and resources related to pharmacology and integrative and functional nutrition. 1.8.4 Identifies the purpose, risks, disadvantages and contraindications of commonly used therapies. 1.9 1.9.1 Understands fundamental statistics concepts and basic application. Demonstrates knowledge of math and statistics. 1.9.2 Demonstrates understanding and applies mathematical concepts and problem solving in nutrition and food-related activities. 1.10 1.10.1 Communicates with health care professionals using basic medical terminology. Demonstrates knowledge of medical terminology when communicating with individuals. 1.10.2 Uses acceptable medical abbreviations and appropriate medical terminology in oral and written communications. 1.10.3 Demonstrates understanding of common terms used by other disciplines. 119 Table 27. cont. Unit 1: Foundational Knowledge (cont.) Competencies Performance Indicators 1.11 1.11.1 Applies appropriate cooking skills and techniques. Demonstrates knowledge of food preparation techniques. 1.11.2 Converts recipes and ingredients based on client/patient preferences or dietary needs. 1.11.3 Properly operates equipment and common culinary hand tools. 1.11.4 Complies with and practices safe work habits, identifies safety hazards and employs preventive safety measures. 1.11.5 Applies consistent portion control skills. 1.11.6 Reads and follows recipes. 1.11.7 Ensures foods are aesthetically pleasing, appealing and tasteful. 1.12 1.12.1 Applies technology in the decision making process. Applies nutrition informatics in the decision making process. 1.12.2 Describes factors to consider when accessing and evaluating nutritional health information online. 1.12.3 Identifies trends in nutritional health care and food systems. 1.12.4 Uses electronic databases to obtain information. 1.12.5 Proficiently uses new technology to enhance practice and client/patient care. 1.13 Applies nutrition knowledge in the provision of nutrition care at all stages of the life cycle. 1.14 Applies knowledge of nutritional health promotion and disease prevention for individuals and groups. 1.13.1 Compares and contrasts nutrition needs of individuals at all stages of the life cycle using standardized templates and guidelines. 1.13.2 Calculates nutritional needs of individuals based on comparative standards. 1.14.1 Determines impact of physical activity and movement on nutritional needs. 1.14.2 Compares the relationship between the determinants of health and dimensions of wellness. 1.14.3 Applies knowledge of epidemiology related to dimensions of wellness and disease prevention. 1.14.4 Recognizes the cause of disease and threats to the health of individuals and groups. 1.14.5 Identifies risk reduction strategies for individuals and groups. 1.14.6 Keeps current about media, culture and peer influences on dimensions of wellness. 1.14.7 Identifies effects of deficiencies and toxicities of nutrients on nutritional health. 1.14.8 Applies behavior change theories for nutritional health promotion and disease prevention. 120 Table 27. cont. Unit 2: Client/Patient Services Applies and integrates client/patient-centered principles and competent nutrition and dietetics practice to ensure positive outcomes. Competencies Performance Indicators 2.1 2.1.1 Conducts an assessment of the practice setting environment, competitive landscape and stakeholder opinions to identify and evaluate data needed to make decisions regarding nutritional products, programs and services. Applies a framework to assess, develop, implement and evaluate nutritional program and services directed to clients/patients whose nutritional health needs are less complex. 2.2 Conducts and interprets nutrition screening using standardized tools for individuals, groups or targeted populations whose nutritional health needs are less complex. 2.3 Utilizes the nutrition care process to manage clients/patients with less complex nutritional health needs when practice setting environmental supports are in place. 2.1.2 Identifies opportunities for nutritional intervention/improvement. 2.1.3 Implements programs or services following predefined designs, plans or models. 2.1.4 Evaluates effectiveness of nutritional programs, products or services by analyzing reasons for variance from expected outcomes and implements new strategies, as appropriate. 2.1.5 Collaborates with appropriate stakeholders. 2.2.1 Selects nutrition and activity screening tools taking into consideration all client/patient factors. 2.2.2 Compares nutrition screening results with normative references to determine the nutritional risk level of individuals. 2.2.3 Determines the appropriate service and referral needs. Nutrition Assessment 2.3.1 Conducts a nutrition assessment on individuals with less complex or less acute nutritional health care needs when environmental supports are in place. 2.3.2 Collects, assesses and interprets vital signs and anthropometric measures. 2.3.3 Collects routine biochemical tests (e.g. capillary blood glucose levels). 2.3.4 Identifies abnormal and normal biochemical values and medical test/procedure results. 2.3.5 Determines barriers that might influence a client/patient’s nutritional status. 2.3.6 Determines accuracy and currency of the nutrition assessment data. Diagnosis 2.3.7 Analyzes and synthesizes nutrition assessment data to inform nutrition diagnosis(es) and plan of care. 2.3.8 Identities the appropriate validated formulas and performs calculations to determine nutritional requirements. 121 Table 27. cont. Unit 2: Client/Patient Services (cont.) Competencies Performance Indicators 2.3 (cont.) Diagnosis (cont.) 2.3.9 Creates PES (problem, etiology and sign or symptom) statement and outlines reasons for professional opinion, cause and contributing factors. 2.3.10 Prioritizes the nutrition diagnosis(es). 2.3.11 Determines the need to consult, transfer nutrition care or refer to others. Intervention 2.3.12 Recommends an individualized plan of care that addresses nutritional care needs, diagnosis and client/patient goals in collaboration with the client/patient and team members. 2.3.13 Implements plan of care or intervention in collaboration with the client/patient and other team members. Monitoring/Evaluation 2.3.14 Monitors and evaluates problems, etiology, signs or symptoms and impact of intervention on the nutrition diagnosis. 2.3.15 Applies standardized nutrition care outcome indicators to measure nutrition interventions. 2.3.16 Assesses client/patient’s understanding and compliance with nutrition intervention. 2.3.17 Identifies barriers to meeting client/patient’s nutrition goals. 2.3.18 Summarizes impact of the sum of all interventions on overall client/patient’s nutrition outcomes. 2.3.19 Identifies reasons for deviation from expected nutrition outcomes for a given nutrition intervention for client/patient. 2.3.20 Makes and implements modifications to the plan of care or nutritional intervention in collaboration with the client/patient and health care team. Documentation 2.3.21 Documents all elements of the nutrition care process following professional standards and organizational policies. 2.3.22 Applies coding and billing procedures and policies for nutrition and dietetics services to obtain reimbursement from public and private insurers. 2.4 Medical Nutrition Therapy Performs nutritional interventions for client/patient with less complex nutrition care needs when environmental supports are in place. 2.4.1 Ensures environmental supports are in place prior to implementing the plan of care. 2.4.2 Manages medical nutrition therapy for clients/patients whose condition or nutritional status is less complex and plan of care, nutrition diagnosis and prognosis are clearly established. 2.4.3 Applies and integrates understanding of foundational sciences to manage medical nutrition therapy. 122 Table 27. cont. Unit 2: Client/Patient Services (cont.) Competencies Performance Indicators 2.4 (cont.) Medical Nutrition Therapy (cont.) 2.4.4 Applies foundational science knowledge and medical nutrition therapy principles to manage oral diets and oral nutritional supplements. 2.4.5 Monitors tolerance of enteral feedings and adherence to nutrition recommendations for client/patient’s whose nutrition therapy has been well established. 2.4.6 Considers client/patient complexity, nutritional impact, indications, side effects, contraindications, benefits, alternatives and foundational sciences when recommending the use of nutritional supplements. 2.4.7 Transfers nutrition care to registered dietitian nutritionist or physician when client/patient needs become more complex, when environment changes or when required nutrition intervention is beyond personal competence or professional scope of practice. Education 2.4.8 Applies education theories, adult learning, pedagogy and education principles. 2.4.9 Assesses audience’s readiness to learn and identifies barriers to learning including client/patient and environmental factors. 2.4.10 Modifies nutrition education materials or delivery methods to meet the needs of the client/ patient or group. 2.4.11 Provides evidence-informed nutrition education to clients/patients and groups. 2.4.12 Translates basic food and general nutrition knowledge into understandable language tailored to the audience. 2.4.13 Evaluates effectiveness of nutrition education and makes modifications as required. Coaching and Counseling 2.4.14 Assesses a client/patient’s needs and appropriateness for the recommended counseling or coaching. 2.4.15 Applies coaching and counseling principles when providing individualized sessions to clients/patients whose needs are less complex and when workplace supports are in place. 2.4.16 Evaluates effectiveness of coaching or counseling and makes modifications as required. 2.4.17 Refers to other professionals when client/patient needs are beyond personal competence or professional scope of practice. 2.5 Considers the client/patient’s use of integrative and functional nutrition and related beliefs and values. 2.5.1 Demonstrates awareness of integrative and functional nutrition interactions. 2.5.2 Recommends nutritional supplements based on nutrition assessment, while adhering to the professional standards and evidence-informed practice. 123 Table 27. cont. Unit 3: Food Systems Management Applies food system principles and management skills to ensure safe and efficient delivery of food and water. Competencies Performance Indicators 3.1 3.1.1 Plans, designs and coordinates nutritionally sound meals that meet client/patient’s needs and promote nutritional health and disease management. Manages the production, distribution and service of quantity and quality of food products. 3.2 Coordinates the purchasing, receipt and storage of food products and services. 3.1.2 Ensures work activities and products reflect the organization’s mission. 3.1.3 Investigates and optimizes opportunities to reduce the environmental carbon footprint of foodservice operations and to enhance sustainability. 3.1.4 Implements the use of new kitchen or dietary processes to facilitate efficient and effective services. 3.2.1 Conducts a facility analysis of equipment and technological needs based on resource availability, anticipated future growth and sustainability. 3.2.2 Identifies and analyzes the need to engage internal or external stakeholders in an agreement or contract. 3.2.3 Applies ethical negotiation skills to manage contracts and professional agreements. 3.2.4 Coordinates human and financial resources to assure appropriate inventory control. 3.2.5 Develops, implements and uses inventory management systems to track and ensure accurate inventory reporting. 3.2.6 Analyzes inventory control as it pertains to the food and supplies of the foodservice operation. 3.2.7 Manages the process of receiving and storing products, demonstrating adherence to food safety code guidelines and regulations. 3.2.8 Manages the relationship between forecasting and production as it pertains to recipe needs and organizational demand. 3.3 Applies principles of food safety and sanitation to the production and service of food. 3.3.1 Maintains currency in and follows applicable legislation and guidelines. 3.3.2 Follows the required safety and legislation, regulations, guidelines, policies and procedures applicable to the practice setting environment and services provided. 3.3.3 Manages activities related to compliance with health and safety requirements. 3.3.4 Applies and educates others on food safety principles. 3.3.5 Identifies local vulnerabilities in the food supply chain as it relates to bioterrorism, natural disasters and food contamination. 