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Dietetics Professionals are Ethically Obligated to Maintain Personal Competence in Practice

An Ethics Opinion reflects the interpretation or application of the ADA/CDR Code of Ethics for the Profession of Dietetics by the Ethics Committee in response to a specific ethics issue or situation facing dietetics professionals in practice. An opinion serves as an educational guide for practitioner conduct. The Ethics Committee initiated the following opinion in 2001. The situations described in the opinion are hypothetical and are not based on factual information from members.

One of the distinguishing features of a profession is the recognition, by professionals as well as the public, of the need to keep up-to-date with the latest advances in the field.(1) Professionals need to build on the basic knowledge and skills learned in school. In addition, in order to remain competent in this changing field, professionals must continue to learn new techniques and the latest evidence-based information, and improve performance to provide quality services for current and future work settings. Professionals also have the responsibility to determine the limits of their competence; a professional who is considering entering a new area of practice or implementing a new treatment approach must become competent to practice in the new area. For example, dietetics professionals who provide nutrition education may need to learn the latest electronic communication techniques as well as the legal and ethical issues in delivering information via the Internet.(2)

Benner(3) defines competence as the ability to demonstrate appropriate professional behaviors with desirable outcomes. Professionals who are competent use up-to-date knowledge and skills; make sound decisions based on appropriate data; communicate effectively with patients, customers, and other professionals; critically evaluate their own practice; and improve performance based on self-awareness, applied practice, and feedback from others.(4)

In recent years various groups have focused increased attention on the need for continuing competence of health professionals. For example, the Joint Commission on Accreditation of Healthcare Organizations requires institutions to assure that staff remain competent in their practice area on an ongoing basis.(5) Consumer organizations, federal agencies, managed care organizations, and legislators are applying increasing pressure for licensure and certifying bodies to take steps to ensure the continuing competence of providers. Employers and the Commission on Dietetic Registration expect dietetics professionals to remain competent throughout their careers.

For dietetics professionals, the Code of Ethics for the Profession of Dietetics,(6) Standards of Professional Practice,(7) and Professional Development Portfolio(8) work together to assure competence. The Code of Ethics defines ethical principles that support the best interests of persons in the society and provides guidelines on how dietetics professionals should conduct business with clients, colleagues, and other professionals. Principle 4 states “the dietetics professional assumes responsibility and accountability for personal competence in practice, continually striving to increase professional knowledge and skills and to apply them in practice.” Therefore, professionals are ethically obligated to remain competent so they can provide the best possible service to clients, customers, and society.

The Standards of Professional Practice guide safe and appropriate practice. The Standards hold the individual professional responsible for continuing competence by participating in self-development to improve knowledge and skills. The Professional Development Portfolio process offers a framework to guide continuing professional education to help the professional achieve self-identified learning needs and goals. The Standards of Professional Practice and the Professional Development Portfolio outline a similar process for maintaining continued competence and professional accountability: conduct regular self-assessments based on self-reflection and feedback from a variety of sources to identify needs for professional development, develop and implement a plan for professional growth, and evaluate the effectiveness of the plan in maintaining competence. For this process to be effective, professionals must accept responsibility for accurately assessing their learning needs, preparing and implementing a learning plan that appropriately addresses identified needs, applying the new knowledge and skills to practice, and honestly evaluating if they remain competent to practice.

When registration was first implemented in 1969, mandatory continuing education was established to promote continuing competence of registered dietitians.(9) As part of the Professional Development Portfolio process, dietetics professionals who are registered must participate in continuing professional education activities that are related to dietetics. Dietetics is defined as “the integration and application of principles derived from the sciences of food, nutrition, management, communication, and biological, physiological, behavioral and social sciences to achieve and maintain optimal human health.”(10) The purpose of continuing professional education is to maintain competence in dietetics. To be most effective, dietetics-related continuing professional education activities should be self-directed, interactive, experience-based, and applied to the learner's professional practice.(11)

Participation in formal professional development activities such as workshops is not the only way professionals learn. Professional development during the years of active practice also occurs as the direct or indirect result of the work itself. Professionals who maintain a mind-set of continuous performance improvement through self-reflection and interaction with others will be more effective professionals. For example, a dietetics professional who would like to improve his or her ability to help clients solve nutrition-related problems may use critical self-analysis to revise his or her counseling approach. Or a dietetics manager may learn about more effective personnel management strategies through informal interactions with other managers in the institution. Other professional development opportunities in the workplace may include problem-oriented information searches, observation of role models, and analysis of errors or unexpected results of one's actions.(3,12,13)

