This article is being published concurrently in the Journal of the Academy of Nutrition and Dietetics and Nutrition in Clinical Practice. The articles are identical except for minor stylistic and spelling differences in keeping with each journal's style. Either citation can be used when citing this article. Approved May 2021 by the Quality Management Committee of the Academy of Nutrition and Dietetics (Academy), the Executive Committee of the Dietitians in Nutrition Support Dietetic Practice Group of the Academy, and the Clinical Practice Committee and the Board of Directors of the American Society for Parenteral and Enteral Nutrition (ASPEN). Scheduled review date: May 2027. Questions regarding the Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists in Nutrition Support may be addressed to Academy Quality Management Staff: Dana Buelsing, MS, manager, Quality Standards Operations; and Carol J. Gilmore, MS, RDN, scope/standards of practice specialist, Quality Management at [email protected].

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Abstract

Nutrition support is a therapy that crosses all ages, diseases, and conditions as health care practitioners strive to meet the nutrition requirements of individuals who are unable to meet nutrition and/or hydration needs with oral intake alone. Registered dietitian nutritionists (RDNs), as integral members of the nutrition support team provide needed information, such as identification of malnutrition risk, macro- and micronutrient requirements, and type of nutrition support therapy (eg, enteral or parenteral), including the route (eg, nasogastric vs nasojejunal or tunneled catheter vs port). The Dietitians in Nutrition Support Dietetic Practice Group, American Society for Parenteral and Enteral Nutrition, along with the Academy of Nutrition and Dietetics Quality Management Committee, have updated the Standards of Practice (SOP) and Standards of Professional Performance (SOPP) for RDNs working in nutrition support. The SOP and SOPP for RDNs in Nutrition Support provide indicators that describe the following 3 levels of practice: competent, proficient, and expert. The SOP uses the Nutrition Care Process and clinical workflow elements for delivering patient/client care. The SOPP describes the 6 domains that focus on professional performance. Specific indicators outlined in the SOP and SOPP depict how these standards apply to practice. The SOP and SOPP are complementary resources for RDNs and are intended to be used as a self-evaluation tool for assuring competent practice in nutrition support and for determining potential education and training needs for advancement to a higher practice level in a variety of settings.

The Dietitians in Nutrition Support Dietetic Practice Group (DNS DPG) of the Academy of Nutrition and Dietetics (Academy), and members of the Dietetics Practice Section of the American Society for Parenteral and Enteral Nutrition (ASPEN), under the guidance of the Academy Quality Management Committee and ASPEN Clinical Practice Committee, have revised the Standards of Practice (SOP) and Standards of Professional Performance (SOPP) for Registered Dietitian Nutritionists (RDNs) in Nutrition Support previously published in 2014.^{1, 2} The revised document, Academy of Nutrition and Dietetics and American Society for Enteral and Parenteral Nutrition: Revised 2021 Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists (Competent, Proficient, and Expert) in Nutrition Support, reflects advances in nutrition support practice during the past 7 years and replace the 2014 Standards. This document builds on the Academy of Nutrition and Dietetics: Revised 2017 SOP in Nutrition Care and SOPP for RDNs.³ The Academy of Nutrition and Dietetics/Commission on Dietetic Registration's (CDR) Code of Ethics for the Nutrition and Dietetics Profession⁴ along with the Academy of Nutrition and Dietetics: Revised 2017 SOP in Nutrition Care and SOPP for RDNs³ and Revised 2017 Scope of Practice for the RDN,⁵ guide the practice and performance of RDNs in all settings. ASPEN documents that guide the practice and performance of RDNs in nutrition support practice include the ASPEN Board of Directors-approved clinical guidelines, standards, clinical recommendations, and position papers, accessible at www.nutritioncare.org.

Scope of practice in nutrition and dietetics is composed of statutory and individual components, includes the code(s) of ethics (eg, Academy/CDR, other national or international organizations, and/or employers code of ethics), and encompasses the range of roles, activities, practice guidelines, and regulations within which RDNs perform. For credentialed practitioners who practice in a state with professional licensure or certification, scope of practice is typically established within the practice act and associated regulations, and interpreted and controlled by the agency or board that regulates the practice of the profession in a given state.⁵ An RDN's statutory scope of practice can delineate the services an RDN is authorized to perform in a state where a practice act or certification exists. For more information, see www.eatrightpro.org/advocacy/licensure/licensure-map.

