FAQ

Frequently Asked Questions

1. CDBC Topics

2. Code of Ethics

3. Continuing Competence

4. Legislation & Practice

5. Registration

6. Restricted Activities

7. Vitamins & Minerals

1. CDBC Topics

Q: Why am I getting so many CDBC emails?

A: A few years ago the Board of Directors made the decision to communicate with registrants electronically whenever possible to save printing and mailing costs. We are required by law to inform you of legislative and regulatory matters and you are required in the CDBC bylaws to keep your contact information current, including your email address. Registrants have a professional responsibility to keep current with regulatory matters, which will be sent to you via email. The choice to open and read CDBC emails is yours. We count on you to make the right choice.

Q: Why was I able to vote for nominees in both the Fraser and Vancouver Island electoral regions during the first CDBC Board of Directors election? I don't live in either region.

A: The ability to vote for nominees in any electoral region is in accordance to section 7(4) of the CDBC Bylaws. Under "Election procedure" the bylaws state "each Registrant may vote in favour of one (1) person for each vacant position to be filled". This bylaw legally allows all CDBC registrants in BC to vote for any nominee in all electoral regions where elections are being held. For more information about the CDBC election procedure, please consult section 6 of the CDBC Bylaws.

Q: I lost my CDBC tax receipt. How do I obtain a duplicate?

A: Registrants are now able to download, print and save copies of 2010-11 and 2011-12 registration tax receipts directly from their online Personal Profile under Registration Receipts.

2. Code of Ethics - Top

Q: Can we post the Code of Ethics on our hospital nutrition website?

A: Yes. Note: The approved Code of Ethics is available on our CDBC website.

Q: Many staff work many jobs, not just one. If one job is private, for example selling/marketing a product, how do we avoid conflict of interest situations in the other roles? 

A: To deal with situations like this, refer to the Code of Ethics, Principle 4: "A Registered Dietitian demonstrates inclusion, honesty and integrity when interacting with clients at all times..." Pay particular attention to the Standard that says, "...avoiding any situation which could be perceived as non-inclusive or dishonest." The Code of Ethics, which is made up of five principles, each supported by a set of standards, is designed to help you in your daily practice. As a Registered Dietitian you are required to be familiar with the Code and use it to guide your practice decisions.

Q: Is it okay to accept sponsorship from drug companies and other corporations? I've been approached by a health products company to sell their vitamins and minerals to my patients. Is this allowed by the College?

A: You may sell vitamins and minerals but must meet the College's Marketing guidelines (s. 74 of the CDBC bylaws) and Code of Ethics principles. Summarized, the vitamins and minerals you are recommending and selling must be needed as determined by an appropriate nutritional assessment, and meet the dosage guidelines stated above.

In addition, you must:

  • be open and transparent with your patients that you are selling the products and making a profit from the sales
  • provide options for buying the recommended vitamins and minerals from other sources
  • not adjust your delivery of dietetic care if the patient decides not to purchase the products from you or from another source

Q: I'd like to create a website for my private practice. What is a good reference to help me draft a "Privacy & Confidentiality" disclaimer?

A: Please refer to Principle 6 of the Code of Ethics. More information may be obtained from the Freedom of Information and Protection of Privacy Act and from the Privacy Legislation for Private Practitioners and the Interpretive Guideline - Privacy Legislation for Private Practitioners on our website.

Q: When is a child considered 'capable' of consenting to care? Do I need to tell the child's parents/guardian about our therapeutic relationship? Do I need parental consent before providing dietetic care?

A: Please refer to Where's the Line?, the College's Patient Relations Program. Page 6 reviews important steps to setting the stage for a therapeutic relationship, including consent to care guidelines:

Obtaining informed consent to treatment:

Adhering to privacy regulations

The BC Branch of the Canadian Bar Association also published Children and consent to Medical Care (relevant to physicians and other health care providers).

Q: Can I provide dietetic counseling to a teenager without parental consent? A high school counselor approached me about a student who is concerned about her weight. She has a BMI of 22. The student says her parents are not concerned and she would prefer them not knowing she wants to talk with a Dietitian about her weight. The counselor would like to schedule an appointment for me and the student without her parents knowing. Can I legally provide dietetic counseling to her?

A: Children (anyone under 19) can consent to their own medical care if they are "capable" (i.e. if he/she understands the medical care requested, the treatment process, and the risks and benefits of care). Children who are capable can normally obtain medical treatment without their parents' or guardian's knowledge or consent. In addition, a healthcare provider can't discuss a capable child's medical care with the parents or guardian unless the child agrees. For more information, please consult http://www.cba.org.

Q: About palliative care and tube feeding...

Below is a summary of an ethical situation recently reported by a RD. It's interesting to note that the resolution of this issue follows the Ethical Problem-solving path discussed in the Quality Assurance Committee's Code of Ethics - Principles & Guidelines. Discussing this case with interns and colleagues would likely generate an interesting debate! Note: the case has been reproduced exactly as received.

A: "The two most difficult issues I have had to deal with are concerning palliative care and feeding tubes, particularly if the Dr. has not documented that the patient is palliative, as well as treatment, including feeding, of a patient with an end stage eating disorder.

A patient of mine, in her late twenties, with a long standing problem with anorexia, presented to the hospital with her first admission with anorexia. At the time she was admitted she was completely emaciated with a dangerously low body weight.

She and her family wanted treatment at that point. She was able to eat small amounts and I seem to recall that we may have had her agree to a tube feeding, although I am not sure. She ended up dying due to the advanced nature of her anorexia. Some of the nursing staff thought we were too aggressive with our approach to treatment. They felt we should have supported this young woman to die with more dignity. These nurses felt that we should have spent more time and effort preparing this patient and her family for her eventual demise. I felt that I was put on the spot to defend our treatment of this patient. Some staff was quite angry and others were tearful.

I reminded the staff that the patient and her family were in agreement with our treatment plan and were seeking treatment. I had also called over to the eating disorder program and sought their advice. They agreed with the treatment plan as well.