3.3.6 Adheres to and educates other on infection prevention and control measures. 3.3.7 Supports the implementation of an emergency preparedness plan and distribution of services pertaining to foodservice operations. 124 Table 27. cont. Unit 3: Food Systems Management (cont.) Competencies Performance Indicators 3.4 3.4.1 Has a working knowledge of different agricultural food production systems and related terminology. Applies an understanding of agricultural practices and processes. 3.4.2 Identifies the need and establishes partnerships with local growers and producers. Unit 4: Community and Population Health Nutrition Applies community and population nutrition health theories when providing support to community or population nutrition programs. 4.1 Works collaboratively with others to assesses, implement and evaluate community and population based programs. 4.1.1 Conducts an assessment of the practice setting, competitive landscape and stakeholder opinions to identify and evaluate data needed to make decisions regarding nutrition products, programs and services. 4.1.2 Identifies opportunities for nutrition intervention and improvement. 4.1.3 Utilizes strategies to evaluate effectiveness, analyzing reasons for variance from expected outcome, and implements new strategies as appropriate. 4.1.4 Collaborates with appropriate stakeholders to support the implementation of the nutrition program plan. 4.1.5 Applies an evaluation framework, using approved tools and methods, to support the evaluation of the community nutrition program. 4.1.6 Makes modifications to the nutrition program or services based on data and in collaboration with others. Unit 5: Leadership, Business, Management and Organization Demonstrates leadership, business and management principles to guide practice and achieve operational goals. 5.1 Demonstrates leadership skills to guide practice. 5.1.1 Demonstrates understanding of social situations and dynamics, and ability to operate effectively in a variety of social environments. 5.1.2 Communicates at the appropriate emotional level, and understands emotions and emotional situations. 5.1.3 Develops interpersonal skills by becoming an active listener and having strong conversational and speaking skills. 5.1.4 Sees other’s perspectives and is open to and considers other’s points of view. 125 Table 27. cont. Unit 5: Leadership, Business, Management and Organization (cont.) Competencies Performance Indicators 5.2 Planning Applies principles of organization management. 5.2.1 Works within an established operational plan by monitoring budget, inventory control, labor and regular daily tasks. 5.2.2 Aligns work and department activities with organizational strategic plan, mission and vision. Organizing 5.2.3 Assigns responsibilities to various team members according to scope of practice and personal competence. 5.2.4 Sets and monitors clear targets for team members that are aligned with common objectives and goals. Management 5.2.5 Engages in human resource activities adhering to applicable legislation and regulations. 5.2.6 Applies understanding of psychological and sociological perspectives when managing staff and engaging in human resource activities. 5.2.7 Applies change management theories and conflict resolution skills to manage and promote positive change. 5.2.8 Uses persuasive communication skills to influence and produce a desired outcome during negotiations and conflict resolution discussions. 5.2.9 Understands and respects roles and responsibilities of the interprofessional team members. Controls 5.2.10 Collects, understands and analyzes financial data to support fiscally responsible decision making. 5.2.11 Collects and reports data to support the analysis of the department’s operational plan and budget. Time Management 5.2.12 Applies principles of time management to monitor and enhance personal productivity and productivity of others. 5.2.13 Prioritizes activities to effectively manage time and workload. 5.2.14 Evaluates the whole system. Motivation and Recognition 5.2.15 Demonstrates appreciation for team involvement and the value and skills of each member. 5.2.16 Models behaviors that maximize group participation by consulting, listening and communicating clearly. 5.2.17 Takes innovative approaches to build support and maintain a diverse workforce. 126 Table 27. cont. Unit 5: Leadership, Business, Management and Organization (cont.) Competencies Performance Indicators 5.3 5.3.1 Collaborates with others to define the project scope and project plan. Applies project management principles to achieve project goals and objectives. 5.3.2 Monitors approved project plan to ensure deliverables are met within scope of the project scope, time and cost. 5.4 5.4.1 Establishes goals for improving quality of services in collaboration with others. Incorporates quality improvement into nutrition and dietetic practice. 5.3.3 Reports potential and real risk and suggests options to resolve the risk. 5.4.2 Identifies quality improvement indicators and supports the development of quality improvement measurement tools. 5.4.3 Participates in the development of policies and performance measures for quality and quantity of work. 5.4.4 Ensures compliance with external standards, collects data and reports findings. 5.4.5 Collects data to assess the quality of services provided and identifies opportunities for improvement. 5.4.6 Evaluates and analyzes data, reports findings and makes recommendations for quality improvement. 5.4.7 Communicates and collaborates with relevant stakeholders to implement changes to improve effectiveness and efficiency. 5.5 Incorporates risk management strategies into practice. 5.5.1 Assesses potential and real risks to an individual, group and or organization. 5.5.2 Identifies and takes action to manage, reduce and or eliminate risk or hazards to self, others and the organization. 5.5.3 Supports implementation of risk management plan. Unit 6: Critical Thinking, Research and Evidence-Informed Practice Integrates evidence-informed practice, research principles, and critical thinking into practice. 6.1 Incorporates critical thinking skills in overall practice. 6.1.1 Identifies how critical thinking allows for consideration of multiple factors when problem solving. 6.1.2 Incorporates the thought process used in critical thinking models. 6.1.3 Engages in reflective practice to promote change and continuous learning. 6.2 6.2.1 Identifies basic steps of the scientific method and scientific processes. Identifies and understands the scientific method and research ethics. 6.2.2 Recognizes research ethics and responsible conduct in research. 6.2.3 Collects and retrieves data using a variety of methods and technologies. 6.2.4 Communicates pre-developed research messaging to a variety of audiences. 127 Table 27. cont. Unit 6: Critical Thinking, Research and Evidence-Informed Practice (cont.) Competencies Performance Indicators 6.3 Applies current research and evidence-informed practice to services. 6.3.1 Uses resources to find accurate and current research and evidence-based literature. 6.3.2 Understands basic components of assessing the strengths and limitations of research articles. 6.3.3 Uses research terminology when communicating with other professionals. 6.3.4 Evaluates current research and evidence-based practice findings to determine the reliability and credibility of information. 6.3. 5 Applies current research and evidence-informed practice to the deliver safe and effective nutrition care. Unit 7: Professionalism Assumes professional responsibilities to provide safe, ethical and effective nutrition services. 7.1 Demonstrates ethical behaviors in accordance to the professional Code of Ethics. 7.1.1 Demonstrates honesty and integrity, and behaves in a trustworthy, transparent, respectful and non-judgmental manner toward clients/patients and colleagues. 7.1.2 Understands governance of nutrition and dietetics practice as outlined in documents such as the Scope of Nutrition and Dietetics Practice and the professional Code of Ethics. 7.1.3 Accepts responsibility and accountability for own actions and decisions. 7.1.4 Practices in a manner that respects diversity and avoids prejudicial treatment of an individual, group or population. 7.1.5 Understands the impact of the client/patient-provider relationship on services. 7.1.6 Applies client/patient-centered principles to all activities and services. 7.1.7 Recognizes and maintains professional boundaries with clients/patients. 7.1.8 Analyzes the impact of one’s own professional behaviors, values, beliefs and actions on others. 7.1.9 Develops advertising and marketing materials that are accurate, truthful and evidence-informed. 7.1.10 Applies principles of the informed consent process to ensure the client/patient is capable of accepting or refusing services. 7.1.11 Advocates for and takes action to ensure others demonstrate professional responsibilities and ethical behaviors 7.1.12 Recognizes and take steps to manage ethical dilemmas. 7.2 Engages in selfreflective practice to maintain ongoing competence and professional behaviors. 7.2.1 Demonstrates continuous self-awareness by critically evaluating one’s knowledge, skill, judgment and learning and leadership style. 7.2.2 Obtains feedback and demonstrates a willingness to consider opinions of others. 7.2.3 Considers and incorporates own experiences and learning in practice. 7.2.4 Develops personal learning goals and objectives, and identifies activities to meet these goals. 7.2.5 Incorporates learning to ensure safe ethical and competent nutrition care. 128 Table 27. cont. Unit 7: Professionalism (cont.) Competencies Performance Indicators 7.3 Adheres to nutrition related legislation, regulations and standards of practice. 7.3.1 Adheres to confidentiality and privacy legislation, practice standards and organization’s policies regarding client/patient information. 7.3.2 Demonstrates awareness of all mandatory reporting obligations. 7.3.3 Obtains consent for the collection, use, sharing, storage and release of personal information. Unit 8: Communication, Collaboration and Advocacy Uses effective communication with others to achieve common goals and enhance relationships in the provision of nutrition and dietetics services. 8.1 8.1.1 Communicates in a clear, effective and respectful manner. Applies effective and ethical communication skills and techniques to achieve desired goals and outcomes. 8.1.2 Selects mode of communication appropriate to the messaging to meet the needs of the audience. 8.1.3 Identifies and addresses barriers to communication. 8.1.4 Adapts communication style to meet needs of diverse individuals and groups. 8.1.5 Uses active listening techniques. 8.1.6 Interprets and responds to nonverbal communications. 8.1.7 Understands and applies media communication principles including presenting with poise, developing key points, conveying scientific accuracy, and translating to consumer language. 8.1.8 Ensures timely, clear and accurate documentation using correct spelling and grammar, following the standards of the profession and organizational policies. 8.1.9 Demonstrates proficient use of nutrition informatics. 8.2 Works with and facilitates intraprofessional and interprofessional collaboration and teamwork. 8.2.1 Demonstrates networking skills to build liaisons with internal and external stakeholders. 8.2.2 Seeks consultation and refers to other professionals when needed. 8.2.3 Networks with internal and community professional groups and organizations. 8.2.4 Demonstrates understanding of meeting management principles by effectively facilitating meetings and small group activities to achieve goals within time frames. 8.2.5 Demonstrates knowledge of the interprofessional team members’ scope of practice and competence. 8.2.6 Supports others in meeting their professional obligations. 8.2.7 Functions as member of the interprofessional team to support a collaborative client/patient-centered approach. 8.2.8 Understands the mentoring role and practices mentoring or precepting others. 129 Table 27. cont. Unit 8: Communication, Collaboration and Advocacy (cont.) Competencies Performance Indicators 8.3 8.3.1 Advocates for the profession by communicating to others the role, scope of practice and areas of expertise of the profession. Demonstrates advocacy skills to promote awareness and required change. 8.3.2 Participates in advocacy activities to change or promote new legislation and regulation. 