The RDN's individual scope of practice is determined by education, training, credentialing, experience, and demonstrating and documenting competence to practice. Individual scope of practice in nutrition and dietetics has flexible boundaries to capture the breadth of the individual's professional practice. Professional advancement beyond the core education and supervised practice to qualify for the RDN credential provides RDNs practice opportunities, such as expanded roles within an organization based on training and certifications, if required; or additional credentials (eg, focus area CDR specialist certification, if applicable, such as the Board Certified Specialist in Pediatric Critical Care Nutrition [CSPCC], and/or Advanced Practitioner Certification in Clinical Nutrition [RDN-AP]; Certified Nutrition Support Clinician [CNSC], Certified Case Manager [CCM], Certified Clinical Transplant Dietitian [CCTD], Nutrition Wound Care Certified [NWCC], and Certified Wound Specialist [CWS]). The Scope of Practice Decision Algorithm (www.eatrightpro.org/scope) guides an RDN through a series of questions to determine whether a particular activity is within their scope of practice. The algorithm is designed to assist an RDN to critically evaluate their personal knowledge, skill, experience, judgment, and demonstrated competence using criteria resources.⁶

All registered dietitians are nutritionists—but not all nutritionists are registered dietitians. The Academy's Board of Directors and Commission on Dietetic Registration have determined that those who hold the credential Registered Dietitian (RD) may optionally use “Registered Dietitian Nutritionist” (RDN). The 2 credentials have identical meanings. In this document, the authors have chosen to use the term RDN to refer to both registered dietitians and registered dietitian nutritionists.

The Centers for Medicare and Medicaid Services (CMS), Department of Health and Human Services, Hospital⁷ and Critical Access Hospital⁸ Conditions of Participation allow a hospital and its medical staff the option of including RDNs or other clinically qualified nutrition professionals within the category of “non-physician practitioners” eligible for ordering privileges for therapeutic diets and nutrition-related services if consistent with state law and health care regulations. RDNs in hospital settings interested in obtaining ordering privileges must review state laws (eg, licensure, certification, and title protection), if applicable, and health care regulations to determine whether there are any barriers or state-specific processes that must be addressed. For more information, review the Academy's practice tips that outline the regulations and implementation steps for obtaining ordering privileges (www.eatrightpro.org/dietorders/). For assistance, refer questions to the Academy's State Affiliate organization.

Medical staff oversight of an RDN(s) occurs in 1 of 2 ways. A hospital has the regulatory flexibility to appoint an RDN(s) to the medical staff and grant the RDN(s) specific nutrition ordering privileges, or can authorize the ordering privileges without appointment to the medical staff. To comply with regulatory requirements, an RDN's eligibility to be considered for ordering privileges must be through the hospital's medical staff rules, regulations, and bylaws, or other facility-specific process.⁹ The actual privileges granted may vary due to state law and the organization and medical staff along with the RDN's knowledge, skills, experience, and specialist certification, if required, and demonstrated and documented competence.

The “Long-Term Care Final Rule” published October 4, 2016 in the Federal Register, now “allows the attending physician to delegate to a qualified dietitian or other clinically qualified nutrition professional the task of prescribing a resident's diet, including a therapeutic diet, to the extent allowed by State law” and permitted by the facility's policies.¹⁰ The qualified professional must be acting within the scope of practice as defined by state law; and is under the supervision of the physician that may include, for example, countersigning the orders written by the qualified dietitian or clinically qualified nutrition professional. RDNs who work in long-term care facilities should review the Academy's updates on CMS that outline the regulatory changes to §483.60 Food and Nutrition Services (www.eatrightpro.org/practice/quality-management/national-quality-accreditation-and-regulations/centers-for-medicare-and-medicaid-services). Review the state's long-term care regulations to identify potential barriers to implementation; and identify considerations for developing the facility's processes with the medical director and for orientation of attending physicians. The CMS State Operations Manual, Appendix PP-Guidance for Surveyors for Long-Term Care Facilities contains the revised regulatory language (new revisions are italicized and in red color).¹¹ CMS periodically revises the State Operations Manual Conditions of Participation; obtain the current information at www.cms.gov/files/document/som107appendicestoc.pdf.

ACADEMY QUALITY AND PRACTICE RESOURCES

The Academy's Revised 2017 SOP in Nutrition Care and SOPP for RDNs³ reflect the minimum competent level of nutrition and dietetics practice and professional performance. The core standards serve as blueprints for the development of focus area SOP and SOPP for RDNs in competent, proficient, and expert levels of practice. The SOP in Nutrition Care is composed of 4 standards consistent with the Nutrition Care Process (NCP) and clinical workflow elements as applied to the care of patients/clients/populations in all settings.¹² The SOPP consist of standards representing 6 domains of professional performance: Quality in Practice, Competence and Accountability, Provision of Services, Application of Research, Communication and Application of Knowledge, and Utilization and Management of Resources. The SOP and SOPP for RDNs are designed to promote the provision of safe, effective, efficient, equitable, and quality food and nutrition care and services; facilitate evidence-based practice; and serve as a professional evaluation resource.