If I had to do this over again, I would have sought help from pastoral care as well as our mental health staff to spend time with the patient and her family. I think too we should have had more patient and family conferences with the staff and attending physician to discuss the plan of care as it evolved. Our hospital now has an ethics committee and I would approach them to assist."

3. Continuing Competence Top

 Q: I am currently working in clinical nutrition, but plan to apply for a managerial position in the future. Should I document this goal in my Professional Development Plan?

A: The answer is "yes" if you plan to start developing this goal within the duration of your current Continuing Competence Program (CCP) cycle. This broad goal may be broken down into smaller, time-framed goals with specific activities such as attending a leadership workshop or taking a leading role in your department by initiating a series of educational sessions for your colleagues.

Q: I drafted my learning goals, but I am not sure if I selected the appropriate learning activities to achieve my goals.

A: Perhaps the best advice we can give here is to keep it simple. Refer to the Professional Development Guidelines for a general list of common professional development activities. Examples may range from reading peer-reviewed resources, such as journals and evidence-based practice tools, attending Toastmasters once a week, filming your own presentation for later review and improvement, participating in a multidisciplinary research project, attending conferences or performing volunteer dietetic work.

Q: Does preceptorship count towards Continuing Competence?

A: Several registrants recently reported in their Professional Development Plans (PDPs) a shared goal to increase their competence as preceptors. Supervision of interns provided these registrants with opportunities to enhance several indicators of the seven Standards of Practice which varied according to the supervising dietitian's area of practice. Not only did preceptorship require good communication skills to establish and maintain rapport with students and confidence to support student learning (constructive criticism), but it also helped registrants fine tune their critical thinking and practice skills in order to evaluate the interns' ability to be accountable and to practice competently, safely, ethically and professionally. Registrants also reported attending a preceptorship workshop offered by their Health Authority as part of their learning process to becoming an effective preceptor.

Q: What happens if a RD does not fulfill the Continuing Competence Program (CCP) requirement yet renews her/his registration?

A: If the RD renews registration by March 31 without making sure CCP requirements are met, she/he is falsely declaring participation in the CCP. By checking the Declaration of Participation to the CCP box on the registration renewal form, the RD is declaring that: "I will maintain my competence with dietetic practice by completing my Self-Assessment relative to the Standards of Practice and my Professional Development Plan as approved by the Quality Assurance Committee and Board." Making a false legal declaration is a serious offence. As a result, the CDBC Registrar is required to document the offence and file an "own motion" complaint to the Inquiry Committee. The registrant would be contacted as part of the investigation and the false declaration remains on the registrant's file for six years (CDBC bylaws section 69.

Q: I am part of the 2010 Continuing Competence Program group (former cohort 3) and I believe that by October 2009 I will have "completed" my three learning plans (goals and activities). My colleagues told me that if this was the case then I would need to add at least 3 more standards/indicators before sending in my Professional Development Plan (PDP) as the completed ones wouldn't count. They tell me that I must always have at least three standards/indicators in "progress" when sending in my Professional Development Plan? Is this correct?

A: Yes and no... Your colleagues are correct when they say you must have at least three standards/ indicators in "progress" when sending in my PDP. That being said, "complete" is a progress stage. If you plan on completing your 3 learning goals and related activities by March 31, 2010, please indicate so in your PDP. You don't need to formulate 3 new learning goals until after March 31, 2010. The 3 new learning goals would be included in your 2013 Professional Development Plan. However, if you suspended 1 or more of your 3 learning goals and related activities before March 31, 2010, you need to indicate why and substitute new learning goal(s) and activities in your Professional Development Plan.

Q: My employer asked me to provide proof of competence or demonstrate that my practice is in line with current dietetic practice guidelines, how can I prove this to my employer?

A: You may want to let your employer know that being registered in good standing with the CDBC proves that you are actively participating in and meeting the requirements of the CDBC Continuing Competence Program. Do you need to develop a performance appraisal process at your new workplace? If so, you may want to consider using your Self-assessment and Professional Development Plan to show your employer how you are ensuring your services meet the Standards of Practice. You may be able to answer your employer's performance appraisal needs/concerns by sharing your learning goals and activities and explain how these relate to your responsibilities and how they help you maintain a competent and safe practice.

4. Legislation & Practice Top

Q: I would like to have information about the title "Dietitian". Are dietitians and nutritionists the same?

A: There's a vast difference between dietitians and nutritionists. You may find information about dietitians' reserved title on the CDBC website in the Employers & the Public section. The titles of "Nutritionist", "Registered Holistic Nutritionist (RHN)" and "Registered Nutritional Consulting Practitioner (RNCP)", are not reserved titles in BC. Nutritionists are not educated to the same standards as Registered Dietitians who:

• have completed four years of recognized university level education and a one-year internship,
• are regulated under the Health Professions Act and must be registered with the CDBC to practice and use the reserved title "Dietitian",
• have passed a national competence examination,
• are required through legislation to maintain their competence and meet government approved Standards of Practice and a Code of Ethics and,
• are required to practice in the best interest of the public - safely, competently and ethically.
Although not registered with a regulatory agency, some nutritionists may use the designation "Registered" because their program of study paid the required fee to Industry Canada to legally trademark the title of their program and diploma.
 

Q: I've noticed a dietitian colleague provide enteral nutrition feeding regimens for several patients that were too high in energy and nutrients. Some of them were at risk for refeeding syndrome and did not tolerate the enteral nutrition the dietitian had recommended. I've approached this dietitian and offered her updated literature about nutritional status assessment for enteral nutrition and refeeding syndrome. However, she declined my offer and said her knowledge was up-to-date. I'm concerned she may harm patients, especially the ones who are at risk for refeeding syndrome. What should I do?

A: According to section 32.2(1) of the Health Professions Act (HPA), if you have reasonable and probable grounds for believing this dietitian is placing patients at risk, you have a duty to report her unsafe practice in writing to the CDBC Registrar. The Registrar will follow the Complaint Resolution Process to ensure public safety.