130 Table 28. Proposed competencies and performance indicators for future master degree programs Unit 1: Foundational Knowledge Applies foundational sciences to food and nutrition knowledge to meet the needs of individuals, groups, and organizations. Competencies Performance Indicators 1.1 1.1.1 Analyzes the usefulness and limitations of epidemiological study designs and identifies trends in diet and disease. Applies an understanding of environmental and genetic factors and food in the development and management of disease. 1.1.2 Examines issues in relation to gene nutrient interactions. 1.1.3 Communicates epidemiological evidence related to the relationship between diet and the development of disease. 1.1.4 Demonstrates an understanding of research techniques and processes used to study the effects of genetics on disease states. 1.1.5 Identifies the influence of food consumption on the development of diseases. 1.1.6 Supports management of food consumption to treat acute and chronic diseases. 1.2 1.2.1 Analyzes the impact of food and nutrition on physiological processes. Applies an understanding of anatomy and physiology. 1.2.2 Integrates knowledge of anatomy and physiology to make decisions related to nutrition care. 1.3 1.3.1 Applies the proper methods of microbial control in food and the environment. Applies knowledge of microbiology and food safety. 1.2.3 Communicates an understanding of the human body and the impact of food and nutrition on body systems. 1.3.2 Applies food safety principles of microbiological food spoilage and strategies for controlling microbial growth. 1.3.3 Applies principles of pathogens microbes, viruses and fungi as it relates to food safety principles and across all stages of the life cycle and physiological state of the individual. 1.3.4 Implements key principles and practices to make foods safe for consumption at all stages during the flow of food. 1.4 Integrates knowledge of chemistry and food science as it pertains to food and nutrition product development and when making modifications to food. 1.4.1 Summarizes and analyzes the impact of fundamental chemistry and organic chemistry principles on food, human health and metabolism. 1.4.2 Integrate nutritional biochemistry knowledge to make informed recommendations. 1.4.3 Analyzes the chemical nature of food and the impact on food quality, acceptability and compatibility. 1.4.4 Analyzes the food components and the chemical elements for food and nutrition products. 131 Table 28. cont. Unit 1: Foundational Knowledge (cont.) Competencies Performance Indicators 1.5 1.5.1 Examines nutritional biochemical indicators specific to the disease process. Demonstrates and applies knowledge of patho-physiology and biochemical functionality and their relationship to physiology, health and disease. 1.6 Applies knowledge of social, psychological and environmental aspects of eating and food. 1.5.2 Interprets and analyzes the effect of diet, fluids, electrolytes and nutritional status on the development and progress of the disease process. 1.5.3 Interprets and analyzes the effects of disease, clinical condition and treatment on nutritional health status. 1.5.4 Analyzes the correlation between mental health conditions and nutritional health. 1.6.1 Formulates food and nutrition services considering psychological and social factors to meet the needs of individuals, communities and populations. 1.6.2 Articulates the impact of nutritional health on psychiatric disorders. 1.6.3 Integrates knowledge of maximizing sustainability, food and water waste, reusable/ biodegradable items, local and global produce sourcing and access to food. 1.6.4 Analyzes the environmental factors affecting access to services and/or adequate nutrition. 1.7 1.7.1 Demonstrates knowledge of the cultural competence models. Integrates the principles of cultural competence within own practice and when directing services. 1.7.2 Applies knowledge of foods, cultural foods, eating patterns and food trends. 1.7.3 Identifies challenges that arise when different cultures, values, beliefs and experiences exist between clients/patients and nutrition and dietetics professionals. 1.7.4 Identifies and implements strategies to address cultural biases and differences. 1.7.5 Applies culturally sensitive approaches and communication skills. 1.7.6 Develops self-awareness of one’s own personal beliefs, values and biases to better serve clients/patients of different cultures and backgrounds. 1.8 Applies knowledge of pharmacology and integrative and functional nutrition to recommend, prescribe and administer medical nutrition therapy. 1.8.1 Identifies the classifications of nutraceutical pharmacological agents and the action of the body. 1.8.2 Demonstrates understanding of pharmacokinetics, absorption, clearance, drug metabolism, latency period, drug and supplement metabolism, accumulation, half-life, and routes of administration. 1.8.3 Identifies potential drug and food interactions based on physiological responses to pharmacological agents and takes appropriate actions. 1.8.4 Describes the clinical use of nutritional therapies. 1.8.5 Critically evaluates evidence-based literature and resources related to integrative and functional nutrition. 1.8.6 Identifies the purpose, risks, advantages, disadvantages and contraindications of commonly used nutritional therapies. 132 Table 28. cont. Unit 1: Foundational Knowledge (cont.) Competencies Performance Indicators 1.9 1.9.1 Chooses appropriate statistical methods and applies them in various data analysis situations. Applies knowledge of math and statistics. 1.9.2 Performs statistical analysis and interprets results. 1.9.3 Applies statistical concepts in interpretation of nutrition related data. 1.9.4 Performs data analysis using various statistical software. 1.9.5 Communicates statistical methods and results both orally and in writing. 1.9.6 Applies mathematical concepts and problem solving in nutrition and food related activities. 1.10 Applies knowledge of medical terminology when communicating with individuals, groups and other health professionals. 1.10.1 Interprets and communicates medical terminology to non-health professional audiences. 1.10.2 Uses acceptable medical abbreviations and appropriate medical terminology in oral and written communication. 1.10.3 Demonstrates understanding of common terms used by other disciplines. 1.11 1.11.1 Understands appropriate cooking skills and techniques. Demonstrates knowledge of food preparation techniques. 1.11.2 Demonstrates understanding of safe work habits and safety hazards and employs preventive safety measures. 1.11.3 Converts recipes and ingredients based on client/patient’s preferences or dietary needs. 1.11.4 Develops recipes and menus. 1.11.5 Ensures foods are aesthetically pleasing, appealing and tasteful. 1.12 Applies nutrition informatics in the decision making process. 1.12.1 Analyzes data derived from electronic media to make best decisions related to nutrition and diet. 1.12.2 Evaluates accuracy and reliability when accessing and evaluating nutrition information online. 1.12.3 Designs and operates nutrition informatics systems in practice. 1.12.4 Analyzes electronic databases to obtain nutrition information and evaluate credible sources in decision making. 1.12.5 Proficiently uses new technology to enhance practice and client/patient care. 1.13 Integrates knowledge of nutrition and physical activity in the provision of nutrition care at all stages of the life cycle. 1.13.1 Analyzes, integrates and communicates nutritional requirements related to all stages of the life cycle. 1.13.2 Identifies nutritional risk factors across all stages of the life cycle. 1.13.3 Explains the general impact of exercise and physical activity on nutrition needs throughout the life cycle. 1.13.4 Teaches the benefits of exercise at all stages of the life cycle to individuals, groups and populations. 1.13.5 Explains and takes into consideration how nutrients, nutritional supplements and hydration influence physical activity and dimensions wellness. 133 Table 28. cont. Unit 1: Foundational Knowledge (cont.) Competencies Performance Indicators 1.14 1.14.1 Recognizes and communicates the cause of disease and nutrition risks. Applies knowledge of nutritional health promotion and disease prevention for individuals, groups and populations. 1.14.2 Identifies and implements health risk reduction strategies for individuals, groups and populations. 1.14.3 Prioritizes dimensions of wellness as a result of a nutrition assessment. 1.14.4 Interprets the impact of demographic and socio economic factors and ecological issues on nutritional well-being of individuals, groups and populations. 1.14.5 Examines the influences of society, media, culture and peer pressure on dimensions of wellness. 1.14.6 Designs food and nutrition activities for various audiences considering factors relevant to individuals, groups and communities. 1.14.7 Educates others on the effects of deficiencies and toxicities of nutrients on nutritional health. 1.14.8 Applies behavior change theories for nutritional health promotion and disease prevention. 1.15 Gains a foundational knowledge on global health issues and nutritional needs. 1.15.1 Examines the trends and current issues that impact public health from existing, new and reemerging diseases that spread through immigration, travel and global trade. 1.15.2 Examines the impact of global food supply and sustainability and related factors. 1.15.3 Examines how globalizing processes impact nutrition, nutrition education and nutrition related diseases in developing countries. 1.15.4 Analyzes public policies to inform and shape policy briefs, short commentaries and longer papers. Unit 2: Client/Patient Services Applies and integrates client/patient-centered principles and competent nutrition and dietetics practice to ensure positive outcomes. 2.1 Uses a framework to assess, develop, implement and evaluate products, programs and services. 2.1.1 Conducts or coordinates an assessment of the environment, competitive landscape and stakeholder opinions to identify and evaluate data needed to make decisions regarding nutritional products, programs and services. 2.1.2 Conducts feasibility studies to determine validity and need for the nutritional programs, services or products. 2.1.3 Identifies and collaborates with stakeholders. 2.1.4 Designs nutritional products, programs or services that promote consumer nutritional health and dimensions wellness, and lifestyle management. 2.1.5 Creates a work plan or project plan to implement nutritional programs and services or launch products. 134 Table 28. cont. Unit 2: Client/Patient Services (cont.) Competencies Performance Indicators 2.1 cont. 2.1.6 Implements activities to ensure nutritional program, product or service goals are met. 2.1.7 Develops strategies to evaluate effectiveness of nutritional program, product or service by analyzing reasons for variance from expected outcomes and implements new strategies for continuous quality improvement. 2.2 Selects, develops or implements nutritional status screening tools for individuals, groups or populations. 2.2.1 Selects or develops nutrition screening tools taking into consideration all client/patient factors. 2.2.2 Evaluates the validity and reliability of the nutrition screening tools and modifies based on current evidence-informed practice. 2.2.3 Identifies appropriate resources needed to complete nutrition screening. 2.2.4 Implements nutrition screening tools in collaboration with other health professionals. 2.2.5 Determines the complexity of the client/patient care needs, appropriate care provider and required environment supports. 2.3 Utilizes the nutrition care process with individuals, groups or populations in a variety of practice settings. Nutrition Assessment 2.3.1 Conducts a nutrition focused physical exam. 2.3.2 Takes a food and nutrition related medical history. 2.3.3 Assesses physical activity and history of physical activity and exercise. 2.3.4 Collects, assesses and interprets anthropometric measures and body composition. 2.3.5 Orders, collects and interprets biochemical tests. 2.3.6 Analyzes diagnostic test results relevant to nutrition (e g. diagnostic imaging related to fluoroscopy, swallowing evaluation, enteral feeding tube placement). 2.3.7 Identifies signs and symptoms of nutrient deficiencies or excesses. 2.3.8 Determines barriers that might influence a client/patient’s nutritional status. 