These focus area standards for RDNs in nutrition support provide a guide for self-evaluation and expanding practice, a means of identifying areas for professional development, and a tool for demonstrating competence in delivering nutrition support care and services. They are used by RDNs to assess their current level of practice and to determine the education and training required to maintain currency in their focus area and advancement to a higher level of practice. In addition, the standards can be used to assist RDNs in general clinical practice with maintaining minimum competence in the focus area, and by RDNs transitioning their knowledge and skills to a new focus area of practice. Like the Academy's core SOP in Nutrition Care and SOPP for RDNs,³ the indicators (ie, measurable action statements that illustrate how each standard can be applied in practice) (see Figures 1 and 2, available at www.jandonline.org or https://aspenjournals.onlinelibrary.wiley.com/doi/10.1002/ncp.10774) for the SOP and SOPP for RDNs in Nutrition Support were revised with input and consensus of content experts representing diverse practice and geographic perspectives. The SOP and SOPP for RDNs in Nutrition Support were reviewed and approved by the Executive Committee of the DNS DPG, the ASPEN Clinical Practice Committee and Board of Directors, and the Academy Quality Management Committee.

THREE LEVELS OF PRACTICE

The Dreyfus model¹⁵ identifies levels of proficiency (novice, advanced beginner, competent, proficient, and expert) (refer to Figure 3) during the acquisition and development of knowledge and skills. The first 2 levels are components of the required didactic education (novice) and supervised practice experience (advanced beginner) that precede credentialing for nutrition and dietetics practitioners. Upon successfully attaining the RDN credential, a practitioner enters professional practice at the competent level and manages their professional development to achieve individual professional goals. This model is helpful in understanding the levels of practice described in the SOP and SOPP for RDNs in Nutrition Support. In Academy focus areas, the 3 levels of practice are represented as competent, proficient, and expert.

With safety and evidence-based practice¹⁷ as guiding factors when working with patients/clients/customers/populations, the RDN identifies the level of evidence, clearly states research limitations, provides safety information from reputable sources, and describes the risk of the intervention(s), when applicable.

The Academy offers the Evidence Analysis Library (www.andeal.org/) as a resource, which provides a synthesis of systematic reviews on a variety of nutrition and dietetics topics, such as malnutrition in older adults, hydration, and preterm infant enteral nutrition guideline. The RDN is responsible for searching literature and assessing the level of evidence to select the best available evidence to inform recommendations. RDNs must evaluate and understand the best available evidence in order to converse authoritatively with the interprofessional team and adequately involve the patient/client/customer/population in shared decision making.

Competent practitioner

In nutrition and dietetics, a competent practitioner is an RDN who is either just starting practice after having obtained RDN registration by CDR or an experienced RDN recently transitioning their practice to a new focus area of nutrition and dietetics. A focus area of nutrition and dietetics practice is a defined area of practice that requires focused knowledge, skills, and experience that apply to all levels of practice.¹⁷ A competent practitioner who has achieved credentialing as an RDN and is starting in professional employment consistently provides safe and reliable services by employing appropriate knowledge, skills, behavior, and values in accordance with accepted standards of the profession; acquires additional on-the-job skills; and engages in tailored continuing education to further enhance knowledge, skills, and judgment obtained in formal education.¹⁷ A general practice RDN can include responsibilities across several areas of practice, including, but not limited to, community; clinical; consultation and business; research; education; and food and nutrition management.

For delivery of quality and safe nutrition support therapy (enteral nutrition [EN] or parenteral nutrition [PN]), specific knowledge and skills are required when providing care and services to patients/clients needing nutrition support therapy. RDNs with limited experience providing EN and/or PN need to explore options for increasing knowledge and skills, particularly with PN, a high-risk medication according to the Institute for Safe Medication Practices.¹⁸ More in-depth knowledge is needed in areas such as PN indications,¹⁹ PN venous access, PN ordering, fluid and electrolyte management, electrolyte disorders, micronutrient requirements, and drug–nutrient interactions, as well as monitoring for and preventing complications (eg, refeeding syndrome²⁰). The RDN entering into the area of nutrition support should seek out a more experienced RDN in nutrition support therapies as a mentor; reference Figure 4 for mentorship opportunities and programs. The competent-level RDN will gain crucial knowledge for safe and quality nutrition support practice by reading articles and books, attending webinars or conferences related to nutrition support, and accessing the Academy and ASPEN resources in Figure 4.

Proficient practitioner

A proficient practitioner is generally 3 or more years beyond RDN credentialing and entry into the profession and consistently provides safe and reliable services; has obtained operational job performance skills; and is successful in the RDN's chosen focus area of practice. The proficient practitioner demonstrates additional knowledge, skills, judgment, and experience in a focus area of nutrition and dietetics practice. An RDN may acquire specialist credentials, if available, to demonstrate proficiency in a focus area of practice.¹⁷ The proficient-level RDN in nutrition support has gained more nutrition support-related clinical skills and knowledge above that of a competent practitioner and functions with more autonomy in managing patients requiring EN or PN. The proficient practitioner has sufficient, or is working towards sufficient, knowledge and qualifications through continuing education or practice hours in nutrition support in order to qualify for the CNSC,²¹ RDN-AP, or CSPCC.

