Interprofessional Practice Q&A

Q1: What are the general considerations when being asked to take on a task that is not traditionally within my job description?

With any task, consider:

  • Consulting the Decision Tool for New Aspects of Dietetic Practice, available on the Quality Assurance page.
    • Is this within legal scope?
    • Is this within organizational scope?
    • Is this within my personal scope?
  • What are the risks to my patient? To me? Managing Risk in Practice Q&A
  • Does my Liability Insurance cover me for this task?
  • Am I at risk of communicating a diagnosis? Dietitians are not authorized to diagnose or share a new diagnosis with clients or their family members.
  • Am I the most appropriate person to undertake this task?
Q2: I am being asked to help out during a surge at my workplace, which includes many tasks that are not traditionally dietetic in nature. Can I do this?

The answer to this question is supported by Standard of Practice 10: “A Dietitian contributes to the provision of quality professional services as a member of the clients’ interprofessional team. Indicator 2: Explain professional scope of practice, roles and responsibilities and seek similar information from team members, and Indicator 4: Engage with team members to plan, coordinate and deliver quality professional services.

Organizations may have surge or emergency/crisis guidelines that are implemented in times of need. Given how busy the medical system is at this time, it is possible that you may be asked to help with tasks that are not traditionally dietetic in nature. It is important to note that the CDBC sets out the expectations and scope of dietitians in BC. An organization/workplace can further narrow a dietitian’s legal scope but cannot expand it. Furthermore, your personal scope may further narrow the tasks you undertake in your workplace.  

Under surge/crisis work circumstances, there may be workplace policies and guidelines that further define a dietitian’s responsibilities. However, workplace policies should not delegate Restricted Activities to dietitians that are not within their scope (see Q3 for details). Additionally, you also need to consider your personal scope of practice. A task may be within the legislative and workplace scopes, but not within your personal scope depending on your own skill, knowledge level, and physical limitations. If you do not feel comfortable or competent to perform a specific task safely and ethically, then you should either request additional training to be able to perform the task, or ask for assistance, or refer to another healthcare professional. In the event of a professional mistake or complaint, the CDBC would be looking at all these layers of scope when determining accountabilities. You are encouraged to review the Decision Tool for New Aspects of Dietetic Practice on the Quality Assurance Page to help you reflect on if a task is within your personal scope.

Another consideration is the balance between dietetic and non-dietetic tasks. Consider that your primary role as a dietitian must be to prioritize dietetic scope tasks over non-dietetic ones (e.g., taking away meal trays, taking blood pressure, recording a client’s medication). Some dietetic tasks are restricted or better accomplished by a dietitian (Restricted Activities). There is also a risk that patients will not receive appropriate nutrition care if you have been redeployed to other tasks during a surge or crisis. Among non-dietetic tasks, some are restricted, and others are not, please be in touch with the CDBC anytime if you would like to discuss your individual circumstances.

Q3: Can you provide information on how to determine if I am being asked to perform a Restricted Activity that is specific to another regulated healthcare professional?

Restricted Activities are specific to healthcare professionals that are regulated under the Health Professions Act. Regulated health professions have a profession-specific regulation that provides a definition of scope of practice and lists authorized, limits on practice and certifications. You can read more about them by looking up that profession’s College website or regulation. Of note, CPSBC-registered physicians are able to perform all Restricted Activities.

In the Dietitians Regulation, Restricted Activities A, B, and C are included in the descriptions, and these are the only Restricted Activities a dietitian can perform if registered to do so. While this regulation includes Restricted Activity D, for administration of parenteral nutrition, this aspect of practice is not part of entry-to-practice competencies. After review and consultation, and given that no registrants practice Restricted Activity D, the CDBC has recommended to the Ministry of Health to remove this restricted activity from the Dietitians Regulation.

An exception exists where a CPSBC-registered physician can delegate insertion of naso/oro enteric tubes to a dietitian who is registered with the CDBC to do so.

Q4: Can I perform a nasopharyngeal swab for COVID-19?