2.3.9 Determines accuracy and currency of nutrition assessment data. Diagnosis 2.3.10 Analyzes and synthesizes nutrition assessment data to inform nutrition diagnosis(es) and nutritional plan of care. 2.3.11 Identifies the appropriate validated formula and performs calculations to determine nutritional requirements. 2.3.12 Devises PES (problem, etiology and sign symptom) statement and outlines reasons for professional opinion cause and contributing factors. 2.3.13 Prioritizes the nutrition diagnosis(es). 2.3.14 Determines the need to consult and refer/transfer nutrition care to others. 135 Table 28. cont. Unit 2: Client/Patient Services (cont.) Competencies Performance Indicators 2.3 (cont.) Intervention 2.3.15 Develops an individualized plan of care that addresses nutritional care needs diagnosis and client nutrition goals in collaboration with the client/patient and team members. 2.3.16 Orders nutrition prescriptions to address nutritional goals. 2.3.17 Implements or facilitates the implementation of the nutrition plan of care or nutrition intervention with the patient and other team members. Monitoring/Evaluation 2.3.18 Monitors and evaluates problems, etiology, signs and symptoms and impact of nutrition intervention on the nutrition diagnosis. 2.3.19 Develops and applies nutrition care outcome indicators to measure nutrition intervention. 2.3.20 Assesses client/patient’s understanding and compliance with nutrition intervention. 2.3.21 Identifies barriers to meeting client/patient’s nutrition goals and makes recommendations to modify the nutrition plan of care or nutrition intervention, and communicates changes to client/patient and others. 2.3.22 Summarizes impact of the sum of the nutrition interventions on client/patient’s nutrition outcomes, considering client/patient-centered care. 2.3.23 Identifies, analyzes and communicates reasons for deviation from expected nutrition outcomes. 2.3.24 Evaluates the availability of services to support access to nutrition care and to help meet client/patient nutrition goals. Documentation 2.3.25 Documents all elements of the nutrition care process following professional standards and organizational policies. 2.3.26 Demonstrates coding and billing procedures and follows policies for nutrition and dietetics services to obtain reimbursement from public and private insurers. 2.4 Medical Nutrition Therapy Performs or coordinates nutritional interventions for individuals, groups or populations. 2.4.1 Manages medical nutrition therapy for clients/patients. 2.4.2 Applies and integrates understanding of foundational sciences to manage medical nutrition therapy, diet and disease management. 2.4.3 Applies foundational science knowledge and medical nutrition therapy principles to establish, order, manage and evaluate the need for nutrition support when prescribing and administering nutritional oral, enteral and parenteral diets. 136 Table 28. cont. Unit 2: Client/Patient Services (cont.) Competencies Performance Indicators 2.4 (cont.) Medical Nutrition Therapy cont. 2.4.4 Considers and applies knowledge of nutritional impact, indications, side effects, contraindications, benefits and alternatives when recommending the use of nutritional supplements. 2.4.5 Transfers care to relevant professionals when patient needs or required interventions are beyond personal competence or professional scope of practice. Education 2.4.6 Applies education theories, adult learning, pedagogy and education principles. 2.4.7 Assesses audience’s readiness to learn and identifies barriers to learning. 2.4.8 Modifies nutrition education materials or delivery methods to meet the needs of the audience. 2.4.9 Develops and provides evidence-informed nutritional wellness and therapeutic diet education to variety of audiences. 2.4.10 Translates basic to advanced food and nutrition science knowledge into understandable language tailored to the audience. 2.4.11 Communicates complex nutrition information to broad and diverse audiences. 2.4.12 Evaluates effectiveness of nutrition education and makes modifications as required. Psychological Counseling and Therapies 2.4.13 Assesses client/patient’s nutritional needs and appropriateness for the recommended counseling or therapy. 2.4.14 Applies counseling principles and evidence-informed practice when providing individual or group sessions. 2.4.15 Identifies the indications, contraindications, benefits, risks and limitations of the counseling or therapy. 2.4.16 Demonstrates understanding of transference and counter transference in the therapeutic relationship. 2.4.17 Demonstrates awareness of various appropriate psychological counseling techniques (e.g. cognitive therapy, behavior modification, motivational interviewing). 2.4.18 Evaluates effectiveness of the counseling or therapy and makes modifications as required. 2.4.19 Refers to other professionals when counseling therapy or client/patient’s mental health issues are beyond personal competence or professional scope of practice. 137 Table 28. cont. Unit 2: Client/Patient Services (cont.) Competencies Performance Indicators 2.5 2.5.1 Applies knowledge of foundational sciences and disease when determining the appropriateness of the therapy. Prescribes or recommends nutrition-related pharmacotherapy and integrative and functional nutrition. 2.5.2 Demonstrates awareness of alternative and complementary therapy and drug interactions. 2.5.3 Assesses client/patient factors to determine the client/patient’s indication for the nutrition related pharmacotherapy. 2.5.4 Considers client/patient factors, nutritional impact, indications, side effects, contraindications, benefits, risks, alternatives and foundational sciences when prescribing or administering nutrition related drug therapy. 2.5.5 Critically analyzes the potential negative effects of the nutrition therapy or supplement and determines the required knowledge, skill and judgment required to manage negative outcomes. 2.5.6 Prescribes or administers nutrition related pharmacotherapy and integrative and functional nutrition adhering to the professional standards and evidence-informed practice. 2.5.7 Applies the standard of practice, legislation, organizational policies and evidence-informed practices for prescribing. 2.5.8 Applies the principles of safe drug administration. 2.5.9 Monitors the response and the effects of the nutrition related drug, supplement and integrative and functional nutrition on the individual and takes the required action to make modifications or adjustments. 2.5.10 Consults and refers client/patient to another professional when client/patient’s needs are beyond personal competence or professional scope of practice. Unit 3: Food Systems Management Applies food systems principles and management skills to ensure safe and efficient delivery of food and water. 3.1 Oversees the production and distribution of quantity and quality of food products. 3.1.1 Manages or oversees the planning, designing and coordination of meals to ensure delivery of nutritionally sound meals. 3.1.2 Analyzes the workflow design and makes recommendations for modifications or approves for implementation. 3.1.3 Communicates the organization’s mission and how work activities impact the clients/patients and organization. 3.1.4 Establishes and analyzes policies and performance measures for quality and quantity of work. 3.1.5 Implements systems to report on local, state and federal compliance. 3.1.6 Directs and analyzes the evaluation of foodservice production and services to inform, change, and/or budget resources and department or corporate direction. 3.1.7 Establishes a culture that is ethical and free of safety and health hazards. 3.1.8 Investigates and optimizes opportunities to reduce the environmental carbon footprint of foodservice operations and to enhance sustainability. 138 Table 28. cont. Unit 3: Food Systems Management (cont.) Competencies Performance Indicators 3.2 3.2.1 Follows a matrix or measures to evaluate the need for financial, technical and equipment resources for the provision of foodservices. Oversees the purchasing, receipt and storage of products used in food production and services. 3.2.2 Applies ethical decision making to determine the need for reduction or increase in resources. 3.2.3 Creates internal or external professional relations and/or agreementsto solve problems in foodservice operations. 3.2.4 Acts as a departmental and organizational liaison between contractual parties involved. 3.2.5 Demonstrates knowledge of inventory control as it pertains to the food and supplies of the foodservice operation. 3.2.6 Applies the principles of the process of receiving and storing products demonstrating adherence to food safety code, nutrition guidelines and regulations. 3.2.7 Applies the relationship between forecasting and production as it pertains to recipe needs and organizational demand. 3.3 Applies principles of food safety and sanitation to the production and service of food. 3.3.1 Maintains currency in and follows applicable legislation and guidelines. 3.3.2 Monitors staff compliance with laws, policies and procedures. 3.3.3 Incorporates the required safety and nutritional health policies and procedures in the organization’s mission and policies. 3.3.4 Identifies local and global vulnerabilities in the food supply chain as it relates to bioterrorism, natural disasters and food contamination. 3.3.5 Ensures systems are in place to encourage compliance with nutritional health and safety requirements and infection control measures. 3.3.6 Develops and facilitates the implementation of an emergency preparedness plan and distribution of services pertaining to local, state and global foodservice operations and feeding programs. 3.4 Applies and demonstrates an understanding of agricultural practices and processes. 3.4.1 Has a working knowledge of different agricultural food production systems and related terminology and concepts including potential nutritional impact. 3.4.2 Understands the local and global food markets and applicable nutrition regulations. 3.4.3 Identifies and supports partnerships with local and global food growers and producers. 139 Table 28. cont. Unit 4: Community and Population Health Nutrition Applies community and population nutrition health theories when providing support to community or population nutrition programs. Competencies Performance Indicators 4.1 4.1.1 Demonstrates knowledge of public health, health promotion and population nutrition health principles. Follows programming planning steps to develop and implement community, population and global programs. 4.1.2 Recognizes how determinants of health influence the nutrition health and well-being of a population. 4.1.3 Develops and conducts community and population based assessments considering all relevant factors. 4.1.4 Identifies and documents epidemiological findings, health disparities, political interests, impacts of determinants of health, availability of resources, accessibility and program goals and objectives. 4.1.5 Identifies the resources and partners needed for sustainability of the program. 4.1.6 Considers the assessment data and potential strengths, benefits, constraints and limitations when developing the program. 4.1.7 Develops the program addressing the nutrition needs of the group, community or population. 4.1.8 Implements program plan applying project management skills and adhering to public nutritional health policies and standards. 4.1.9 Collects nutrition surveillance and global health and safety data and evaluates the program using measure indicators and outcomes. 4.1.10 Communicates evaluation findings, outcomes, recommendations and research findings to stakeholders to promote change and justify program. 4.2 Identifies environmental and public health hazards that impact nutrition and participates in or coordinates the management of the situation. 4.3 Engages in legislative and regulatory activities that address community, population and global nutrition health and nutrition policy. 4.2.1 Maintains knowledge of current environmental, food safety and nutrition issues at a community, population and global level. 4.2.2 Investigates and analyzes key factors that impact nutrition. 4.2.3 Imparts expertise in nutrition, food safety and sustainability to key stakeholders. 4.2.4 Recommends strategies and coordinates programs for preventing or minimizing nutrition and food safety issues. 4.3.1 Interprets legal terminology used to establish nutrition regulations and policies for populations. 4.3.2 Navigates governmental, intergovernmental and nongovernmental organizations to promote proclamations of nutrition legislation and regulations that address public, population and global nutrition health. 