If your Health Authority/ health facility has policies in place for addressing unsafe practice, you may also have to report your concerns to the designated person. If this person is a regulated health professional, they too are mandated under the HPA to report the dietitian's alleged unsafe practice to the CDBC. If the person is not a regulated health professional, they do not have a duty under the HPA to report unsafe practice but may still choose to do so. If that person doesn't report your concerns to the CDBC, you should.

At times, dietitians may observe unsafe practice by other regulated health professionals. If that occurs, dietitians have a duty to report the unsafe practice to that professional's regulatory college. The process for managing complaints is the same for all colleges regulated under the HPA although, depending on circumstances, the timing of some parts of the process may vary. Section 32.5 of the Health Professions Act provides immunity to dietitians who make a complaint in good faith, which would prevent the person you are complaining about from seeking damages against you.

Q: To Document or Not to Document?

A: Section 1, Definitions, of the Dietitians Regulation defines "dietetics" as "the assessment of nutritional needs, design, implementation and evaluation of nutritional care plans and therapeutic diets, the science of food and human nutrition..." When providing client specific advice, a RD performs a nutrition assessment, obtaining enough information to identify nutrition related problems, and makes appropriate recommendations. This level of advice requires unique dietetic knowledge and enables the RD to design a therapeutic diet for a specific nutritional concern. Dietetic care that includes "the assessment of nutritional needs, design, implementation and evaluation of nutritional care plans..." requires documentation. The RD's care plan is based on a client-specific assessment.
The definition of "dietetics" also states "...and dissemination of information about food and human nutrition to attain, maintain and provide the health of individuals, groups and the community." Disseminating general nutritional information, verbally or in writing, directly to individuals, populations or communities, or relayed by another health professional, is not based on an individualized assessment and does not need to be documented.
  • Scenario 1: A casual RD in a health facility is called on the weekend to adjust the tube feeding regime of a patient with an existing tube feeding (initial assessment and consult written by the RD who normally works on this ward). Does she document or not document the adjustment to the enteral feed? Documentation is needed and may be recorded in the manner most convenient at the time. The casual RD may add notes to the patient's chart if she has access to it. If not, she may relay notes in writing or verbally to the RD who is caring for the patient. This is the safest approach to communicate and ensure continuity of care.
  • Scenario 2: A community RD is approached by a RN in the hallway about dietary advice for her client. The client is a mother complaining that her child is a picky eater. The community RD offers the RN a copy of Canada's Food Guide, a pamphlet on suggestions for feeding a child with definite likes and dislikes, and contact information for the RD should the client require further information. Does the RD need to document the information provided to the RN who will relay it to the client? Documentation is not needed as the community RD provided handouts that consist of generic information, accessible to the public on the Internet. The RD did not assess or make recommendations specific to a particular child.

 

Q: What are public domain activities?

A: Did you know that some activities, such as pricking the finger for a blood sample, are in the public domain? Being "in the public domain" means that the activity is not restricted to any specific health professional. Anyone can prick another person's finger and draw blood, assuming they have consent. Another example is taking blood pressure. Anyone can take another's blood pressure and, in fact, many people take their own blood pressure at home and in pharmacies. You may perform both of these activities. However, as a health professional, you must have a dietetic-based reason, such as pricking a finger to obtain a blood glucose reading. When taking a client's blood pressure, you must have a dietetic related reason as well as understanding the implications of the reading obtained and refer your client to the appropriate health professional when appropriate.

Q: New regulations come into force in Fall 2009 and I'm not sure how they apply to a Dietitian's ability to write an order for a therapeutic diet. I've included the sections below. Would you mind explaining them?

  • Adult Care Regulations (in force September 30, 2009) Section 7.3 (1) A licensee must ensure that meals and snacks (e) fulfill the requirements of any therapeutic diet ordered by the person in care's primary health care provider.
  • Residential Care Regulation (in force October 1, 2009) Section 81 (3) A care plan must include all of the following (c) a nutrition plan that (ii) specifies the nutrition to be provided to the person in care, including the requirements of any therapeutic diets.

A: A Dietitian is a primary health care provider along with a physician, nurse, etc., and can currently determine the therapeutic diet required by an adult. In the Dietitians Regulation, the definition of "dietetics" includes reference to "therapeutic diets." To the CDBC, therapeutic diets refer to diets designed for any preventive or corrective medical reason and clearly differentiate the scope of practice of a Registered Dietitians from a non-regulated nutritionist.

After the two new regulations come into effect, the same reasoning applies. "Writing an order" for a therapeutic diet is a common term for Dietitians although the College prefers to use terms such as "designing" a therapeutic diet (as used in the Dietitians Regulation) or "selecting ingredients for" a therapeutic diet. This Fall you may continue to design or select ingredients for therapeutic diets.

The only limitation for a Registered Dietitian applies to enteral/parenteral therapeutic diets that include vitamins, minerals, insulin or oral hypoglycemic agents that are re-classified in a hospital setting as Schedule 1 drugs requiring a prescription. You may still legally design the diet but currently need a physician or nurse practitioner ("authorized practitioners") to relay the order to the pharmacist so the pharmacist can legally accept the diet order from an authorized practitioner, even though it was designed by the Dietitian. The pharmacist can then compound and dispense the enteral or parenteral therapeutic diet.

Q: Is it legal for a RD to adjust insulin?

A: The answer depends on several factors. The most straightforward situation is an ambulatory patient receiving diabetes counseling from a RD in an outpatient setting. The RD educates the patient on the correct amount of insulin to take for a range of blood glucose readings. Education is part of community diabetes practice and providing information is legal. The RD is not adjusting the patient's insulin but instructing the patient in appropriate self-management of diabetes. (Note: Insulin is a Schedule II drug and may be obtained by the patient "over the counter" from a community pharmacy.)