The PHO order dated November 16, 2020, speaks to COVID-19 screening activities. The order applies to dietitians and includes performing a nasopharyngeal swab or mouth rinse for analysis, provided a dietitian has received training1 to do so safely and competently. Dietitians need to be a Health Authority (HA) employee, complete a training program and be assessed as competent by the HA or medical health officer prior to doing the sample collection. The order does not permit dietitians to perform analytical and diagnostic activities such as operating a PCR device.

1. http://www.bccdc.ca/Health-Professionals-Site/Documents/BCCDC_PHL_Updated_nCoV_Lab_Guidance.pdf

 

Q5: Can I perform a PCR COVID testing device or administer a COVID-19 vaccine?

PCR testing is not within scope of dietetic practice.

Administration of vaccinations is not within dietetic scope.

PCR (polymerase chain reaction) is a method used to make copies of DNA. DNA tests can also detect viral DNA. Public health laboratories in Canada and around the world use DNA testing to diagnose COVID-19. This test is considered the gold standard to diagnose active COVID-19 infection in patients with symptoms. Testing devices may be intended for laboratory use, point-of-care or self-testing1. As per the BCCDC policy on point-of-care testing2, practitioners interpreting, and/or performing PCR must do so within their scope of practice. Within a health authority and designated health facility for testing, use of a PCR device is limited to authorized professionals who have received appropriate training to perform PCR testing.

The PHO order dated March 24, 2021 includes the current list of health professionals authorized to administer immunizations under specific circumstances and outlines required training to do so. Dietitians are not included in this list in British Columbia.

If dietitians are requested to be trained in performing activities that do not fall under the PHO order, such as PCR testing or immunization, dietitians need to advise their employers that they are not currently authorized to do so. Dietitians should also consider that their liability insurance policy may not cover such activities as they are not within the dietetic scope, even though the intention to lend a helping hand during the pandemic is commendable.

1. https://www.canada.ca/en/health-canada/services/drugs-health-products/covid19-industry/medical-devices/testing/nucleic-acid-devices.html

2. Point-of-Care COVID-19 Testing (bccdc.ca)

Q6: A physician has delegated the task of insertion of naso/oro enteric tubes to me. Can I perform this task?

In the Dietitians Regulation, Dietitians can only accept delegation for insertion of naso/oro enteric tubes, if they are registered to do so. To find out more about how to become certified to perform this task, including the Standards required for certification, visit Insertion of Feeding Tubes – College of Dietitians of British Columbia (collegeofdietitiansofbc.org) and be in touch with the CDBC for more details on the competencies associated with this task.

A dietitian cannot accept any other delegated task.

Q7: Can I perform medication reconciliation as part of my nutrition assessment?

As discussed in Q2, there may be healthcare related tasks requested of you that you can undertake, which do not fall in the defined legal scope of practice for a dietitian, but which are also not Restricted Activities in another regulated health profession.

A dietitian (and indeed, anyone) is able to collect data about medication use by a client. In this situation, “collect” is interpreted a “simple medication history” (from ISMP Canada Medication Reconciliation Project (ismp-canada.org)). However, the rest of the medication reconciliation (including verification/clarification and reconciliation/medication orders) is not within dietetic scope; it is within the scope of authorized prescribers, pharmacists, and pharmacy technicians.

Some Health Authorities may use the words “verification” or “verify” on their medication reconciliation form as part of the “collection” step. If this is the case, dietitians are encouraged to talk to the most appropriate person in their Health Authority about the interpretation of the form and expectations for collection of medication information.

While dietitians can collect medication information in any format as outlined in the workplace, this is considered to be a task that is separate from and different than the medication/supplement information gathered by a dietitian for a nutrition assessment. Per the CDBC Standards of Record Keeping 3f, documentation must include: “The client’s relevant medical history and social data related to the nutrition intervention.”  You may find that your workplace has education accessible to you if you are tasked with collecting data about medication.