4.3.3 Identifies and prioritizes health disparities and security contributing to community, population and global nutrition health issues. 4.3.4 Uses various tools to formulate and advocate for legislative and policy changes to impact nutrition and health policies at all government levels. 140 Table 28. cont. Unit 5: Leadership, Business, Management and Organization Demonstrates leadership, business and management principles to guide practice and achieve operational goals. Competencies Performance Indicators 5.1 5.1.1 Exhibits self-awareness in terms of personality, learning, leadership style and cultural orientation Demonstrates leadership skills to guide practice. 5.1.2 Demonstrates understanding of social situations and dynamics and ability to operate effectively in a variety of social environments. 5.1.3 Communicates at the appropriate emotional level, understands emotions and emotional situations and is in tune with one’s own emotions. 5.1.4 Develops interpersonal skills by becoming an active listener and having strong conversational and speaking skills. 5.1.5 Sees others’ perspectives and is open to and considers other’s points of view. 5.2 Planning Applies principles of organization management. 5.2.1 Establishes operational plan considering budget, inventory control, labor and regular daily tasks. 5.2.2 Aligns plans with the organizational strategic plan, mission and vision. Organizing 5.2.3 Assigns responsibilities to various team members according to scope of practice and personal competence. 5.2.4 Sets and monitors clear targets for team members, departments and the organization aligned with common objectives and goals. 5.2.5 Demonstrates an understanding of how individuals and groups interact within the organization. 5.2.6 Takes into consideration individual and organizational culture and behaviors when planning and managing. Management 5.2.7 Applies understanding of psychological and sociological perspectives when managing staff and engaging in human resource activities. 5.2.8 Engages in, manages or leads human resource activities adhering to applicable legislation and regulations. 5.2.9 Integrates change management theories and conflict resolution skills to manage and promote positive change. 5.2.10 Uses persuasive communication skills to influence or produce a desired outcome during negotiations and conflict resolution discussions. 5.2.11 Understands and respects roles and responsibilities of inter professional team members. Controls 5.2.12 Collects, understands and analyzes financial data to support fiscally responsible decision making. 141 Table 28. cont. Unit 5: Leadership, Business, Management and Organization (cont.) Competencies Performance Indicators 5.2 (cont.) Controls (cont.) 5.2.13 Conducts cost effectiveness and cost benefit analyses to identify ways to meet budget priorities. 5.2.14 Analyzes components of a productivity system including units of service and work hours and makes recommendations. 5.2.15 Sets controls to analyze the progress and effectiveness of the operational plan and budget. 5.2.16 Collects and analyzes data to evaluate outcomes and determine if established goals and objectives are met. 5.2.17 Reevaluates the plan to make modifications to ensure positive outcomes and that goals and objectives are met. Time Management 5.2.18 Applies principles of time management to monitor and enhance personal productivity and productivity of others. 5.2.19 Prioritizes activities to effectively manage time and workload. 5.2.20 Evaluates the whole system. Motivation and Recognition 5.2.21 Promotes team involvement and values the skills of each member. 5.2.22 Models behaviors that maximize group participation by consulting, listening and communicating clearly. 5.2.23 Takes innovative approaches to build support and maintain a diverse workforce. 5.2.24 Coaches and advises team leaders on resolving differences or dealing with conflict. 5.3 5.3.1 Leads the development and completion of a project plan and budget. Applies project management principles to achieve project goals and objectives. 5.3.2 Identifies the project strengths, weaknesses, opportunities and threats. 5.4 5.4.1 Identifies and communicates quality improvement indicators and benchmarks using evidence-based practice. Leads quality improvement activities to measure evaluate and improve a program services products and initiatives. 5.3.3 Identifies and manages potential and real risks to the plan, individuals or organization. 5.3.4 Conducts regular review of project to note strengths and opportunities for improvement and to implement adjusted actions. 5.4.2 Develops quality improvement measurement tools and analyzes data to inform baselines and to identify root causes and potential solutions. 5.4.3 Develops, implements and communicates a quality improvement action plan for further improvement and monitors impact. 5.4.4 Develops, implements and communicates an ongoing measuring and monitoring system to ensure ongoing quality improvement. 5.4.5 Applies change management theories and principles to effectively implement change. 142 Table 28. cont. Unit 5: Leadership, Business, Management and Organization (cont.) Competencies Performance Indicators 5.5 5.5.1 Assesses potential and real risks to an individual, group and or organization. Develops and implements risk management strategies and programs. 5.5.2 Identifies and takes action to manage, reduce and or eliminate risk to self, others and the organization. 5.5.3 Develops risk management plans and protocols. Unit 6: Critical Thinking, Research and Evidence-Informed Practice Integrates evidence-informed practice, research principles, and critical thinking into practice. 6.1 6.1.1 Considers multiple factors when problem solving. Incorporates critical thinking skills in managing complex situations. 6.1.2 Incorporates the thought process used in critical thinking models. 6.2 6.2.1 Identifies, explains and applies the steps of the scientific method and processes. Applies scientific methods utilizing ethical research practices when reviewing, evaluating and conducting research. 6.1.3 Engages in reflective practice to promote change and continuous learning. 6.2.2 Articulates a clear research question or problem and formulates a hypothesis. 6.2.3 Identifies and demonstrates appropriate research methods. 6.2.4 Interprets and applies research ethics and responsible conduct in research. 6.2.5 Collects and retrieves data using a variety of methods (qualitative, quantitative) and technologies. 6.2.6 Analyzes research data using appropriate data analysis techniques (qualitative, quantitative, mixed). 6.2.7 Formulates a professional opinion based on the research findings, evidence-informed practice and experiential learning. 6.2.8 Translates and communicates research findings and conclusions through a variety of media to a wide range of audiences tailoring messaging appropriate to the audience. 6.3 Applies current research and evidence-informed practice to services. 6.3.1 Use resources to find accurate and current research and evidence-based literature. 6.3.2 Uses research terminology when communicating with other professionals and publishing research. 6.3.3 Critically examines and interprets current research and evidence-based practice findings to determine the validity, reliability and credibility of information. 6.3.4 Integrates current research and evidence-informed practice findings into delivery of safe and effective nutrition care. 6.3. 5 Analyzes and formulates a professional opinion based on the current research and evidence-based findings and experiential learning. 143 Table 28. cont. Unit 7: Professionalism Assumes professional responsibilities to provide safe, ethical and effective nutrition services. Competencies Performance Indicators 7.1 7.1.1 Demonstrates honesty and integrity and behaves in a trustworthy, transparent, respectful and non-judgmental manner toward clients/patients and colleagues. Demonstrates ethical behaviors in accordance to the professional Code of Ethics. 7.1.2 Understands governance of nutrition and dietetics practice as outlined in documents such as the Scope of Nutrition and Dietetics Practice and the professional Code of Ethics. 7.1.3 Accepts responsibility and accountability for own actions and decisions. 7.1.4 Practices in a manner that respects diversity and avoids prejudicial treatment of an individual, group or population. 7.1.5 Understands the impact of the client/patient-provider relationship on services. 7.1.6 Applies client/patient-centered principles to all activities and services. 7.1.7 Recognizes and maintains professional boundaries with clients/patients. 7.1.8 Analyzes the impact of one’s own professional behaviors, values, beliefs and actions on others. 7.1.9 Develops advertising and marketing materials that are accurate, truthful and evidence-informed. 7.1.10 Applies principles of the informed consent process to ensure the client/patient is capable of accepting or refusing services. 7.1.11 Advocates for and takes action to ensure others demonstrate professional responsibilities and ethical behaviors 7.1.12 Recognizes and take steps to manage ethical dilemmas and supports ethical decision making with team members. 7.2 Engages in selfreflective practice activities to develop and demonstrate social and emotional intelligence to maintain ongoing competence and professional behaviors. 7.3 Adheres to nutrition related legislation, regulations and standards of practice. 7.2.1 Demonstrates continuous self-awareness by critically evaluating one’s knowledge, skill, judgment and learning and leadership style. 7.2.2 Obtains feedback and demonstrates a willingness to consider opinions of others. 7.2.3 Considers and incorporates own experiences and learning in practice. 7.2.4 Develops personal learning goals and objectives and identifies activities to meet these goals. 7.2.5 Incorporates learning to ensure safe ethical and competent nutrition care. 7.3.1 Adheres to confidentiality and privacy legislation, practice standards and organization’s policies regarding client/patient information. 7.3.2 Demonstrates awareness of all mandatory reporting obligations. 7.3.3 Obtains consent for the collection, use, sharing, storage and release of personal information. 144 Table 28. cont. Unit 8: Communication, Collaboration and Advocacy Uses effective communication with others to achieve common goals and enhance relationships in the provision of nutrition and dietetics services. Competencies Performance Indicators 8.1 8.1.1 Communicates in a clear, effective and respectful manner. Applies effective and ethical communication skills and techniques to achieve desired goals and outcomes. 8.1.2 Selects mode of communication appropriate to the messaging to meet the needs of the audience. 8.1.3 Identifies and addresses barriers to communication. 8.1.4 Adapts communication style to meet needs of diverse individuals and groups. 8.1.5 Uses active listening techniques. 8.1.6 Interprets and responds to nonverbal communications. 8.1.7 Understands and applies media communication principles including presenting with poise, developing key points, conveying scientific accuracy and translating to consumer language. 8.1.8 Ensures timely, clear and accurate documentation using correct spelling and grammar, following the standards of the profession and organizational policies. 8.1.9 Demonstrates proficient use of nutrition informatics. 8.1.10 Analyzes communications from others to inform opinions and impressions, gain knowledge and promote change. 8.2 Works with and facilitates intraprofessional and interprofessional collaboration and teamwork. 8.2.1 Demonstrates networking skills to build liaisons with internal and external stakeholders. 8.2.2 Seeks consultation and refers to other professionals when needed. 8.2.3 Networks with internal, community, state, national and global professional groups and organizations. 8.2.4 Demonstrates understanding of meeting management principles by effectively facilitating meetings and small group activities to achieve goals within time frames. 8.2.5 Demonstrates knowledge of the interprofessional team members’ scope of practice and competence. 8.2.6 Supports others in meeting their professional obligations. 8.2.7 Functions as member of the interprofessional team to support a collaborative, client/patient-centered approach. 8.2.8 Understands the mentoring role and practices mentoring or precepting others. 8.3 Demonstrates advocacy skills to promote awareness and required change. 8.3.1 Advocates for the profession by communicating to others the role, scope of practice and areas of expertise of the profession. 