If the same patient is admitted to a health care facility (hospital, long-term care facility, etc.) admittance records would include the patient's use of insulin. In most facilities, all drugs are dispensed from the facility pharmacy on prescription, even if the drug is classed as non-scheduled or Schedule II. A prescription is required because pharmacists may only legally dispense drugs to specific health professionals referred to as "authorized prescribers" (physicians, dentists, veterinarians, midwives, nurse practitioners, etc). If a RD determined the need to adjust the patient's insulin, the prescription would have to be changed by an authorized prescriber in order for the pharmacist to legally dispense the new insulin dose. This can delay the patient obtaining the correct amount of insulin and is a barrier to efficient, effective health care delivery. In response to this problem (and other "barrier" problems), some health care facilities, mostly rural, have developed an inter-professional protocol for insulin that outlines the range of adjustment a RD could make that would be dispensed by the pharmacist without a prescription. If a protocol like this exists in your facility, it was probably developed and approved by an inter-disciplinary health care committee in conjunction with facility administrators. The Health Authority may be also asked to review and agree to the protocol. The CDBC encourages development of workable protocols such as this and is working to include specified drugs in the "design" of enteral and parenteral formulas. If approved by government, these principles will be included as new Restricted Activities.

Q: Our hospital does not have a policy for dietitians to accept verbal or telephone orders from doctors. Can we legally accept telephone and verbal orders?

A: Dietitians can legally accept verbal, telephone or written orders as they pertain to the practice of dietetics. A physician writing or saying "as per dietitian" regarding a therapeutic diet is giving a general order. Orders may also be much more specific. A Dietitian is required to detail and record in the patient chart any order a physician issues including any changes in treatment. Although legally allowed, some facilities may have a specific operational process for detailing and recording an order. This may include a facility decision as to who should record a dietetic order - the physician giving the order, the Dietitian taking the order and/or other designated licensed/registered health professionals who may record orders in that facility. If you're unsure of any limits in your facility for accepting verbal, telephone or written orders, check with your supervisor.

Q: May I use the word "Specialist" in my professional title? I've just earned my Certified Diabetes Educator (CDE) credential and work only in diabetes management. I'd like to add "Diabetes Specialist" on my business cards.

A: According to section 75(6) of the CDBC bylaws: "Unless otherwise authorized by the Act, the regulations, these bylaws, or the board, a registrant (a) must not use the title "specialist" or any similar designation suggesting a recognized special status or accreditation on any letterhead or business card or in any other marketing, and (b) must take all reasonable steps to discourage the use, in relation to the registrant by another person, of the title "specialist" or any similar designation suggesting a recognized special status or accreditation in any marketing." As the CDBC Board has not recognized any specialty designation, you may not use the term "specialist". However, you may add diploma (e.g., BSc, MSc, PhD) or certification titles (e.g., CDE,Certified Nutrition Support Dietitian (CNSD), Sports Dietitian, etc.) to your signature.

Q: I had an unusual experience in my out-patient hospital clinic the other day. A patient attended for routine counseling and brought her teenage daughter, and the daughter recorded the teaching session on her smart-phone without my knowledge or permission. Do clients and/or family members have the right to do this? Do you know if audio recordings have ever been used in a court of law against healthcare workers?

A: This response is a summary of a legal opinion provided by Catharine Herb-Kelly, QC, LLB, the CDBC’s lawyer. Audio recordings in the context of a health care relationship have not been squarely addressed by the courts. However, there is enough information available to provide reasonably solid advice. In short:

  • a patient does have the right to record a counseling session without the dietitian's consent,
  • a dietitian does not have a right to expect that the patient would ask permission before making a recording, and
  • a recording could be used in court.

Reasons for the legal advice: the Supreme Court of Canada has stated that the health professional is the owner of the health record but "the information that a patient reveals…remains one's own...” The patient has control of his/her information which suggests that he/she can deal with it however he/she wishes. It is not an offence under the Criminal Code for a patient to record a conversation to which they are a party without the other party's consent. Neither the “Freedom of Information and Protection of Privacy Act” (FIPPA) nor the “Personal Information Privacy Act” (PIPA) applies to the patient, although the provisions apply to a dietitian’s disclosure of the patient's information, depending upon whether the dietitian is working in an institution (FIPPA) or a private clinic (PIPA). The BC “Privacy Act” makes it an offense to violate the privacy of another but it does not create an absolute right to privacy, only a right that is reasonable. Based on these Acts, it is doubtful that a dietitian or other health care practitioner has a right to privacy regarding his/her advice in a counseling session.

Although regulatory cases where audio recordings were used in court were not found, there are many examples in family law. Audio recordings of conversations are generally admissible as evidence if the court is satisfied that the evidence is relevant to the issue and the recording is truth worthy. A recording of a counseling session would likely be treated in a similar manner.

Q: If a patient is referred to me by a doctor and discloses confidential information during an outpatient appointment, but say they don’t want you (the RD) to share the information with the doctor, do we have to keep it confidential? Are we obligated to tell the doctor about anything related to nutrition that might affect the patient’s condition?

A: Answer provided by Catharine Herb-Kelly, QC, legal counsel for the CDBC. This is a difficult situation. I don't think the dietitian can disclose the information to the physician if she has been specifically instructed not to. The dietitian should try to talk the patient out of his/her position if it is necessary for optimal care in a shared care setting. I don't think the legal position of the dietitian is clear here in that this issue has not been litigated, but I read some material that suggested the dietitian should advise the physician that he/she does not have full information about the patient, but not more in such a situation. Also, the Health Authorities often have policies on these situations. This one, in particular, is not clear, so I think it would be wise for the dietitian to consult with people within the Health Authority as well.

5. Registration Top

Q: I didn't receive notice of the registration renewal deadline. Why do I have to pay the $250 late fee?

A: If you missed the registration renewal deadline (March 31 midnight), you registered "late" and were required to pay the fee. If you didn't receive renewal information, you probably also didn't receive our:
• Monthly Updates (ask your colleagues if they received this issue)
• Notice of Elections, election nomination form and election ballots
• News: CDBC initiatives, changes in legislation/registration requirements, etc.
• Invitations: Annual General Meeting, College events and contract bids.