Expert practitioner

An expert practitioner is an RDN recognized within the profession and has mastered the highest degree of skill in, and knowledge of, nutrition and dietetics. Expert-level achievement is acquired through ongoing critical evaluation of practice and feedback from others. The individual at this level strives for additional knowledge, experience, and training. An expert has the ability to quickly identify “what” is happening and “how” to approach the situation. Experts easily use nutrition and dietetics skills to become successful through demonstrating quality practice and leadership, and to consider new opportunities that build on nutrition and dietetics.¹⁷ An expert practitioner may have an expanded or specialist role, or both, and may possess an advanced credential(s), such as the CNSC, RDN-AP, and/or CSPCC. Generally, the practice is more complex, and the practitioner has a high degree of professional autonomy and responsibility. Expert-level RDNs in nutrition support serve as a principal source of information and guidance for RDN colleagues and interprofessional team members. They promote the practice and expertise needed for quality nutrition support practice through publications, speaking engagements, and serve the profession by participating in Academy and ASPEN organizations at the local, state, and/or national level. Expert-level RDNs participate and lead research and/or quality improvement projects to assess the efficacy of services and contribute to the nutrition support body of knowledge, thus promoting and improving evidence-based practice in nutrition support.

These Standards, along with the Academy/CDR Code of Ethics,³ answer the questions: Why is an RDN uniquely qualified to provide nutrition support care and services? What knowledge, skills, and competencies does an RDN need to demonstrate for the provision of safe, effective, efficient, and quality nutrition support care and service at the competent, proficient, and expert levels?

OVERVIEW

Nutrition support therapy is defined as providing enteral or parenteral nutrition with therapeutic intent or to treat or prevent malnutrition.^22-26 Nutrition support is a therapy used with individuals of all ages, diseases, and conditions. Health care practitioners strive to meet the nutrition requirements of individuals who are unable to meet nutrient needs with oral intake alone, have intestinal failure, and/or are unable to meet hydration needs for a variety of reasons. RDNs, integral members of the nutrition support or interprofessional team,²² provide needed expertise on the identification of risk or presence of malnutrition, macro- and micronutrient requirements, type of nutrition support therapy (eg, enteral or parenteral), and appropriate nutrition support access and route (eg, nasogastric vs nasojejunal or tunneled catheter vs port).

Enteral nutrition is a delivery system “providing nutrition directly into the gastrointestinal tract via a tube, catheter, or stoma that bypasses the oral cavity.”^{17, 22}

“Parenteral nutrition is the intravenous administration of nutrients such as amino acids, carbohydrate, lipid, and added vitamins and minerals delivered via central or peripheral route. Central means parenteral nutrition delivered into a large-diameter vein, usually the superior vena cava adjacent to the right atrium. Peripheral means parenteral nutrition delivered into a peripheral vein, usually of the hand or forearm.”^{17, 22}

An RDN's practice in nutrition support varies according to practice setting, the number of individuals requiring specialized nutrition support, and role and responsibilities. The primary setting is acute care hospitals (eg, academic, community, and critical access). Populations encompass adults, pediatric and neonatal, surgical, oncology, renal, gastrointestinal, and transplant, among others. In addition, RDNs practicing in nutrition support work in ambulatory/outpatient settings, home care, and alternate site care (ie, long-term acute care, rehabilitation, and skilled/long-term care).²⁷ RDNs practicing in nutrition support therapy may conduct research, teach, consult, and write for peer-reviewed professional publications (solely or in combination with a clinical practice).

In clinical settings, RDNs in nutrition support evaluate nutrition screening results, conduct nutrition assessments with nutrition-focused physical examinations,^{28, 29} confer with interprofessional team members, determine plan(s) of care, and provide ongoing monitoring and adjustments to the plan of care. With privileging^{5, 30} and/or organization-approved policies and protocols, RDNs place enteral feeding tubes^{31, 32} and initiate, implement, and/or adjust protocol- or physician-order driven EN- or PN-related plans.

There are a variety of patients/clients seen by RDNs in nutrition support who span all ages (including neonatal, pediatric,^{33, 34} and adult³⁵) and diseases/conditions. Therefore, a person-centered approach is critical to care. RDNs must have the knowledge, skill, and experience in the application of principles and guidelines in delivering nutrition support, along with general knowledge of all potential comorbidities of a patient/client, in order to appropriately address and provide quality nutrition care and services or know when to confer with or refer to another provider.