8.3.2 Participates in advocacy activities to change or promote new legislation and regulation. 145 PUBLIC COMMENTS ON THE FIRST DRAFT OF THE FUTURE EDUCATION MODEL ACCREDITATION STANDARDS FOR ASSOCIATE, BACHELOR AND MASTER DEGREE PROGRAMS IN NUTRITION AND DIETETICS FALL 2016 PURPOSE The purpose of this project was to gather information from various stakeholders on the draft Future Education Model Accreditation Standards for Associate, Bachelor and Master Degree Programs in Nutrition and Dietetics. METHODOLOGY ACEND® conducted an online survey (September – December, 2016) to gather stakeholder comments related to the draft Future Education Model Accreditation Standards. A copy of the questionnaire is included in Appendix K. Demographics. The questionnaire was divided into six sections. The first section requested demographic information and gave respondents the opportunity to choose which section of the questionnaire they wanted to complete. Standards and Required Elements. Section two focused on the standards and required elements. Respondents were asked to rate their level of agreement with the statement “This required element is clear and easy to interpret” for each required element within each standard using a fivepoint agreement scale that ranged from 1, strongly disagree to 5, strongly agree. A space for comments was included with each required element. Competencies and Performance Indicators. In Section three, respondents were asked for input on the competencies and performance indicators for the associate degree program. For each competency and its associated performance indicators, respondents were asked to provide two ratings using a five-point agreement scale (1, strongly disagree to 5, strongly agree). Ratings were provided for the statements “This competency and its performance indicators are clear” and “This competency is important for future practice in nutrition and dietetics”. A space for comments was included for each competency. Section four and five were similar to section three. Section four asked for input on the competencies and performance indicators for the bachelor degree program and section five requested input on the competencies and performance indicators for the master degree program. The same two rating scales that were used for the associate degree program competencies and performance indicators were used for the bachelor and master degree competencies and performance indicators. A space for comments was included for each competency. General Comments. Section six provided comment boxes for general input on the associate, bachelor and master degree standards, competencies and performance indicators. A general comment box also was provided. 146 RESULTS A total of 1,250 individuals responded to the online public comment survey (Table 29). Additionally, nine organizations/groups [Nutrition and Dietetics Educators and Practitioners; Council on Future Practice; Nutrition Informatics Committee (NIC); Interoperability and Standards Committee (ISC); Nutrition Services Payment Committee; School Nutrition Services DPG; Consumer Protection and Licensure Subcommittee; Veteran’s Administration administrators; internship directors, nutrition and dietetics educators offering an alternate model; Association of Nutrition Departments and Programs] provided written comments on behalf of their organization/group. Input Related to Standards and Required Elements A portion (13%) of survey respondents chose to provide in depth input on the standards and required elements (Table 30). These respondents provided ratings on the clarity and ease of interpreting each standard and its required elements and gave written comments for potential ways to improve the required elements. As shown in Table 31, most of the required elements were rated 3.75 or higher on the five-point scale suggesting that the required element was clear and easy to interpret. Table 32 includes the ACEND decisions related to the required elements with lower ratings and/or with multiple comments addressing the same concern. Input Related to Competencies and Performance Indicators Several individuals chose to provide in depth input on the competencies and performance indicators for the associate, bachelor and master degree programs (Table 33). These respondents provided ratings on the clarity and importance for future practice of each competency and its performance indicators and gave written comments for potential ways to improve them. Associate Degree. The roles of those who chose to provide in depth input on the competencies and performance indicators for the associate degree program are in Table 33. As shown in Table 34, all of the competencies and performance indicators were rated 3.5 or higher on the five-point scales suggesting that the associate degree competencies and performance indicators were clear and were important for future practice. Table 35 includes ACEND decisions related to the competencies and performance indicators with lower ratings and/or with multiple comments addressing the same concern. Bachelor Degree. A number of individuals chose to provide in depth input on the competencies and performance indicators for the bachelor degree program (Table 33). Table 36 includes ratings for the competencies and performance indicators; all were rated 3.5 or higher on the five-point scales suggesting that the bachelor degree competencies and performance indicators were clear and were important for future practice. Analysis of variance was used to explore whether ratings differed based on the role of the respondent (e.g. program directors, practitioners) providing the rating. Several differences were found and are noted in Table 36. For differences found in the clarity ratings, preceptors, practitioners and employers indicated more agreement that the competencies and performance indicators were clear than did program directors and faculty. For differences found in the importance to future practice ratings, practitioners and employers indicated more agreement that the competencies were important to future practice than did program directors and faculty. 147 Table 37 includes ACEND decisions related to the competencies and performance indicators with lower ratings and/or with multiple comments addressing the same concern. Master Degree. Many individuals chose to provide in depth input on the competencies and performance indicators for the master degree program (Table 33). As shown in Table 38, all of the competencies and performance indicators were rated 3.5 or higher on the five-point scales suggesting that the master degree competencies and performance indicators were clear and were important for future practice. Analysis of variance was used to explore whether ratings differed based on the role of the individual (e.g. program directors, practitioners) providing the rating. Very few differences were found. Table 39 includes ACEND decisions related to the competencies and performance indicators with lower ratings and/or with multiple comments addressing the same concern. General Comments Related to the Future Education Model Standards Many of the respondents in the public comment survey (55%) chose to make their comments in the general comments section of the survey. Some organizations submitted written letters with their comments. Several themes, which were not specific to the standards or competencies emerged. Table 40 includes ACEND decisions related to those themes that reflected multiple comments. 148 Table 29. Individuals providing public comments Role n % Practitioners 532 43.9 Program Directors 229 18.9 Preceptors 115 9.5 Program Faculty Members 101 8.3 Students/Interns 97 8.0 Professionals in Other Disciplines 38 3.1 Employers 37 3.0 62 5.1 Other a a Other includes former program directors, retired faculty and practitioners Table 30. Individuals providing in depth input on the future education model standards Role n a % Program Directors 61 37.0 Practitioners 45 27.3 Preceptors 14 8.5 Program Faculty Members 13 7.9 Employers 7 5.5 Professionals Outside Nutrition and Dietetics 6 3.6 Othera 20 10.2 Other includes former program directors, students, retired faculty and practitioners 149 Table 31. Ratings for Future Education Model Required Elements Standard/Required Elements n Claritya Mean ± SD % Agree/ Strongly Agree Standard 1. Program Characteristics and Resources 1.1 Program location 166 3.89±1.39 77% 1.2 Organization culture 162 3.75±1.42 71% 1.3 Program setting 159 4.20±1.03 85% 1.4 Program resources 155 4.06±1.10 81% 1.5 Degree/verification awarded 155 3.83±1.39 73% 1.6 Program director required credentials 153 3.27±1.57 56% 1.6 Program director responsibilities 142 4.10±1.08 85% 1.7 Program length 143 3.17±1.51 52% Standard 2. Program Mission, Goals and Objectives 2.1 Mission 126 3.60±1.31 65% 2.2 Goals 125 4.18±0.99 86% 2.3 Program objectives 125 4.11±1.06 86% 2.4 Program required objectives 128 3.91±1.14 76% Standard 3. Program Evaluation and Improvement 3.1 Program evaluation plan 124 4.16±0.88 84% 3.2 Evaluation evidence 121 4.11±0.90 84% 3.3 Use of plan 122 4.22±0.74 86% Standard 4. Curriculum and Learning Activities 4.1 Curriculum map 121 3.78±1.24 71% 4.2 Learning activities 118 3.39±1.48 60% Standard 5. Competency Assessment and Curriculum Improvement 5.1 Competency assessment plan 120 3.83±1.06 74% 5.2 Curriculum review 119 4.00±1.02 80% Standard 6. Faculty and Preceptors 6.1 Number of faculty and preceptors 113 4.16±1.00 83% 6.2 Faculty and preceptor requirements 119 3.37±1.39 58% 6.3 Orientation and training 117 3.76±1.25 73% Standard 7. Supervised Learning Experience Sites 7.1 Site requirements 115 3.91±1.14 73% Standard 8. Information to Prospective Students and the Public 8.1 Compliance with regulations 116 4.24±1.00 85% 8.2 Source of information 115 4.30±0.85 89% 8.3 Required program information 116 4.19±0.96 84% Standard 9. Policies and Procedures 9.1 Program operations policies 111 3.94±1.18 76% 9.2 Program policies (a – j) 110 4.14±0.84 84% 9.2 Program policies (k – t) 108 4.22±0.77 85% a Scale: Required element is clear and easy to interpret. 1, strongly disagree to 5, strongly agree 150 Table 32. Public comments related to required elements and ACEND decision Required Element Examples of Comments ACEND Decision 1.1 Program location Consortium implies one under another Use term “partnership”; defined in RE Define what is meant by consortium or partnership 1.2 Organization Structure Concern if this means the institution providing the experiential learning needs to be incorporated as part of the organizational structure of a university Deleted; covered in RE 1.1 Is this needed – covered in RE 1.1 1.3 Program Setting Unclear what is meant by this RE – more clarity needed Eliminated RE 1.3 The RE seem unnecessary – covered in other REs Not clear how this would this be measured 1.4 Program resources Clarify what is meant by this; very wordy 1.5 Degree/ verification awarded What is purpose of verification statement for associate degree Why is “scholarship and service” included; the mission of the program is to educate students; scholarship and service are the institution not program responsibility Change language to be similar to 2017 to allow for individuals coming into the program with a degree already 1.6 Program director requirements & responsibilities Director of master program does not need to have a doctorate – use same language as faculty 1.7 Program length Hours required for bachelor degree are too high Hours required for bachelor are not high enough Amount of time allowed for alternate experiences should be less Hours required for master degree are not high enough Since standards are designed to be competency based; let program determine what is needed to meet the competencies Learning activities for bachelors should not be same as master; if bachelor doing “less complex” should all disease states be included 4.2 Learning activities Performance indicators should not need to be included on the syllabi Include intellectually and developmentally disabled as one of the conditions 6.2 Faculty and preceptor requirements Reworded for clarity Faculty in master program should not need a doctorate degree; should say graduate degree Faculty in associate and bachelor program should not need a master degree 151 Verification statement removed from RE 1.5 for associate degree; bachelor and master changed to language in 2017 Standards Degree and experience requirements for director of master degree program changed Specified hours of supervised learning experience removed; will assess in demonstration programs Performance indicators removed as a requirement on syllabi; learning activities rewritten to better clarify difference in bachelor and master degree Degree requirements for faculty changed Table 33. Individuals providing in depth input on the future education model competencies and performance indicators Role a Associate Bachelor Master n % n % n % Program Directors 9 30.0 23 22.5 30 34.5 Practitioners 8 26.7 45 44.1 20 23.0 Preceptors 1 3.3 5 4.9 8 9.2 Program Faculty Members 2 6.7 8 7.8 10 11.5 Employers 4 13.3 5 4.9 4 4.6 Othera 6 20.0 16 15.7 15 17.2 Other includes former program directors, students, retired faculty and practitioners 152 Table 34. Ratings for Associate Degree Competencies and Performance indicators Competency Unit 1 Foundational Knowledge 1.1 Demonstrates an understanding of the principles of food and nutrition. 