For the medication to be reconciled (i.e., issue a medication order/tell the client what medication take), a regulated health professional authorized to practice pharmacy or prescribe, will undertake a medication review based on the BPMH information collected and assess issues such as polypharmacy, missing medication, medication incompatibility, and incorrect dosage. The CDBC requires that if you are being asked to complete this task, you refer to a pharmacist or an authorized prescriber.

Dietitians are generally very familiar with medications that affect nutrition status as part of a nutrition assessment. While dietitians can support authorized prescribers and pharmacists with information about some medications’ nutritional impact (those that can affect blood sugar level, electrolytes, gastric emptying, bowel transit time, etc.), the responsibility for medication reconciliations rests with health regulated professionals whose scope of practice involve prescribing and dispensing medication.

Are you the best person to complete this task? Do you have a colleague more suited to completing a BPMH form? Here are examples of risks registrants may want to consider when asked to collect medication information:   

  • Lack of understanding when major unsafe drug therapy is being communicated from the patient to the dietitian (or indeed, any healthcare practitioner who may not identify it),
  • Major errors or contraindications that have not been identified by a dietitian, as part of BPMH.
  • Lack of understanding when a medication may be administered or dosed incorrectly.
  • Partial completion of  a BPMH form only and the potential risk that other members of the interdisciplinary team might assume the entire form is complete.

Refer to Q1 for resources to further support your reflection on this question.

Q8: To provide support to nursing staff, can I help to assess parenteral nutrition vein access, or discuss best site access with patients who are or will be receiving parenteral nutrition?

There is risk for crossover into the practice of Restricted Activity D, administration of parenteral nutrition. Although, administration of parenteral nutrition is within the Dietitians Regulation, there are no registrants registered with Restricted Activity D. Please refer to Q3 for more information.

Having said that, if you are registered with Restricted Activity B and work with the design of PN, you can identify observed risks that are not explicitly within dietetic scope and refer to another health professional, who can address the risk as part of their scope. Refer to the Restricted Activity B competencies in the Interpretive Guide on the Restricted Activities page.

There is a role for a dietitian registered with Restricted Activity B (PN design), to screen, observe and review information on appropriate route of PN administration, and recommend to the most responsible physician (MRP), but ultimately the decision must be signed by an MRP, or a health professional authorized to administer parenteral nutrition. Discussions with patients about parenteral nutrition design may come from you, but PN administration options and handling education, including access options, must come from a health professional authorized to administer PN.

Q9: I have specific questions about my area of work and the tasks I am being asked to do. What should I do?

You may find one of our “Have a Practice Question?” topics and content can answer your specific question. As the CDBC receives questions from registrants, these Q&As are updated regularly to best support registrants in providing safe and competent dietetic care.

If you cannot find the answer to your question in the Q&As, you can reach out to the CDBC at  practice.advisory@collegeofdietitiansbc.org.

Q10: Can I delegate some of my duties to another regulated healthcare professional, or an unregulated one, to help alleviate my own caseload?

No, a dietitian is not able to delegate any tasks to any healthcare professional or member of the public. There are three considerations here:

1. The CDBC bylaws do not include criteria for Dietitians to delegate aspects of dietetic scope of practice.

2. The meaning of “delegation”. A delegation means that a regulated health professional can authorize all or part of an aspect of practice to be performed by another person without supervision, for a specified client. It can involve the teaching of a task or aspect of practice and verifying that the person is competent to perform it safely without supervision. Providing instruction on a task, for example, EN provision or diet education for discharge, to a non-regulated staff (e.g., care aide) or to a client or family member is not deemed a delegation, since your responsibility ends with the teaching process, and you are not accountable for the actions of the person performing the task.

3. You cannot delegate a task to another regulated healthcare professional when the activity lies within the scope of that profession. Regulated healthcare professionals are legally responsible for their own practice.

If your caseload is consistently difficult to manage and you are at risk of providing suboptimal patient care, you are encouraged to speak to your manager or practice leader.

Useful Resources

CDBC Decision Tool for New Aspects of Dietetic Practice on the Quality Assurance Page

CDBC Have a Practice Question? Various topics.

CDBC Restricted Activities.

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