Since patients/clients requiring nutrition support therapy present with varied and complex treatment issues, the RDN must consider the ethical implications^36-38 of nutrition and hydration,^{39, 40} particularly in certain populations, such as those with dementia⁴¹ or receiving palliative⁴² or end-of-life care. Care decisions need to reflect the wishes of the patient/client and/or family/surrogate decision-maker, consistent with an advanced directive that may be in place.

The RDN practicing in nutrition support collaborates with the interprofessional team that includes multiple disciplines according to the specific needs of the patient/client. Core nutrition support team²² members, in addition to the RDN, include a physician(s), pharmacist, and nurse. Other professionals, such as physician assistant, nurse practitioner, respiratory therapist, speech language pathologist, and social worker, may be included in the team to meet the care goals and outcomes. An interprofessional approach has been shown to enhance quality of care, improve patient safety and outcomes,²⁴ and reduce health care costs.⁴³ Within the interprofessional team, the RDN is a key resource on medical nutrition therapy and various aspects of nutrition support therapy. RDNs may also collaborate with their information technology teams to advance personalized nutrition efforts.^44-46 Personalized nutrition refers to the use of individual measurable data to affect nutrition status or outcomes, such as continuous glucose monitoring or indirect calorimetry.⁴³ RDNs may also collaborate with their information technology team to enhance electronic health record workflow and functionality and improve nutrition support safety.^{45, 46}

Both the Academy⁴⁷ and ASPEN⁴⁸ have evidence-based practice guidelines and position papers related to nutrition support to help guide RDNs in nutrition support practice. These guidelines cover a variety of topics, including malnutrition in older adults,⁴⁹ selection and care of central venous access devices for adult home parenteral nutrition administration,⁵⁰ nutrition support in the pediatric critically ill patient,⁵¹ and nutrition support in the adult critically ill patient,⁵² use of visceral protein markers,⁵³ among others.ASPEN also publishes discipline-based standards for nurses,⁵⁴ pharmacists,⁵⁵ and physicians.⁵⁶ Other resources for RDNs in nutrition support can be found in Figure 4.

The DNS DPG⁵⁷ and ASPEN⁵⁸ provide an abundance of information and resources for RDNs in nutrition support. The DNS DPG offers resources such as the Support Line newsletter, webinars, symposium, videos, toolkits, mentorship program, podcast recordings, and an online forum. ASPEN resources include webinars, an eLearning Center, an online community, conference, books, journals (Nutrition in Clinical Practice and Journal of Parenteral and Enteral Nutrition), and a Malnutrition Solution Center. The DNS DPG and ASPEN offer volunteer opportunities that promote development of professional relationships.

ACADEMY AND ASPEN REVISED 2021 SOP AND SOPP FOR RDNs (COMPETENT, PROFICIENT, AND EXPERT) IN NUTRITION SUPPORT

An RDN can use the Academy and ASPEN Revised 2021 SOP and SOPP for RDNs (Competent, Proficient, and Expert) in Nutrition Support (see Figures 1 and 2, available at www.jandonline.org or https://aspenjournals.onlinelibrary.wiley.com/doi/10.1002/ncp.10774, and Figure 3) to:

▪ identify the competencies needed to provide nutrition support care and services;
▪ self-evaluate whether they have the appropriate knowledge, skills, and judgment to provide safe, effective, equitable, and quality nutrition support care and service for their level of practice;
▪ identify the areas in which additional knowledge, skills, and experience are needed to practice at the competent, proficient, or expert level of nutrition support practice;
▪ provide a foundation for public and professional accountability in nutrition support care and services;
▪ support efforts for strategic planning, performance improvement, outcomes reporting, and assist management in the planning and communicating of nutrition support services and resources;
▪ enhance professional identity and skill in communicating the nature of nutrition support care and services;
▪ guide the development of nutrition support-related education and continuing education programs, job descriptions, practice guidelines, protocols, clinical models, competence evaluation tools, and career pathways; and
▪ assist educators and preceptors in teaching students and interns the knowledge, skills, and competencies needed to work in nutrition support, and the understanding of the full scope of this focus area of practice.

APPLICATION TO PRACTICE

All RDNs, even those with significant experience in other practice areas, must begin at the competent level when practicing in a new setting or new focus area of practice. At the competent level, an RDN in nutrition support is learning the principles that underpin this focus area and is developing knowledge, skills, judgment, and gaining experience for safe and effective nutrition support practice. This RDN, who may be new to the profession or may be an experienced RDN, has a breadth of knowledge in nutrition and dietetics and may have proficient or expert knowledge/practice in another focus area. However, the RDN new to the focus area of nutrition support must accept the challenge of becoming familiar with the body of knowledge, required clinical judgment skills, practice guidelines, and available resources to support and ensure quality nutrition support–related nutrition and dietetics practice. Specific to nutrition support, RDNs at the competent level are able to independently complete nutrition assessments for patients with a variety of co-morbid conditions, calculate macronutrient needs to promote or sustain recovery, and recommend nutrition support regimens according to best practice and consistent with individualized care plans.

