Managing Risk in Practice Q&A

Risk management is the process of analyzing risks to mitigate or prevent harm from occurring. Risk management considers how likely a risk is to occur, what the potential for harm is, its gravity, and identifies strategies and processes informed by data to respond to situations that may place clients at risk of harm. Managing risk applies to dietitians in all practice settings, stages, and years of experience.

There are multiple steps you can implement to identify, monitor, and manage risks in your practice. This process is similar to the College’s Ethical Problem-Solving model (found in the Code of Ethics):

While not an exhaustive list, the following provides a sample of practice settings, contexts, and activities, to consider as sources of risk.^(1-3)

Aspects of practice:

• Nutrition support (EN/PN); Restricted Activities A, B and/or C
• Eating disorders
• Refeeding syndrome associated with different conditions
• Malnutrition
• Complex care: renal, dysphagia, diabetes (i.e., insulin adjustment, managing hypoglycemia)
• Long-term care, ICU, transplant, surgery, medicine, psychiatric care
• Food production and distribution for therapeutic diets such as allergies, dysphagia or low potassium
• Conflict of interest related to the sale or promotion of products. For example, CDBC discourages the provision of counselling services while also selling products to the same client, as it can cause a (perceived) conflict of interest, potentially resulting in a care plan that may not prioritize the needs of the client.
• Participating to social media publications where you do not have final control on what is published. This could result in third-party advertising of services that the dietitian cannot provide, are outside of practice scope, or information that is not evidence-informed, or go against CDBC marketing bylaws.

Self (Dietitian-specific or intra-individual):

• RD(T) status, upgrading or returning to practice, dietitians new to BC, with lack of oversight or access to a professional network
• Lack of competence, experience or training in a practice setting, lack of recognition of limits in competence in certain practice areas
• Working in isolation without a personal/professional network
• Working in a new clinical area after being in the same area for an extended time
• Lack of confidence and/or motivation
• Poor emotional or mental wellbeing (e.g., burnout, exhaustion, compassion fatigue)
• Personal stressors that affect work performance (e.g., grief, trauma, financial hardship)
• Not understanding scope of practice or professional boundaries
• Lack of sensitivity, self-awareness of personal bias towards client diversity (potential for prejudice or discrimination based on race, faith, culture, age, gender, ability, sexual orientation, etc.)
• Minimizing client concerns or lack of recognition of severity of client concerns
• Refusal to seek assistance when needed or make appropriate referrals
• Cognitive decline linked to aging.⁴

Work environment:

• Interprofessional issues (e.g., conflicting and competitive personalities, disrespectful/ dysfunctional team dynamics, lack of understanding of RD role by colleagues in other professions)
• Poor communication among colleagues
• Outdated dietetic practice guidelines and protocols that do not reflect patient centered care and current evidence-informed practice
• Lack of workplace support for personal well-being (i.e., not prioritizing personnel physical and mental health) and time to integrate professional development into practice
• Suboptimal leadership: unclear performance expectations, lack of/infrequent performance reviews, uneven workload management, reporting to non-dietitian manager who may have sub-optimal understanding of the RD role and responsibilities
• Lack of mentorship and limited resources for learning opportunities
• Increased patient and/or acuity caseload, short-staffed workplace, lack of workload coverage when needed
• Limited or lack of funding to support sufficient dietitian work hours.
• System and leadership practices that may contribute to racism and inequities.

Additionally, there are other factors and unforeseen complications that may negatively impact your client and are beyond your control, but for which you could be held accountable by the client and others. For example, a client may have unrealistic expectations for weight loss and may blame you for not reaching their goal. Risk mitigation strategies may involve clear record keeping of the discussions you have with the client about realistic weight loss goals and the recommendations you and the client agreed on.

Other examples of risks that may be out your control are the lack of improvement or decline in a client’s health despite nutrition intervention, and administrative or medical errors and omissions.⁵

Low-risk situations often require solutions that are relatively simple, such as enabling password protection encryption on links to virtual health visits or obtaining and recording consent to nutrition care. Low-risk situations are not likely to directly affect a client’s health.

Moderate-risk situations often require more in-depth (but less immediate) action, such as obtaining further training if you identify that your knowledge in a specific area may be lacking. This could include planning a learning goal for the Continuing Competency Program (CCP), enrolling in a webinar, or asking to shadow a more experienced dietitian. Moderate-risk situations could affect a client’s health, directly or indirectly, if they are not remedied.