1.2 Integrates knowledge of determinants of health into all aspects of nutrition care and services. 1.3 Demonstrates knowledge of wellness strategies that contribute to long term health. 1.4 Applies principles of food safety and sanitation standards specific to culinary skills, food supply and food storage 1.5 Demonstrates understanding of the public health system. Unit 2: Professionalism 2.1 Demonstrates ethical behaviors becoming of a professional. 2.2 Engages in reflective practice activities to maintain ongoing competence and self-awareness. 2.3 Adheres to legislation, regulations, standards of practice and organizational policies. Unit 3: Individual and Community Services 3.1 Screens basic nutrition and health needs of individuals and communities. 3.2 Participates in the development, monitoring and modifications of the client/patient’s nutrition programs. 3.3 Considers the factors that impact food availability in the community within the social determinants of health. 3.4 Supports recipe modification and meal planning based on cultural needs and preferences in collaboration with other professionals. 3.5 Coordinates community nutrition programs and promotes access to community resources. 3.6 Provides nutrition information and approved evidenceinformed nutrition educational materials to meet the needs of the individual and community. Unit 4: Cultural Competence 4.1 Demonstrates an understanding of the principles of cultural competence. 4.2 Identifies and addresses cultural needs of the individual and community. 4.3 Demonstrates knowledge of foods, cultural and religious food traditions, eating patterns and trends in the community. a Scale: “This competency and its performance indicators are clear” b a Importance to Future Practiceb n Clarity 28 3.57±1.29 3.50±1.55 27 3.56±1.34 3.63±1.36 27 3.59±1.37 3.65±1.32 26 4.15±0.73 4.04±0.93 27 3.85±1.13 3.78±1.19 26 4.00±1.20 4.12±0.99 26 3.69±1.38 3.88±1.13 26 4.04±1.04 4.04±0.96 26 3.73±1.25 3.72±1.34 25 3.72±1.34 3.64±1.38 26 4.04±1.04 4.04±0.96 24 4.08±0.93 3.83±1.27 24 3.71±1.19 3.79±1.10 24 3.67±1.24 3.71±1.12 24 3.71±1.27 4.13±0.79 24 3.83±1.24 4.00±1.02 22 3.73±1.32 3.82±1.18 1, strongly disagree to 5, strongly agree Scale: “This competency is important for future practice in nutrition and dietetics” 1, strongly disagree to 5, strongly agree 153 Table 34. cont. Unit 5: Communication, Collaboration and Advocacy 5.1 Applies effective written and oral communication skills and techniques to achieve desired goals and outcomes. 5.2 Works collaboratively with intraprofessional and interprofessional team members, individuals and the community. 5.3 Advocates for nutrition programs and services for individuals and the community. 154 21 3.90±1.04 3.95±1.16 21 3.95±1.16 4.00±1.09 21 3.67±1.15 3.71±1.01 Table 35. Public comments related to associate degree competencies and performance indicators and ACEND decision Competency/Performance Indicator PI 1.1.4 Investigates and suggests improvements to basic nutritional risk management plans Examples of Comments ACEND Decision “Investigates” too high a level verb C 1.3. Demonstrates knowledge of wellness strategies that contribute to long term health Per Physical Activity Guidelines for Americans change “exercise” to ‘physical activity” Changed to: Identifies common risks and suggests improvements to basic nutritional risk management plans Changed “exercise” to “physical activity” throughout; changed from “client/patient” to “individual” throughout; deleted 1.3.5 and 1.3.6 Question whether the practitioner works with “clients/patients” or “individuals” PI 2.3.1 Understands governance of nutrition and dietetics such as legislative scope of nutrition and dietetics practice and the Code of Ethics for the nutrition and dietetics profession Awkward wording; can it be stated more clearly Changed to: Understands legislative scope of practice and the professional ethics for nutrition and dietetics practitioners. C 5.1 Applies effective written and oral communication skills and techniques Many of the performance indicators seem duplicative; can some be eliminated Eliminated PI 5.1.1, 5.1.6, 5.1.8, 5.1.9, 5.1.10 155 Table 36. Ratings for Bachelor Degree Competencies Competency n Clarity a Mean±SD Importance to Future Practiceb Mean±SD Unit 1 Foundational Knowledge 1.1 Applies a basic understanding of environmental and genetic 102 4.19±1.02 4.47±0.87 factors and food in the development and management of disease. 1.2 Demonstrates an understanding of anatomy and physiology. 100 4.31±1.09 4.52±0.79 1.3 Demonstrates an understanding of microbiology related to food 97 4.28±1.02 4.47±0.76 and nutrition and food safety. 1.4 Demonstrates knowledge of chemistry and food science as it 97 4.15±1.18 4.30±0.98 pertains to food and nutrition. 1.5 Demonstrates and applies knowledge of patho-physiology and 96 4.35±1.08 4.49±0.97 biochemical functionality and their relationship to physiology. 1.6 Applies knowledge of social, psychological and environmental 98 4.32±1.05 4.48±0.87 aspects of eating and food. 1.7 Applies the principles of cultural competence within own practice. 98 4.31±0.98 4.52±0.86 1.8 Demonstrates basic knowledge of pharmacology and integrative 97 4.08±1.24 4.33±1.06 and functional nutrition. 1.9 Demonstrates knowledge of math and statistics. 97 4.18±0.99 4.24±0.90 1.10 Demonstrates knowledge of medical terminology when 95 4.35±0.99 4.46±0.88 communicating with individuals. 1.11 Demonstrates knowledge of food preparation techniques. 96 4.35±0.98 4.46±0.88 1.12 Applies nutrition informatics in the decision making process. 95 4.14±1.11 4.30±1.01 1.13 Applies nutrition knowledge in the provision of nutrition care at all 97 4.33±0.95 4.56±0.75 stages of the life cycle. 1.14 Applies knowledge of nutritional health promotion and disease 98 4.28±1.01 4.52±0.79 prevention for individuals and groups. Unit 2: Client/Patient Services 2.1 Applies a framework to assess, develop, implement and evaluate 87 4.28±0.99* 4.39±0.91 nutritional program and services directed to clients/patients whose nutritional health needs are less complex. 2.2 Conducts and interprets nutrition screening using standardized 85 4.34±0.92 4.48±0.77 tools for individuals, groups or targeted populations whose nutritional health needs are less complex. 2.3 Utilizes the nutrition care process to manage clients/patients with 88 3.76±1.36 4.25±1.22 less complex nutritional health needs when practice setting environmental supports are in place. 2.4 Performs nutritional interventions for client/patient with less 79 4.05±1.30* 4.22±1.28* complex nutrition care needs when environmental supports are in place. 2.5 Considers the client/patient’s use of integrative and functional 80 4.09±1.15* 4.19±1.20* nutrition and related beliefs and values. a Scale: “This competency and its performance indicators are clear” 1, strongly disagree to 5, strongly agree b Scale: “This competency is important for future practice in nutrition and dietetics” 1, strongly disagree to 5, strongly agree * p<.05; analysis of variance of ratings based on group responding (i.e. program directors, practitioners) 156 Table 36 cont. Competency Clarity Importance to Future Practice Mean±SD Mean±SD 77 4.25±0.92 4.19±1.10 77 4.30±0.81 4.13±1.14 77 4.32±0.89 4.3±0.94 75 4.05±1.05 3.99±1.10 76 4.39±0.71 4.18±1.02 74 73 74 4.18±1.02* 4.18±1.11* 4.24±0.99* 4.41±0.81 4.21±1.11* 4.28±1.01* 73 4.27±0.96* 4.27±0.99* 73 4.14±1.03* 3.97±1.19* 74 73 4.28±1.00* 4.30±0.97* 4.46±0.83* 4.44±0.77 74 4.38±0.85* 4.53±0.73* 74 4.42±0.96 4.59±0.74* 73 4.40±0.88 4.47±0.85 74 4.46±0.83 4.51±0.76 74 4.45±0.81 4.55±0.68 73 4.22±1.00* 4.33±0.97* 74 4.26±0.86 4.23±0.91 n Unit 3: Food Systems Management 3.1 Manages the production, distribution and service of quantity and quality of food products. 3.2 Coordinates the purchasing, receipt and storage of food products and services. 3.3 Applies principles of food safety and sanitation to the production and service of food. 3.4 Applies an understanding of agricultural practices and processes. Unit 4: Community and Population Health Nutrition 4.1 Works collaboratively with others to assesses, implement and evaluate community and population based programs. Unit 5: Leadership, Business, Management and Organization 5.1 Demonstrates leadership skills to guide practice. 5.2 Applies principles of organization management. 5.3 Applies project management principles to achieve project goals and objectives. 5.4 Incorporates quality improvement into nutrition and dietetic practice. 5.5 Incorporates risk management strategies into practice. Unit 6: Critical Thinking, Research and Evidence-Informed Practice 6.1 Incorporates critical thinking skills in overall practice. 6.2 Identifies and understands the scientific method and research ethics. 6.3 Applies current research and evidence-informed practice to services. Unit 7: Professionalism 7.1 Demonstrates ethical behaviors in accordance to the professional Code of Ethics. 7.2 Engages in self-reflective practice to maintain ongoing competence and professional behaviors. 7.3 Adheres to nutrition related legislation, regulations and standards of practice. Unit 8: Communication, Collaboration and Advocacy 8.1 Applies effective and ethical communication skills and techniques to achieve desired goals and outcomes. 8.2 Works with and facilitates intraprofessional and interprofessional collaboration and teamwork. 8.3 Demonstrates advocacy skills to promote awareness and required change. 157 Table 37. Public comments related to bachelor degree competencies and performance indicators and ACEND decision Competency/Performance Indicator C 1.1 Applies basic understanding of environmental and genetic factors and food in the development and management of disease Examples of Comments ACEND Decision Term “genetic” is not broad enough to reflect current practice Changed to: Applies a basic understanding of environmental and molecular factors (e.g. genes, proteins, metabolites) and food in the development and management of disease. C 1.8 Demonstrates basic knowledge of pharmacology and integrative and functional nutrition Concepts of pharmacology and integrative and functional nutrition should be separated Created two new competencies and modified performance indicators. C 1.8 Demonstrates knowledge of food and drug interactions C 1.9 Demonstrates basic knowledge of complementary and integrative nutrition Use NIH term “complementary and integrative nutrition” Ensure that integrative and functional nutrition is evidencebased Too high a level for bachelor level C 2.3 Utilizes the nutrition care process to manage clients/patients with less complex nutritional health needs when practice setting environmental supports are in place C 2.4 Performs nutritional interventions for client/patient with less complex nutrition care needs when environmental supports are in place C 2.5 Considers client/patent’s use of integrative and functional nutrition and related beliefs and values Too high level for bachelor prepared; overlaps with master Better differentiate role of bachelor and master prepared practitioners Concern for licensure and scope of practice Not clear what is meant by “environmental supports” Major revision to clarify and differentiate bachelor and master graduates. C 2.3, 2.4, and 2.5 deleted; new competencies written (C 2,3 – C 2.5) and environmental supports defined (C 2.3): C 2.3 Conducts a nutrition assessment on individuals with less complex or less acute nutritional health care needs when environmental supports (e.g. policies, procedures, validated tools, administration, credentialed staff such as registered dietitian nutritionists) are in place C 2.4 Creates PES (problem, etiology and sign or symptom) statement for less complex, less acute nutritional health care needs when environmental supports are in place to inform the plan of care. C 2.5 Recommends and implements interventions in collaboration with the client/patient and other team members, when environmental supports are in place C 2.6 Monitors and evaluates the impact of the intervention 158 Table 37. cont. Competency/Performance Indicator Examples of Comments ACEND Decision C 5.1 Applies leadership skills to guide practice Too high a level for bachelor degree Changed wording to: Demonstrates leadership skills C 5.2 Applies principles of organization management Intent of competency not clear Competency Unit 7 Professionalism Behaviors and Unit 8 Communication, Collaboration and Advocacy Is all the detail in the performance indicators needed; much of this seems like common sense General Comments Too many competencies and performance indicators. Changed wording to: Applies organization management to direct staff and support department operations Combined competency units 7 and 8 into a new unit 7 Core Professional Behaviors with two competencies: C 7.1 Assumes professional responsibilities to provide safe, ethical and effective nutrition services and C 7.2 Uses effective communication, collaboration and advocacy skills Number of competencies reduced from 38 to 36 and performance indicators reduced from 216 to 166 159 Table 38. Ratings for Master Degree Competencies Competency n Clarity a Mean±SD Importance to Future Practiceb Mean±SD Unit 1 Foundational Knowledge 1.1 Applies an understanding of environmental and genetic factors 88 3.85±1.20 4.06±1.12 and food in the development and management of disease. 