At the proficient level, an RDN has developed a more in-depth understanding of nutrition support practice and is more skilled at adapting and applying evidence-based guidelines and best practices than at the competent level. This RDN is able to modify practice according to unique situations. The RDN at the proficient level may possess a specialist credential(s). RDNs in nutrition support practicing at the proficient level may have obtained privileges or receive physician-delegated orders to order and manage nutrition support therapies, and are able to manage a higher-volume, more complex patient load compared to the RDN at the competent level. Experienced RDNs in nutrition support may also serve as a mentor or preceptor to nutrition and dietetics students/interns and/or a mentor to competent-level practitioners on management of patients requiring nutrition support therapies.

At the expert level, the RDN thinks critically about nutrition support, demonstrates a more intuitive understanding of the practice area, displays a range of highly developed clinical and technical skills, and formulates judgments acquired through a combination of education, experience, and critical thinking. Essentially, practice at the expert level requires the application of composite nutrition and dietetics knowledge, with practitioners drawing not only on their practice experience, but also on the experience of the nutrition support RDNs in various disciplines and practice settings. Expert RDNs, with their extensive experience and ability to see the significance and meaning of nutrition support within a contextual whole, are fluid and flexible, and have considerable autonomy in practice. They not only develop and implement nutrition support services; they also manage, drive, and direct clinical care; conduct and collaborate in research and advocacy; work for pharmaceutical companies; accept organization leadership roles; engage in scholarly work; guide interprofessional teams; and lead the advancement of nutrition support practice. RDNs in nutrition support practicing at the expert practitioner level are considered experts in the field and incorporate, as appropriate and within state regulations and organizational policies, skills such as insertion of nasoenteric feeding tubes,^{31, 59, 60} and EN and PN order writing.^{5, 30} RDNs with extensive experience in the use of nutrition support therapy, often with the CNSC, are leaders in the intensive care units or other settings in which nutrition support is administered. Nutrition care is person-centered and proactive in identifying and addressing needs through the effective application of oral, enteral, and/or parenteral nutrition. The expert-level RDN may also be serving as team coordinator or manager and/or leading an interprofessional team effort to measure and track outcomes data related to malnutrition⁶¹ and other nutrition-related quality measures.

Indicators for the SOP and SOPP for RDNs in Nutrition Support are measurable action statements that illustrate how each standard can be applied in practice (Figures 1 [SOP] and 2 [SOPP], available at www.jandonline.org and https://aspenjournals.onlinelibrary.wiley.com/doi/10.1002/ncp.10774). Within the SOP and SOPP for RDNs in Nutrition Support, an “X” in the competent column indicates that an RDN who is caring for patients/clients is expected to complete this activity and/or seek assistance to learn how to perform at the level of the standard. A competent-level RDN in nutrition support could be an RDN starting practice after registration or an experienced RDN who has recently assumed responsibility to provide nutrition support care for patients/clients. Examples of patients/clients evaluated by a competent-level RDN include those with malnutrition,^62-66 gastrointestinal disorders (eg, inflammatory bowel disease), cystic fibrosis,⁶⁷ and dysphagia.^68-71

An “X” in the proficient column indicates that an RDN who performs at this level has a deeper understanding of nutrition support therapy and has the ability to modify or guide therapy to meet the needs of patients/clients in various situations (eg, patients/clients with diabetes,⁷² renal conditions,⁷³ electrolyte disturbances, acute pulmonary failure on a ventilator, complicated wounds, or neonates on enteral nutrition^{33, 34, 74}).

An “X” in the expert column indicates that the RDN who performs at this level possesses a comprehensive understanding of nutrition support therapy and a highly developed range of skills and judgments acquired through a combination of experience and education. The expert RDN builds and maintains the highest level of knowledge, skills, and behaviors, including leadership, vision, and credentials.

Standards and indicators presented in Figure 1 and Figure 2 (available at www.jandonline.org and at https://aspenjournals.onlinelibrary.wiley.com/doi/10.1002/ncp.10774) in boldface type originate from the Academy's Revised 2017 SOP in Nutrition Care and SOPP for RDNs³ and should apply to RDNs in all 3 levels. Additional indicators not in boldface type developed for this focus area are identified as applicable to all levels of practice. Where an “X” is placed in all 3 levels of practice, it is understood that all RDNs in nutrition support are accountable for practice within each of these indicators. However, the depth with which an RDN performs each activity will increase as the individual moves beyond the competent level. Several levels of practice are considered in this document; thus, taking a holistic view of the SOP and SOPP for RDNs in Nutrition Support is warranted. It is the totality of individual practice that defines a practitioner's level of practice and not any one indicator or standard.

