Dysphagia Q&A

Will you be working as the sole dietitian at your worksite? If you, as an RD(T), are in a sole and private practitioner role, as defined in RC-04 Temporary Registration, you must have a mentorship agreement in place. The details of a mentorship agreement can be found in RC-19 Sole and Private Practitioner and its Interpretive Guide. Mentorship can take place in-person or remotely, as per section 6c) of RC-19: “Mentorship must include regular, communication (in-person, telephone and/or or internet) between the CDBC full registrant and the temporary registrant.”

Per section 4: “The mentor must be:

1. i) a current, full registrant, of the CDBC, in good standing; and
   ii) actively working in a dietetics field that supports the temporary registrant’s intended practice area, as a sole and private practitioner.
   iii) registered to practice the required restricted activities if the temporary registrant’s intended practice area includes enteral or parenteral nutrition support.
   iv) free from conflict of interest, including personal relationships and family.”

Dysphagia and swallowing assessments are within the dietetic scope of practice. There are no special courses or certificates in BC that are required to perform bedside swallowing assessments. The Alliance of Canadian Dietetic Regulatory Bodies has developed a document called Competencies for Dysphagia Assessment and Management in Dietetic Practice. It may be helpful to use this document in considering competency to perform swallowing assessments.

Here are some considerations:

1. Do you have the knowledge, skills and judgement to take on this aspect of practice safely, ethically and competently? Included in the Standards of Practice, “a Dietitian uses critical thinking to obtain assessment date, determine practice problems, plan, implement and evaluate professional services.”  It is important for you to have the skills necessary to be deemed capable in this area of practice. These skills can be gained with training opportunities provided by your employer such as on-the-job training, courses and workshops offered by Dietitians of Canada and/or workshops offered by other dietitians with an expertise in this area.
2. The College encourages you to reflect on your practice question using the CDBC’s newly developed resource, Decision Tool for New Aspects of Dietetic Practice. Using this framework, if you find you are outside of your personal scope (i.e., being able to identify and assess dysphagia), you may reflect on this Standard of Practice: ‘A Dietitian provides professional services concurrently with another provider from the same or a different profession only when the concurrent provision of services is beneficial to the client’, by choosing to refer to another health professional for independent or collaborative practice, as appropriate. Ultimately, it is your responsibility to ensure you are capable and competent to provide swallowing assessments, should you be requested to perform these in your job.

The dysphagia competencies set out the expectations for safe, ethical, and effective dietetic practice in the area of dysphagia assessment and management. The dysphagia competencies build on entry to practice competencies (Integrated Competencies for Dietetic Education and Practice – ICDEP) and identify additional performance indicators for this area of practice. The competencies apply to dietitians through the career continuum, from initial stages where one might be gaining experience to those with many years of experience and expertise.

The updated dysphagia competencies (see Q1 for link) may be helpful in this instance. Dysphagia and swallowing assessments are within dietetic scope of practice. However, you may want to consider the following points:

What is your work environment? Is the role of dysphagia management under the umbrella of your job description in your workplace?

For example, in some Health Authorities, swallowing disorders fall under the responsibility of the Speech-language Pathologist (SLP) and/or Occupational Therapist (OT). In this instance, the dietitian’s role is not to provide swallowing assessments; rather, it would be to ensure that the kitchen is providing a culturally appropriate diet of correct texture and fluid consistency that falls within the SLP/OT recommendation while considering the preferences and the allergy status of the patient, as well to monitor the intake, acceptance and adequacy of that diet.

If the role of the dietitian in your workplace is expanding to provide swallowing assessments, it is important to consider your own personal limitations on scope. You are encouraged to refer to the Decision Tool for New Aspects of Dietetic Practice. Do you have the knowledge, skills and judgement to take on this aspect of practice safely, ethically and competently? Included in the Standards of Practice, “a Dietitian uses critical thinking to obtain assessment date, determine practice problems, plan, implement and evaluate professional services.”  It is important for you to have the skills necessary to be deemed capable in this area of practice. These skills can be gained with training opportunities provided by your employer such as on-the-job training, courses and workshops offered by Dietitians of Canada and/or workshops offered by other dietitians with an expertise in this area.