 Why? Here are possible reasons:

• You are not registered with the CDBC (practising illegally)
• You moved or changed your email address, but haven't updated your contact information in your CDBC profile
• You changed jobs/employers, but haven't updated your workplace information in your CDBC account
• You forgot your user ID and/or password and can't access your CDBC profile, or
• You (and over 35 others) "unsubscribed" from the Constant Contact software that delivers most of our email correspondence and our emails were undeliverable.

According to section 54(1) of the CDBC bylaws: "A registrant must immediately notify the registrar of any change of address, name or any other registration information previously provided to the registrar." You must keep your contact information up-to-date. By doing so, and ensuring you're a subscriber to Constant Contact, you'll receive all CDBC correspondence, including renewal information. Next year you'll be able to renew your registration on time.

Q: I have the opportunity to work in BC this summer. I'm currently registered with the College of Dietitians of Ontario. Do I have to register with the CDBC too?

A: Yes, you do. The College of Dietitians of BC has obtained legal advice about cross-jurisdictional practice which includes in-person, electronic and/or telephone consultation between provinces and countries, most often the USA and Canada. For the purpose of this question, comments are limited to cross-provincial counselling.

While our College's legal counsel agrees that the issues raised by cross-jurisdictional practice are complex, our current legislative framework requires a dietitian to be registered with the CDBC in order to practice dietetics in BC. The CDBC's mandate includes enforcement of BC's health legislation. Therefore, the CDBC is required under the Health Professions Act to register qualified dietitians wishing to practice dietetics in BC. If a CDBC Registered Dietitian (RD) informs us that he/she wishes to practice in another province while living in BC, the registrant is advised to contact the regulatory college of that province and register.

In reality, the CDBC is unable to monitor dietetic practice being provided in BC by RDs who live and are registered in another province. Without this knowledge, the CDBC is unable to enforce registration requirements. The CDBC and other BC regulatory colleges are very aware that cross-jurisdictional health practice is occurring. Until provincial and federal health legislators address the issue and all its nuances, individual regulatory colleges in BC are required to regulate practice in the best interests of the public which means the health care provider is registered in BC, providing health care to BC citizens and practicing in accordance with BC laws.

Q: What does RD(t) designate?

A: These initials fit with the CDBC bylaws and Temporary Registrants are required to use this designation after initial registration and prior to passing the Canadian Dietetic Registration Examination (CDRE).

Q: What does your CDBC registration fee pay for?

A: The fee entitles you to practice your profession and use the protected title of Registered Dietitian until March 31 following initial registration. It is the College's main source of funding which provides the means to meet the public protection services and processes required under the Health Professions Act. The fee is in line with the other larger Canadian dietetic regulatory colleges: Alberta's fee is $525, Quebec's $595 and Ontario's $500.

Q: Can a new graduate (a soon-to-be RD) be hired?

A: A registration number is provided verbally as soon as the CDBC receives written confirmation that a new graduate has fully completed their dietetics program. All documents and fees must be submitted except for a final transcript. It takes approximately one day to post the information on the website. It's not illegal to hire a soon-to-be RD before they are registered (that's an employment matter). The new (or soon-to-be) registrant may participate in Orientation but, must NOT provide client care. New applicants who have jobs waiting for them should inform the College so that registration documents can be reviewed as they are received.

Q: What is emergency registration?

A: In December 2009, the BC Ministry of Health Services approved an amendment to the Full Registration section of our bylaws (section 44(3) and (4)) prior to the 2010 Winter Olympic and Paralympic Games. The amendment is similar to amendments made to the bylaws of colleges regulating physicians, RNs, LPNs, emergency medical assistants, pharmacists and dentists, and enables 90-day registration of Canadian and American armed forces Dietitians so that health care teams are immediately available to provide assistance in the event of an emergency or disaster in BC. The bylaw amendment remains in force after the Olympics for possible future emergencies, such as an earthquake.

Q: When do I need a Criminal Record Check (CRC)?

A: Your current CRC meets the government's requirement and does not need to be redone. You would not be eligible for registration if your CRC was outdated. The Criminal Record Review Act was recently amended to include a check on crimes against vulnerable adults as well as children. The CDBC and all other regulatory colleges are implementing the new requirement as applicants apply to register for the first time and as part of the five-year CRC recheck program. If employers have questions after verifying your registration status on the CDBC website, please refer them to the Ministry of Public Safety and Solicitor General by email at This email address is being protected from spambots. You need JavaScript enabled to view it. or phone between 8:30am and 4:30pm in Victoria at (250)387-6981; Vancouver at (604)660-2421 and ask to be transferred to (250)387-6981; and toll free at 1-800-663-7867 and ask to be transferred to (250)387-6981.

Q: What does "entry-level" competence mean?

A: Dietitians who are registered with the Restricted Activities the intern is applying for may sign the intern's required forms. The Verification of Current Competence to Practice Restricted Activities form outlines core and specific competencies for each restricted activity. The verifier's role is to review these competencies with the applicant and make sure the applicant has a good understanding of safe practice of the restricted activities they're applying for. Restricted Activity competencies may be reviewed in different ways: fictional case studies, actual patient cases, open-ended questions, literature discussion, etc. Both pages of the Verification form must be forwarded to the CDBC.

The minimum level of competence expected for the practice of Restricted Activities is entry- to-practice proficiency, defined as follows by the national Partnership for Dietetic Education and Practice (PDEP) group in 2011: "When presented with routine situations, the entry-level dietitian applies relevant competencies (job tasks) in a manner consistent with generally accepted standards in the profession, without supervision or direction, and within a reasonable timeframe. The dietitian selects and applies competencies (job tasks) in an informed manner. The dietitian anticipates what outcomes to expect in a given situation, and responds appropriately. The entry-level dietitian recognizes unusual, difficult to resolve and complex situations which may be beyond their capacity.

The dietitian takes appropriate and ethical steps to address these situations that may include seeking consultation, supervision or mentorship, reviewing research literature, or a referral."