RDNs should review the SOP and SOPP in Nutrition Support at determined intervals to evaluate their individual focus area knowledge, skill, and competence. Consistent self-evaluation is important because it helps identify opportunities to improve and enhance practice and professional performance and set goals for professional development. This self-appraisal also enables nutrition support RDNs to better use these Standards as part of the Professional Development Portfolio recertification process,⁷⁵ which encourages CDR-credentialed nutrition and dietetics practitioners to incorporate self-reflection and learning needs assessment for development of a learning plan for improvement and commitment to lifelong learning. CDR's 5-year recertification cycle incorporates the use of essential practice competencies for determining professional development needs.⁷⁶ In the 3-step process, the credentialed practitioner accesses the Competency Plan Builder⁷⁷ (step 1), which is a digital tool that assists practitioners in creating a continuing education learning plan. It helps identify focus areas during each 5-year recertification cycle for verified CDR-credentialed nutrition and dietetics practitioners. The Activity Log (step 2) is used to log and document continuing professional education during the 5-year period. The Professional Development Evaluation (step 3) guides self-reflection and assessment of learning and how it is applied. The outcome is a completed evaluation of the effectiveness of the practitioner's learning plan and continuing professional education. The self-assessment information can then be used in developing the plan for the practitioner's next 5-year recertification cycle. For more information, see www.cdrnet.org/competencies-for-practitioners.

RDNs are encouraged to pursue additional knowledge, skills, and training, regardless of practice setting, to maintain currency and to expand individual scope of practice within the limitations of the legal scope of practice, as defined by state law, where applicable. RDNs are expected to practice only at the level at which they are competent, and this will vary depending on education, training, and experience.⁷⁸ RDNs should collaborate with other RDNs in nutrition support to gain and provide learning opportunities, promote consistency in practice, and perpetuate alliances in continuous quality improvement and research. See Figure 5 for role examples of how RDNs in different roles, at different levels of practice, can use the SOP and SOPP for RDNs in Nutrition Support.

Details are in the caption following the image — **FIGURE 3**
Open in figure viewer PowerPoint

Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists (RDNs) (Competent, Proficient, and Expert) in Nutrition Support. Image adapted from the Dietetics Career Development Guide, with permission.¹⁶

In some instances, components of the SOP and SOPP for RDNs in Nutrition Support do not specifically differentiate between proficient-level and expert-level practice. In these areas, it remains the consensus of the content experts that the distinctions are subtle and captured in the knowledge, experience, and intuition demonstrated in the context of practice at the expert level, which combines dimensions of understanding, performance, and value as an integrated whole.⁷⁹ A wealth of knowledge is embedded in the experience, discernment, and practice of expert-level RDN practitioners. The experienced practitioner observes events, analyzes them to make new connections between events and ideas, and produces a synthesized whole. The knowledge and skills acquired through practice will continually expand and mature. The SOP and SOPP indicators are refined with each review of these Standards as expert-level RDNs systematically record and document their experiences, often through use of exemplars. Exemplary actions of individual nutrition support RDNs in practice settings and professional activities that enhance patient/client/population care and/or services, can be used to illustrate outstanding practice models (eg, DNS Distinguished Practice Award,⁸⁰ ASPEN Distinguished Nutrition Support Dietitian: Advanced Clinical Practice Award,⁸¹ ASPEN Distinguished Nutrition Support Dietitian Service Award,⁸¹ Fellow of ASPEN,⁸¹ and Fellow of the Academy⁸²).

FUTURE DIRECTIONS

The SOP and SOPP for RDNs in Nutrition Support are innovative and dynamic documents. Future revisions will reflect changes and advances in practice, changes to dietetics education standards, regulatory changes, and outcomes of practice audits. Continued clarity and differentiation of the 3 practice levels in support of safe, effective, equitable, and quality practice in nutrition support remains an expectation of each revision to serve tomorrow's practitioners and their patients, clients, and customers.

To enhance competitiveness in today's health care environment, RDNs may need to broaden their skill set with additional education (eg, master's in public health, doctorate in clinical nutrition) and/or credentials (eg, CNSC, CSPCC, and/or RDN-AP) consistent with personal interests and skills needed to address patient/client population needs and preferences and organization objectives. Achieving certification or other credentials is an assured way to demonstrate RDNs are equipped to meet their next challenge, and to expand options for future opportunities. RDNs in nutrition support also have the opportunity to strengthen the role and responsibilities of the profession through promotion of clinical privileging for ordering therapeutic diets and nutrition-related services, including nutrition support therapies, when consistent with state law and health care regulations. Nutrition support RDNs can advance nutrition and dietetics practice by assisting with measurement and reporting of patient-related outcomes; increasing promotion and use of resources related to telehealth^{83, 84}: placing feeding tubes^{31, 59, 60}; becoming trained on new technologies, such as bedside ultrasound to assess muscle changes⁸⁵; leading nutrition support clinics to assess adequacy and tolerance of nutrition support therapies⁸⁶; providing education; demonstrating leadership in emergency planning for natural disasters, product shortages and using approved care protocols to assess, monitor, maintain, and troubleshoot enteral access devices.