You are correct in that dietitians may not administer an instrumental exam for dysphagia assessment and management. The act of administering a device beyond the pharynx is considered a restricted activity in BC. Section 3.012 of the new dysphagia competencies outlines the scope for a dietitian during an instrumental swallowing study. You’ll note that “review and interpret findings, including limitations [of the test]” is included.

The College encourages you to reflect on your practice question using the CDBC’s resource, Decision Tool for New Aspects of Dietetic Practice. Using this framework, if you find you are outside of your personal scope (i.e., being able to identify and assess dysphagia), you may reflect on this Standard of Practice: “A Dietitian provides professional services concurrently with another provider from the same or a different profession only when the concurrent provision of services is beneficial to the client”, by choosing to refer to another health professional for independent or collaborative practice, as appropriate. Ultimately, it is your responsibility to ensure you are capable and competent to assess and manage dysphagia, should you be requested to perform these in your job.

Yes, one health professional (e.g., SLP or OT) may train another health professional (e.g., RD) in a procedure (i.e., swallowing assessments) because this specific procedure is within these health professionals’ scope of practice.  This competency for RDs is in the Integrated Competencies for Dietetic Education and Practice (2020) and is a standard competence expected of all new dietetic program graduates in Canada. This type of professional collaboration is one of the objectives of a Regulatory College legislated under the Health Professions Act (section 16(2)(k)).  In the case of an SLP training an RD to perform dysphagia assessments, competence is ensure by the teaching and assessment of the SLP.

Collaborative education is not permitted/legal when the procedure is outside of the learning health professional’s scope of practice.

In the Competencies for Dysphagia Assessment and Management in Dietetic Practice, Section 3.011 “Conduct a Clinical Swallowing Assessment”, page 18 includes:

1. Manage adverse events. [Practice Illustration: Ensures nursing staff are accessible during the assessment in case of a choking episode.]
2. Recognize when to terminate assessment related to adverse reactions. [Practice Illustration: Terminates assessment if there are signs of aspiration.]
3. Perform Cardiopulmonary Resuscitation and manage airway obstruction (RD is certified in CPR if assessing without another health professional certified in CPR). [Practice Illustration: Ensures health care professionals certified in CPR are available during the swallowing assessment.]

If the nursing staff are certified in CPR and First Aid and are on site and available to assist you should an adverse event occur during your swallowing assessment, it is not necessary for you to be trained. An exception to this would be any workplace or Health Authority policies that exist, that might require you to be trained.

The Competencies for Dysphagia Assessment and Management in Dietetic Practice (Q1 of the Dysphagia Q&A) don’t speak to this.

It sounds as though you are the professional performing bedside swallowing assessments and managing dysphagia in your workplace, where a client is seen to be at risk of aspiration, by your assessment and/or on an instrumental assessment (FEES or MBS) by an SLP, while expressing their desire to proceed with oral intake.

“Eat at risk” in acute care settings cannot be declared without the results of an instrumental assessment and involvement of an SLP. However, in settings such as long-term care, the eat at risk definition can be expanded to include any food texture or fluid consistency that is contrary to the recommendations for safe intake.

In this situation, you should collaborate with the physician to discuss what an eat at risk plan would look like as well as provide education to the client/substitute decision maker on the associated risks and ways to mitigate risk (if possible). An order in the chart would indicate that the client is eating at risk and which diet texture they have chosen.

Some sites use an “eat at risk” contract that is signed by the client or substitute decision maker. All of the above areas of risk and mitigation of risk must be discussed at this time. The CDBC doesn’t have templates for this, as it would never encompass all of the workplace considerations that need to be taken into account. Constraints in your workplace scope will determine how an order for “eat at risk” must be written, and by whom. It is important to understand your role as well as potential limitations for ordering this type of diet.

It is important that you document thoroughly and regularly, per the CDBC Standards for Record Keeping.