Q: What happens to my registration if I’ve changed my name?

If you're practicing under a name that differs from your name as it appears on the website's list of Registered Dietitians in BC, you need to inform the CDBC and provide official proof of name change so we can update the list. Otherwise, the name you are practicing under will not be on the list and it appears as if you are not a Registered Dietitian. This is not only illegal, it raises liability issues and contributes to public confusion. Please contact the office immediately if this pertains to you.

Q: What is the professional liability insurance requirement?

Section 54 of the CDBC bylaws requires all registrants to carry professional liability insurance in an amount of not less than 1 million dollars per occurrence. In the past, applicants and registrants had to submit paper proof of professional liability insurance purchase. This is no longer required. Now applicants and registrants will legally declare that they carry professional liability insurance when they apply/renew their registration. The legal declaration will be part of the Statutory Declaration section of applications for registration and reinstatement. The CDBC will no longer collect paper receipts for liability insurance. Registrants are encouraged to save proof of insurance in their personal records.

Q: What are my options for professional liability insurance?

Registrants may obtain liability insurance from:

  • Employers/ Health Authorities. Please verify this coverage meets the minimum requirement set in the CDBC bylaws. Remember, this coverage may not include dietetic practice performed outside the employer/ Health Authority’s jurisdiction.
  • Membership with Dietitians of Canada through LMS-Prolink Ltd.
  • Sheppard Insurance Service Inc.
  • Other private insurance providers

 

6. Restricted Activities Top

Q: Do dietitians practising as food service managers need to have Restricted Activity A?

A: A Registered Dietitian (RD) who does not design or compound enteral products, but who is responsible for the supervision of a non-registered staff member who dispenses enteral products, must be registered with Restricted Activity A:

Examples:
  • An RD who directly supervises non-regulated food service staff who mix nutritional formulae (for example, modular or powdered products that require dilution with water)
  • An RD who directly supervises non-regulated food service staff who mix commercial enteral products to create a new product that best meets the patient's needs

When an RD practices one or more of the aspects of any of the Restricted Activities, he/she is required to be registered with that Restricted Activity. A dietitian practicing a Restricted Activity is competent to perform each aspect of the Restricted Activity.

Q: Under what circumstances would I need Restricted Activity C?

A: "Administer" is defined by the CDBC as physically providing a nutritional or non-nutritional substance via an enteral or parenteral delivery device or system or providing instruction for same. You need Restricted Activity C if you are providing the following services:

If a substance is being administered by instillation through enteral means, the RD:

  • physically manipulates or adjusts the enteral delivery device or system, and/or
  • physically changes an enteral feeding bag to provide a nutritional or non-nutritional substance to a client, and/or
  • instructs clients, caregivers, RDs or other health care professionals to do so.

Example A: The RD instructs the client and/or caregiver to connect the feeding bag to the enteral pump, adjust the delivery system as required and flush the enteral feeding tube with water or other non-nutritional substance.

Example B: The RD demonstrates to another RD how to flush a feeding tube with water in order to prevent tube occlusion and how to instill pancreatic enzyme if the tube is occluded.

Example C: The RD demonstrates to the client and/or caregiver in simulation or directly how to clear a feeding tube occlusion.

Read the complete "Interpretive Guide: Restricted Activities" here. Restricted Activities can be added to your registration immediately by providing Appendix A or B as applicable, and paying the $35 fee.

Q: Do you need Restricted Activity C if you advise a Licensed Practical Nurse (LPN) on the administration of enteral nutrition?

A: Yes. After checking with the College of Licensed Practical Nurses, the CDBC learned that the administration of enteral nutrition is within the Licensed Practical Nurses' (LPNs') scope of practice. LPN students are taught to administer enteral tube feedings during their education program. As registered health professionals, LPNs are legally responsible for their practice, including the administration of enteral nutrition on a doctor's order. If an LPN was not competent with administering enteral feeds, they would ask a Registered Nurse or Registered Nurse Practitioner for assistance, guidance or further education.

The only time a Registered Dietitian would become involved is if the LPN (or another health care professional) questioned the enteral design or contents of the enteral feed. If the RD advises the health care professional, they require Restricted Activity A which applies to designing therapeutic diets administered through enteral means.

In rare cases where a Registered Nurse or Registered Nurse Practitioner is unavailable, the RD who is competent and registered with Restricted Activity C may instruct a health care professional who is not competent on the administration of enteral nutrition.

Q: This year (2010) I needed to have the Verification of Current Competence to Practice Restricted Activities (Appendix 2) signed by colleagues who are registered with the same Restricted Activity that I am applying for. Why did this change?

A: The Registration Committee brought in the change to help meet the College's mandate for public safety. The verification confirms that you are safe and competent to practice the Restricted Activity you register for. A dietitian registered with a specific Restricted Activity obtains a verification of current competence from a RD and/or allied health colleague (Physician, Nurse Practitioner, Registered Nurse or Pharmacist) who provides clinical nutrition support and understands the requirements for safe and competent practice of that Restricted Activity. It isn't logical that a dietitian who isn't registered with a particular Restricted Activity or an allied health colleague who does not practice within the same scope could judge that you are safe and competent with that Restricted Activity.

Q: What are the Restricted Activities requirements?

A: The "Application to Practice Restricted Activities (Appendix 1)" with proof of competence and/or the "Verification of Current Competence to Practice Restricted Activities (Appendix 2)" must be submitted annually. Restricted Activities cannot be included with your registration status on the Public Register unless annual documentation is on file. This legal requirement impacts your liability insurance coverage.

Q: Restricted Activities: What do I get for $35?

A: The fee entitles you to practice Restricted Activities for one year: from April 1 to March 31 of the following year. You must be registered with Restricted Activities if you practice, supervise others practising them or teach them. It is highly unlikely your liability insurance carrier will cover a malpractice claim against you if you practice a Restricted Activity without being registered.