Dietetics professionals who fail to remain competent or are less than competent to practice expose themselves to many professional risks, including the possibility that they may cause harm to clients or customers. For example, a food service manager who does not remain current with procedures to prevent food-borne illness may risk causing injury or death to vulnerable clients, or a professional in private practice may exacerbate a patient's medical condition by recommending inappropriate diet restrictions. Incompetent professionals may also become the subject of a lawsuit; for example, the family of a patient in a long-term care facility who dies of malnutrition may sue the dietetics professional who failed to appropriately identify and recommend treatment for the patient. Other professional risks of practicing in an incompetent or less-than-competent manner include the possibility that the professional may lose his or her job, or become the subject of a complaint to a state licensure board or the Ethics Committee of the American Dietetic Association and Commission on Dietetic Registration. Licensure boards and the Ethics Committee may suspend or revoke the individual's registration(6) or license to practice.

EVALUATION OF COMPETENCE

How does a professional know if he or she is competent to practice? Most professionals believe that they are competent to practice, but overconfidence or resistance to change may cloud their judgment. Both experienced professionals and those who are considering entering a new area of practice or implementing a new treatment approach must be sure that they have the appropriate training and understand the scientific basis of practice. Professionals have the responsibility to identify the limits of their competence. Professionals may use a number of strategies to evaluate their competence. Self-reflection, a key component of lifelong learning, is an important strategy for evaluating competence.(5,12) Dietetics professionals may evaluate how successful they have been in maintaining competence by analytically reflecting on their performance during critical incidents. For example, a professional who volunteers to coordinate meal preparation in a homeless shelter should evaluate his or her knowledge of cost control strategies if the food costs exceed the budget. Effective analysis of critical incidents is based on sound and sufficient knowledge, the ability to transfer learning from one situation to another, and a willingness to change.

Obtaining feedback on performance from a variety of sources including clients, supervisors, peers, and mentors, is another effective strategy to determine if one is maintaining competence.(12) These individuals, who are in a position to directly observe the professional's behavior, can provide valuable evidence of competence. A dietetics professional who observes incompetent practice by another professional has the ethical responsibility to confront the incompetent individual and, if necessary, provide evidence to the state licensing board and the Commission on Dietetic Registration if the incompetent practice can harm the public.

Another strategy for dietetics professionals is to compare their performance to evidence-based practice guidelines.(14) Evidence-based practice guidelines are developed from current research on the effectiveness of different approaches to practice. The resulting guidelines translate the research findings into the most appropriate strategies to use in practice. Thus, a professional who is following the guidelines appropriately should be providing high-quality services.

Another way dietetics professionals can determine if they are maintaining competence is to compare their performance in the worksite to the best practices identified in professional development activities.(7) For example, a dietetics professional who teaches nutrition to nursing students may attend a training session on effective strategies for distance education courses, and then determine if the Web-based course designed for his or her students incorporates the most effective strategies.

Finally, some professionals may evaluate competence by completing the requirements to achieve and maintain relevant certification. For example, a professional may demonstrate application of knowledge and decision-making skills for the appropriate care of children by passing the examination to become a Certified Specialist in Pediatric Nutrition.(15)

EXAMPLES OF THE NEED FOR PERSONAL COMPETENCE IN PRACTICE

The following three examples demonstrate the need for dietetics professionals to maintain personal competence in practice:

Ben is a dietetics professional who has worked for two years as the manager of a school lunch program in a rural area. The local school board received a complaint that Ben's department is not following acceptable financial practices. Upon further investigation, the board determines that Ben must update his knowledge and skills in budgeting, record keeping, and interpreting financial data or lose his job. Ben agrees to complete a workshop on financial practices and to meet regularly with the school district's chief financial officer for one year. If Ben had assumed responsibility for remaining competent to practice, he could have avoided the potential loss of his job.
Jordan was recently elected as an officer of the district dietetic association. Jordan would like to become an effective officer, so she establishes a mentoring relationship with an experienced officer to develop her leadership and team-building skills. As a result of identifying and addressing a learning need, Jordan has maintained competence as a professional.
Jane is a dietetics professional who has been out of the workforce for 10 years. When she decides to return to work, she accepts a position working with renal patients. During her 10 years away from practice, Jane participated in continuing professional education activities related to medical nutrition therapy; however, when she accepts the position Jane determines that she must identify opportunities to quickly update her knowledge and skills in renal nutrition. Jane completes a self-study program on renal nutrition and works with a mentor to identify evidence-based practice guidelines, apply the guidelines to her practice, and evaluate the effectiveness of the medical nutrition therapy she provides to her clients. Jane has demonstrated that she is willing to assume responsibility and accountability for competence in practice.