SUMMARY

RDNs face complex situations every day. Addressing the unique needs of each situation and applying standards appropriately is essential to providing safe, timely, person-centered quality care and service. All RDNs are advised to conduct their practice based on the most recent edition of the Code of Ethics for the Nutrition and Dietetics Profession, the Scope of Practice for RDNs, and the SOP in Nutrition Care and SOPP for RDNs, along with applicable federal and state regulations and facility accreditation standards. The SOP and SOPP for RDNs in Nutrition Support are complementary documents and are key resources for RDNs at all knowledge and performance levels. These standards can and should be used by RDNs in nutrition support daily practice who provide care to individuals to consistently improve and appropriately demonstrate competence and value as providers of safe, effective, equitable, and quality nutrition and dietetics care and services. These standards also serve as a professional resource for self-evaluation and professional development for RDNs specializing in nutrition support practice. Just as a professional's self-evaluation and continuing education process is an ongoing cycle, these standards are also a work in progress and will be reviewed and updated every 7 years.

Current and future initiatives of the Academy and ASPEN, as well as advances in nutrition support care and services, will provide information to use in future updates and in further clarifying and documenting the specific roles and responsibilities of RDNs at each level of practice. As a quality initiative of the Academy, the DNS DPG, and ASPEN and its Dietetics Practice Section, these standards are an application of continuous quality improvement and represent an important collaborative endeavor.

These standards have been formulated for use by individuals in self-evaluation, practice advancement, development of practice guidelines and specialist credentials, and as indicators of quality. These standards do not constitute medical or other professional advice, and should not be taken as such. The information presented in the standards is not a substitute for the exercise of professional judgment by the credentialed nutrition and dietetics practitioner. These standards are not intended for disciplinary actions or determinations of negligence or misconduct. The use of the standards for any other purpose than that for which they were formulated must be undertaken within the sole authority and discretion of the user.

ACKNOWLEDGMENTS

Special acknowledgement and thanks to Stephanie Dobak, MS, RD, and Ainsley Malone, MS, RDN, in addition to Brett Baney, MS, RD; Kalli Castille, MS, RDN; June Greaves, RD; Carol Ireton-Jones, PhD, RDN; Jessica Justice, RD; Steven Plogsted, BS, PharmD; Jennifer Sporay, MS, RDN-AP; Renee Walker, MS, RDN; and Hailey Wilson, MS, RD, who willingly gave their time to review these standards. The authors also give thanks to the Dietitians in Nutrition Support Dietetic Practice Group's Executive Committee and the American Society for Parenteral and Enteral Nutrition's Clinical Practice Committee. The authors also extend thanks to all who were instrumental in the process for the revisions of the article. Finally, the authors thank Academy staff, in particular, Carol Gilmore, MS, RDN; Dana Buelsing, MS; Karen Hui, RDN; and Sharon McCauley, MS, RDN, who supported and facilitated the development of these SOP and SOPPs.

CONFLICT OF INTEREST

No potential conflict of interest was reported by the authors.

AUTHOR CONTRIBUTIONS

Each author contributed to drafting and editing the components of the article (eg, article text and figures) and reviewed all drafts of the manuscript.

Supporting Information

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Citing Literature

Volume36, Issue6

Pediatric Nutrition

December 2021

Pages 1126-1143

Filename	Description
ncp10774-sup-0001-Figure1.pdf24.5 MB	Figure 1. Standards of Practice for Registered Dietitian Nutritionists (RDNs) in Nutrition Support. Note: The terms patient, client, customer, individual, person, group, or population are used interchangeably with the actual term used in a given situation depending on the setting and the population receiving care or services.
ncp10774-sup-0002-Figure2.pdf27.7 MB	Figure 2. Standards of Professional Performance for Registered Dietitian Nutritionists (RDNs) in Nutrition Support. Note: The term customer is used in this evaluation resource as a universal term. Customer could also mean client/patient/customer, family, participant, consumer, or any individual, group, or organization to which the RDN provides service.

Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition: Revised 2021 standards of practice and standards of professional performance for registered dietitian nutritionists (competent, proficient, and expert) in nutrition support

Abstract

ACADEMY QUALITY AND PRACTICE RESOURCES