Q: My patient needs and is able to drink enteral products on his own. Do I need to be registered with Restricted Activity A to recommend him taking these products?

A: Liquid nutritional supplements such as Boost, Ensure, Resource, etc. may be indicated for patients who are capable and willing to ingest products orally. Recommending, designing, mixing and dispensing liquid nutritional supplements orally do not require the RD to be registered with any Restricted Activity.

Registered Dietitians (RDs) must be registered with Restricted Activity A when they design, compound or dispense a diet with liquid nutritional products delivered via tube feeding (enteral instillation) to help their patient attain or maintain their daily caloric/nutrient needs. Liquid nutritional supplements may be appropriate for both oral and enteral feeding. Please remember that Restricted Activities aren't tied to the type of formula required to feed the patient, but to the manner in which the nutrition enters the body. Conditions for enteral feeding are 1) the patient's gut is functional and 2) the patient is unable to attain their daily caloric/nutrient needs via oral intake only.

Please refer to the CDBC's Restricted Activities Interpretive Guidelines for more detailed information.

Q: Who is qualified to verify an intern's current competence to practice restricted activities?

A: Dietitians who are registered with the Restricted Activities the intern is applying for may sign the intern's required forms. The Verification of Current Competence to Practice Restricted Activities outlines core and specific competencies for each Restricted Activity. The verifier's role is to review these competencies with the applicant and make sure the applicant has a good understanding of safe practice of the Restricted Activities they're applying for. Restricted Activity competencies may be reviewed in different ways: fictional case studies, actual patient cases, open-ended questions, literature discussion, etc. Both pages of the Verification form must be forwarded to the CDBC.

Q: Our dietitians in acute care are expected to be on call on weekends. We have dietitians who specialize in areas such as paediatrics who haven't seen adult patients in years, are unfamiliar with the adult formulary, current practice and protocols. These dietitians are uncomfortable being on call as the issues they are called on usually relate to adult care. I discussed this with my manager, but we are all still expected to be on call and practise restricted activities. What is the best practice in this case?

A: RDs must not provide any dietetic services they are not competent with. Doing so goes against the CDBC Standards of Practice and Code of Ethics. However, employers have the right to require employees to have particular education and/or skills. If the employer insists or needs an employee to be competent with a service he/she is not currently competent with, ideally the employer would work with the RD to help him/her become competent. I don't know the complexity of adult versus child care you're referring to but upgrading to an entry-level of safety and competence could perhaps be covered by an in-service session(s), shadowing (even at another facility), a course, etc. The College's role is public protection. The College is concerned that an RD is on call to provide services he/she is not competent with. The on call RD must be competent in the interest of public safety.

7. Vitamins & Minerals Top

Q: I have a private practice and some of my clients require vitamin and mineral supplements to balance their food intake. Is it appropriate for me to recommend and sell vitamin and mineral supplements to my clients?

A: Under the current federal and provincial laws, unscheduled drugs (available outside a pharmacy setting), which include vitamin and mineral supplements for oral intake, may be recommended and sold to clients as they relate directly to the practice of dietetics.

In the past, we have reminded registrants to follow the College's Marketing guidelines (s.75 of the CDBC bylaws and Code of Ethics) principles. Summarized, the vitamins and minerals recommended and sold must:
  • be needed as determined by an appropriate nutritional assessment,

  • meet the dosage guidelines for unscheduled substances,

  • be open and transparent that you are selling the products and making a profit from the sales,
  • provide options for buying the recommended vitamins and minerals from other sources,
  • provide consistent nutrition care whether or not the client decides to purchase vitamin/ mineral supplements from you or another source.

Q: Is it appropriate for RDs to distribute food supplement or vitamin and mineral supplement samples to patients?

A: Under the current federal and provincial laws, unscheduled food, supplements, and vitamin and mineral supplements (not intended for enteral or parenteral use) may be distributed or sold to patients as they relate directly to the practice of dietetics. Exceptions include supplements for which the active ingredient dosage exceeds those referred to in the Food and Drugs Act Drug Schedules and where a prescription is required. For more information, please refer to the Food and Drugs Act and the Drug Schedules on the College of Pharmacists of BC's website.

Q: May I tell my patients they need specific vitamins and minerals?

A: Yes, you may recommend vitamins and minerals to your patients. Under the current federal and provincial laws, schedule 3 drugs (selected from the pharmacy shelf) and unscheduled drugs (available outside a pharmacy setting), which include vitamin and mineral supplements not intended for enteral or parenteral use, may be recommended to patients as they relate directly to the practice of dietetics. Examples include Vitamin A in oral dosage form: 10,000 International Units (IU) or less per dosage and Vitamin D in oral dosage form: 1,000 IU or less per dosage. Vitamins and minerals listed as Schedule 1 drugs require a prescription for the dosage stated. For complete information, please refer to the drugs listed alphabetically in the Drug Schedules Regulation on the College of Pharmacists of BC website.

Q: About recommending Vitamin D supplements in acute & residential care...

A: Written by Liz da Silva, RD, CNSC, at the College’s request. The Institute of Medicine released the new Dietary Reference Intakes (DRIs) for vitamin D in November 2010. There was sufficient evidence to make significant changes to the DRIs. Specifically, the Adequate Intake level was replaced by a Recommended Dietary Allowance (RDA) and the Upper Level (UL) Intake was doubled for those nine years and older (from 2000 IU/day to 4000 IU/day).[1] It is important to keep in mind however, that the DRIs reflect the needs of a healthy population and assume no deficit exists. The new DRIs for vitamin D was based on the needs of maintaining bone health. The committee felt there was currently insufficient evidence to establish values for other health outcomes such as the prevention of cancer or heart disease. 

Should I change my recommendations for those with a vitamin D deficiency or osteoporosis?

Recommendations for treating a vitamin D deficiency should not change. Individuals with a vitamin D deficiency have therapeutic vitamin D needs which are not met by the DRIs. A deficiency means that a deficit exists. Treating a vitamin D deficiency requires prolonged treatment with doses well above even the new UL.[2] For example, treating a deficiency usually requires a cumulative dose of 600,000 IU given over a period of several months [3, 4].