CONCLUSION

All dietetics professionals have an ethical responsibility to remain competent throughout their careers. Professionals who are returning to the workforce, changing job responsibilities, or continuing to practice in the same position must all accept responsibility for learning and improving performance throughout their careers. Changing professional roles requires individuals to plan and implement learning experiences that will keep them ready to safely and effectively provide nutrition services. When each professional chooses the most appropriate learning strategy to train for his or her specific area of practice, the result will be a diverse group of competent dietetics professionals with a solid foundation of knowledge and skills. Participating in critical self-evaluation, gathering feedback from others, following evidence-based practice guidelines, adopting best practices, or obtaining certification will help professionals evaluate how successful they are in maintaining competence.

REFERENCES

Houle CO. Continuing Learning in the Professions. San Francisco, CA: Jossey-Bass Publishers. 1981.
Rodriguez JC. Legal, Ethical, and Professional Issues to Consider When Communicating via the Internet: A Suggested Response Model and Policy. J Am Diet Assoc. 1999;99:1428-1432.
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Benner P. Issues in Competency-Based Testing. Nurs Outlook. 1982;30:303-309.
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Epstein RM, Hundert EM. Defining and Assessing Professional Competence. JAMA. 2002;287:226-235.
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CROSSREF
Comprehensive Accreditation Manual for Hospitals: The Official Handbook. Oakbrook Terrace, IL: Joint Commission on Accreditation of Healthcare Organizations. 2001.
Code of Ethics for the Profession of Dietetics. J Am Diet Assoc. 1999;99:109-113.
MEDLINE
Implementing the Standards of Professional Practice: Is Your Career Ready for the New Millennium? J Am Diet Assoc. 1999;99:1128-1131. Accessed February 5, 2003.
The Professional Development 2001 Portfolio. J Am Diet Assoc. 1999;99:612-614. Accessed February 5, 2003.
American Dietetic Association Annual Reports and Proceedings, 1965-66. Chicago, IL: American Dietetic Association. 1967.
American Dietetic Association Board of Directors. June 10, 2000.
Duyff RL. The Value of Lifelong Learning: Key Element in Professional Career Development. J Am Diet Assoc. 1999;99:538-543.
MEDLINE
Redfern S, Norman I, Calman L, Watson R, Murrells T. Assessing Competence to Practise in Nursing: A Review of the Literature. Research Papers Education. 2002;17:51-76.
CROSSREF
Epstein RM. Mindful Practice. JAMA. 1999;282:833-839.
MEDLINE
CROSSREF
American Dietetic Association Medical Nutrition Therapy Evidence-Based Guides for Practice. Chicago, IL: American Dietetic Association. 2001.
Commission on Dietetic Registration. Certified Specialist in Pediatric Nutrition. Available at www.cdrnet.org/certifications/spec. Accessed February 5, 2003.

The Ethics Committee approved this Ethics Opinion on January 27, 2003. The American Dietetic Association authorizes republication of the Ethics Opinion, in its entirety, provided full and proper credit is given. Requests to use portions of the Ethics Opinion must be directed to ADA Headquarters at 800/877-1600, ext. 4896 or ethics@eatright.org.

Recognition is given to the following individuals for their contributions:

Author

Gail Gates, PhD, RD, Nutritional Sciences, Oklahoma State University, Stillwater, OK

Reviewers

Sara Long Anderson, PhD, RD, Didactic Program in Dietetics, Southern Illinois University, Carbondale, IL
Bruce Rengers, PhD, RD, Nutrition Consultation and Clinical Services, Colorado Department of Public Health & Environment, Denver, CO
Lori Roth-Yousey, MPH, RD, LN, Lori Roth-Yousey & Associates, North Branch, MN

Ethics Committee (2001-02)

M. Rosita Schiller, PhD, RD, FADA, chair
Cheryl Rock, PhD, RD, FADA
Judith Dodd, MS, RD, FADA

Ethics Committee (2002-03)

Cheryl Rock, PhD, RD, FADA, chair
Judith Dodd, MS, RD, FADA
Cathie Christie, PhD, RD, FADA