1.2 Applies an understanding of anatomy and physiology. 85 4.26±1.09 4.34±1.08 1.3 Applies knowledge of microbiology and food safety. 85 3.91±1.23 4.17±1.11 1.4 Integrates knowledge of chemistry and food science as it pertains 83 3.89±1.23 4.08±1.16 to food and nutrition product development and when making modifications to food. 1.5 Demonstrates and applies knowledge of patho-physiology and 84 4.14±1.12 4.43±1.00 biochemical functionality and their relationship to physiology, health and disease. 1.6 Applies knowledge of social, psychological and environmental 83 3.92±1.20 4.15±1.11 aspects of eating and food. 1.7 Integrates the principles of cultural competence within own 83 4.07±1.10 4.24±1.07 practice and when directing services. 1.8 Applies knowledge of pharmacology and integrative and 83 3.73±1.28 4.19±1.11 functional nutrition to recommend, prescribe and administer medical nutrition therapy. 1.9 Applies knowledge of math and statistics. 83 4.01±1.13 4.02±1.16 1.10 Applies knowledge of medical terminology when communicating 79 4.23±1.05 4.30±1.04 with individuals, groups and other health professionals. 1.11 Demonstrates knowledge of food preparation techniques. 81 3.98±1.21 4.06±1.13 1.12 Applies nutrition informatics in the decision making process. 81 3.75±1.17* 4.11±1.01 1.13 Integrates knowledge of nutrition and physical activity in the 81 4.19±1.03 4.29±.99 provision of nutrition care at all stages of the life cycle. 1.14 Applies knowledge of nutritional health promotion and disease 83 3.99±1.21 4.35±1.03 prevention for individuals, groups and populations. 1.15 Gains a foundational knowledge on global health issues and 82 3.84±1.12 3.94±1.13 nutritional needs. Unit 2: Client/Patient Services 2.1 Uses a framework to assess, develop, implement and evaluate 73 3.77±1.18 4.14±1.04 products, programs and services. 2.2 Selects, develops or implements nutritional status screening tools 72 4.03±1.15 4.25±1.10 for individuals, groups or populations. 2.3 Utilizes the nutrition care process with individuals, groups or 72 4.10±1.19 4.44±1.05 populations in a variety of practice settings. 2.4 Performs or coordinates nutritional interventions for individuals, 74 3.85±1.32 4.30±1.08 groups or populations. 2.5 Prescribes or recommends nutrition-related pharmacotherapy 70 3.63±1.41 3.86±1.33 and integrative and functional nutrition. a Scale: “This competency and its performance indicators are clear” 1, strongly disagree to 5, strongly agree b Scale: “This competency is important for future practice in nutrition and dietetics” 1, strongly disagree to 5, strongly agree * p<.05; analysis of variance of ratings based on group responding (i.e. program directors, practitioners) 160 Table 38. cont. Competency n Clarity Mean±SD Importance to Future Practice Mean±SD Unit 3: Food Systems Management 3.1 Oversees the production and distribution of quantity and quality food products. 3.2 Oversees the purchasing, receipt and storage of products used in food production and services. 3.3 Applies principles of food safety and sanitation to the production and service of food. 3.4 Applies and demonstrates an understanding of agricultural practices and processes. Unit 4: Community and Population Health Nutrition 4.1 Follows programming planning steps to develop and implement community, population and global programs. 4.2 Identifies environmental and public health hazards that impact nutrition and participates in or coordinates the management of the situation. 4.3 Engages in legislative and regulatory activities that address community, population and global nutrition health and nutrition policy. Unit 5: Leadership, Business, Management and Organization 5.1 Demonstrates leadership skills to guide practice. 5.2 Applies principles of organization management. 5.3 Applies project management principles to achieve project goals and objectives. 5.4 Leads quality improvement activities to measure evaluate and improve a program services products and initiatives. 5.5 Develops and implements risk management strategies and programs. Unit 6: Critical Thinking, Research and Evidence-Informed Practice 6.1 Incorporates critical thinking skills in managing complex situations. 6.2 Applies scientific methods utilizing ethical research practices when reviewing, evaluating and conducting research. 6.3 Applies current research and evidence-informed practice to services. Unit 7: Professionalism 7.1 Demonstrates ethical behaviors in accordance to the professional Code of Ethics. 7.2 Engages in self-reflective practice activities to develop and demonstrate social and emotional intelligence to maintain ongoing competence and professional behaviors. 7.3 Adheres to nutrition related legislation, regulations and standards of practice. 161 73 3.97±1.13 3.95±1.20 72 3.97±1.05 3.70±1.28 73 3.86±1.18 3.83±1.24 71 3.88±1.16 3.72±1.27 71 3.94±1.23 4.04±1.13 69 3.86±1.27 3.90±1.21 70 3.66±1.38 3.74±1.31 69 71 70 3.86±1.29 3.80±1.40 4.01±1.23 4.10±1.15 3.93±1.32 3.93±1.22 71 4.00±1.29 4.11±1.19 70 3.74±1.30 3.68±1.30 70 3.94±1.35 4.11±1.30 71 4.27±1.06 4.25±1.11 71 4.31±1.12 4.45±1.05 71 4.30±.98 4.38±1.03 69 4.10±1.09 4.22±1.06 71 4.30±1.01 4.42±.94 Table 38. cont. Unit 8: Communication, Collaboration and Advocacy 8.1 Applies effective and ethical communication skills and techniques to achieve desired goals and outcomes. 8.2 Works with and facilitates intraprofessional and interprofessional collaboration and teamwork. 8.3 Demonstrates advocacy skills to promote awareness and required change. 162 72 4.04±1.30 4.18±1.25 71 3.97±1.40 4.14±1.28 71 3.86±1.42 3.72±1.46 Table 39. Public comments related to master degree competencies and performance indicators and ACEND decision Competency/Performance Indicator C 1.1 Applies an understanding of environmental and genetic factors and food in the development and management of disease Examples of Comments ACEND Decision Term “genetic” is not broad enough to reflect current practice Changed to: Applies an understanding of environmental and molecular factors (e.g. genes, proteins, metabolites) and food in the development and management of disease. C 1.8 Applies knowledge of pharmacology and integrative and functional nutrition to recommend, prescribe and administer medical nutrition therapy Concepts of pharmacology and integrative and function nutrition should be separated Created two new competencies and modified performance indicators. C 1.8 Applies knowledge of pharmacology to recommend, prescribe and administer medical nutrition therapy C 1.9 Applies an understanding of complementary and integrative nutrition on drugs, disease, health and wellness C 2.5 Prescribes or recommends nutrition-related pharmacotherapy and integrative and function nutrition Too high level for entry-level master prepared C 3.1 Oversees the production and distribution of quantity and quality food products “oversees” seems too low of a verb level Wording changed to: Directs the production and distribution of quantity and quality of food products C 4.2 Identifies environmental and public health hazards that impact nutrition and participate in or coordinates the management of the situation Too high level for entry-level master prepared C 4.2 and its performance indicators deleted Competency Unit 7 Professionalism Behaviors and Unit 8 Communication, Collaboration and Advocacy Is all the detail in the performance indicators needed; much of this seems like common sense General Comments Too many competencies and performance indicators. Use NIH term “complementary and integrative nutrition” Ensure that integrative and function nutrition is evidence-based Much of the Integrative and function nutrition is not evidence-based; not sure dietitian should be prescribing this Integrative and function nutrition removed from this competency; Revised wording: Prescribes, recommends and administers nutrition-related pharmacotherapy. Practice sites will not allow students to do this 163 Combined competency units 7 and 8 into a new unit 7 Core Professional Behaviors with two competencies: C 7.1 Assumes professional responsibilities to provide safe, ethical and effective nutrition services and C 7.2 Uses effective communication, collaboration and advocacy skills Number of competencies reduced from 41 to 37 and performance indicators reduced from 274 to 218 Table 40. Public comments related to Future Education Model Standards and ACEND decision Competency/Performance Indicator Examples of Comments ACEND Decision Degree for entry-level Registered Dietitian Nutritionist (RDN) Degree should be master degree as proposed Continue with development of master degree standards with competencies designed for added skills needed in future practice; evaluate outcomes in the demonstration programs Degree should be bachelor level using current education model (CP, DPD, DI); master degree should be advanced practice Degree should be practice doctorate Degree for entry-level Nutrition and Dietetics Technician, Registered (NDTR) Degree should be bachelor degree as proposed Degree should be associate level using current education model Universities will not support a bachelor degree program that prepares “technicians” Associate degree for Nutrition Health Worker This new degree/position should be implemented as proposed This option should be eliminated, there are not positions for this proposed associate degree practitioner Change the title, term “worker” is demeaning Prerequisite requirement for master degree Generalist vs specialist for master degree Program should be given flexibility to set the prerequisites for their program The bachelor degree should be a required prerequisite for the master degree Master degree should have designated specialist focus; foodservice, clinical, community Programs should be able to determine whether to have focus area Share raw data All raw data should be shared 164 Continue with development of bachelor degree standards with competencies designed to elevate practice; evaluate outcomes in the demonstration programs; rename the graduate a Food and Nutrition Practitioner Continue with development of associate degree standards with competencies designed to prepare a community support practitioner; evaluate outcomes in the demonstration programs; rename the graduate a Nutrition Health Associate Continue to allow master degree programs the flexibility to establish their own pre-requisite requirements; evaluate in the demonstration programs Establish the core competencies for the master degree program; programs will retain the flexibility to choose whether to offer specialty tracks/concentrations; evaluate in the demonstration programs To follow common research practice, reduce confirmation bias, and protect confidentiality, ACEND has data analyzed and releases a summary of input received REFERENCES 1. 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