Medical Nutrition Therapy for osteoporosis should not be guided by the DRIs either since it is a clinical condition with unique requirements. For vitamin D supplementation recommendations, in the presence of osteoporosis, please refer to the new 2010 Canadian Osteoporosis Clinical Practice Guidelines.[5]

What dose of vitamin D can I recommend in acute and residential care?

Vitamin D supplements above 1000 IU are considered a Schedule 1 drug and therefore require a prescription for a Pharmacist to sell or dispense it. In both the acute and residential care setting, vitamin D supplements currently require a physician’s prescription. In the outpatient or public health setting however, the RD can recommend whatever dose of vitamin D is appropriate for the patient, but it can only be provided in increments of 1000 IU since this is the highest dose available without a prescription. For example, if an RD assesses that a patient requires 2000 IU daily to maintain desirable serum levels, she/he can recommend the patient take two 1000 IU tablets daily and no physician or pharmacist involvement is required.

References:
1. Institute of Medicine. Dietary Reference Intakes for Calcium and Vitamin D. 2010. January 10, 2011. Available from: http://nationalacademies.org/hmd/Reports/2010/Dietary-Reference-Intakes-for-Calcium-and-Vitamin-D/DRI-Values.aspx
2. Pearce, SH and Cheetham, TD. Diagnosis and management of vitamin D deficiency. BMJ. 2010. 340: p. b5664.
3. Kennel, KA, Drake, MT and Hurley, DL. Vitamin D deficiency in adults: when to test and how to treat. Mayo Clin Proc. 2010. 85(8): p. 752-7; quiz 757-8.
4. Pittas, AG, et al. Role of vitamin D in adults requiring nutrition support. JPEN J Parenter Enteral Nutr. 2010. 34(1): p. 70-8.
5. Osteoporosis Canada. 2010 Clinical Practice Guidelines for the Diagnosis and Management of Osteoporosis in Canada. 2010. January 10, 2011. Available from: http://www.osteoporosis.ca/multimedia/pdf/Executive_Summary_October_2010.pdf.

Q: Under what circumstances would it be appropriate to recommend 4,000 International Units (IU) of vitamin D daily? Is this level alright for Dietitians to recommend to the general population on a long term basis given that the Upper Limit (UL) has been set at 4,000 IU? Could there be liability issues associated with any possible adverse outcomes as a result of recommending more than the UL?

A: In November 2010, Health Canada updated the Dietary Reference Intakes (DRIs) for vitamin D based on a report from the Institute of Medicine (IOM) [1]. Of more than 25 health outcomes reviewed by the expert committee, conclusive evidence is only available for bone health outcomes. The DRIs have been set, based on the benefits for skeletal health, assuming minimal sun exposure for all populations. However, the DRIs are set for healthy populations assuming no deficit exists [2].

Several recent studies have suggested that the DRIs may be inadequate, especially for patients who have underlying conditions or are receiving medications that put them at risk for vitamin D deficiency [3]. For populations at risk for vitamin D deficiency, for reasons such as decreased intake, gastro-intestinal, hepatic, and/or renal problems, the recommendations should not be guided by the DRIs. Recommendation levels for the "at-risk" individuals may often exceed the upper tolerable limit (UL). For example, patients with gastric bypass may require dosages of 50,000 IU as frequently as daily to maintain sufficiency [4]. Specific examples of vitamin D recommendations are available in the Evaluation, Treatment, and Prevention of Vitamin D Deficiency: An Endocrine Society Clinical Practice Guideline.

There is general agreement that total serum 25-OH vitamin D levels below 50 nmol/L are deficient and those above 200 nmol/L are toxic [5]. Vitamin D toxicity is extremely rare and is more common in infants and children; daily doses of up to 10,000 IU for up to five months have not been shown to cause harm in healthy adults [6].

The BC Ministry of Health has expressed concern about the exponential growth of the laboratory testing for vitamin D. Measuring serum 25-OH vitamin D level is considered an expensive lab test and seldom indicated, except in selected patients with advanced renal failure, mineral and/or bone diseases. Testing for vitamin D in populations at risk is usually not considered required by the BC Ministry of Health in view of the safety and low cost of supplementation.

Dietitians are accountable and responsible for the provision of competent, safe, ethical and professional practice. Dietitians should base their clinical recommendations for vitamin D on current evidence-based research [7].

References:
1. Institute of Medicine. Dietary Reference Intakes for Calcium and Vitamin D. 2010. Available from: http://nationalacademies.org/hmd/Reports/2010/Dietary-Reference-Intakes-for-Calcium-and-Vitamin-D/DRI-Values.aspx
2. Health Canada. Vitamin D and Calcium: Updated Dietary Reference Intakes. 2010. Available from: http://www.hc-sc.gc.ca/fn-an/nutrition/vitamin/vita-d-eng.php
3. Holick MF, et al. Evaluation, Treatment, and Prevention of Vitamin D Deficiency: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinology Metabolism. 2011; 97(7): 1911-1930. Available from: http://press.endocrine.org/doi/10.1210/jc.2011-0385
4. Kennel KA, Drake MT, Hurley DL. Vitamin D Deficiency in Adults: When to Test and How to Treat. Mayo Clinic Proceedings. 2010; 85:8 752-758. Available from: http://mayoclinicproceedings.com/content/85/8/752.full
5. LifeLabs Medical Laboratory Services. Vitamin D (blood). 2010. Available from: http://www.lifelabs.com/Lifelabs_BC/Patients/TestAZ.asp
6. BC Ministry of Health. Vitamin D Testing Protocol. 2010. Available from: http://www2.gov.bc.ca/gov/content/health/practitioner-professional-resources/bc-guidelines/vitamin-d-testing
7. College of Dietitians of BC. Schedule B: Standards of Practice. CDBC Bylaws. 2009. Available from: http://www.collegeofdietitiansofbc.org/legislation