High-risk situations require more critical urgent action. For example, immediate action is required if an error in a patient’s parenteral nutrition design is discovered.  High-risk situations are very likely to affect the client’s health.

These risk delineations are fluid and could change depending on the context. For example, a dietitian who has little knowledge of dysphagia assessment and management may not pose a risk of harm if working in an outpatient diabetes clinic that does not require dysphagia care (low risk). However, in a in a long-term care home setting where the dietitian is expected to perform independently swallowing assessments and dysphagia management, a lack of dysphagia knowledge and skills poses a high risk to patients if steps are not addressed to gain competence.

Below is an illustration of the relationship between severity and likelihood of harm occurring and the resulting spectrum of relative risk of harm.

As per section 73 of the CDBC bylaws, and Standard of Practice #15, dietitians must keep organized and detailed client records whenever dietetic services are provided. If you practice competently and safely, yet a complaint is filed against you, documentation is your best objective and reliable defense, rather than relying on verbal recall. If a risk is identified and managed, report which strategies you used to help inform others and prevent future risk of harm (and protect yourself in the case of an investigation or a complaint from a client). Record keeping helps you understand the situation fully, strengthens communication with other healthcare professionals, minimizes errors, and supports safe and client-centered care. For more information, review the Standards for Record Keeping and CDBC Record Keeping Q&A.

The ability to communicate effectively is essential to all dietitians, regardless of work setting. Involving team members in decision making whenever possible helps glean additional insight that may have not been previously considered. Honest and clear communication strengthens relationships and lessens chances for misunderstanding. Always obtain informed consent and confirm that your client understands your  recommendations. When in doubt, it is likely better to over-communicate than under-communicate. When you make a mistake in practice or encounter a near-miss, you may be embarrassed to discuss this with colleagues. However, sharing your experiences among the interprofessional team promotes learning, encourages networking and support, and helps prevent these situations from occurring again. Refer to CDBC Standards of Practice #9, for more information regarding expectations of communication.

The best way to manage risks is to prevent them from occurring in the first place. But if they do occur, take the opportunity to reflect on and learn from your experiences and consider preventative strategies.

For example, to prevent breaches of client confidentiality, you can ensure the following steps are taken to protect client information: changing passwords frequently, installing anti-malware software and firewall security, backing up your information, and always locking office doors when not in use. Be aware of the regulations in your health authority public practice (FIPPA) or in your private practice (PIPA).

Knowledge and understanding of legislation are also important components of risk management. Become familiar with the CDBC Code of Ethics and Standards of Practice, and stay up-to-date on College business and activities (through Monthly Updates, committee participation, newsletters, etc.).  If you are uncertain about your understanding of these requirements or to apply them in a specific context, reaching out to the College is also an appropriate risk management strategy.

Protect yourself with professional liability insurance. This is a requirement for all practicing dietitians in BC. While you may have coverage provided by your employer, keep in mind that you may need to purchase additional coverage for work or activities performed outside of the scope covered by your employer, such as: private practice or volunteer work.

There are certain tools you can focus on to help you prevent risks and cope with stress, increase confidence, and offset the likelihood of risk to your clients. Preventative strategies include:

Personal:

• Resilience, self-compassion, focusing on what you can control
• Having a successful work-life balance
• Knowledge and respect of rules around client consent, privacy, and confidentiality
• Having a supportive network of other dietitians and colleagues

At work:

• Ask for help if your workload is too heavy
• Establish clear communication channels
• Use a collaborative approach to resolve conflict within your team
• Engage in regular team meetings
• Seek learning opportunities that can contribute to achieving goals set out in your CCP (see Question 9).

Risk management in dietetics is a way to stop and think as a way in which to prevent harm from occurring to patients, clients, and the public. Through applying this framework, dietitians can ensure they are doing their best to eliminate or mitigate harm in their practice.

While “Continuing education may not improve performance in incompetent individuals”⁶, the CCP process can support dietitians maintaining or striving toward competence in the current format of its program. The CDBC CCP process includes self-assessment and reflection on one’s abilities and actions, portfolio development, maintenance and goal setting, which are powerful supports to achieving competence.^3,7 The strongest predictor in helping practice change and advancement has been reported as individual personal drive and enthusiasm of healthcare practitioners.⁸

A large analysis of articles from a 40-year period was completed as part of a scoping review of competence of multiple health care professions, by the College of Physiotherapists of Ontario in 2017, found that most frequent supports to competence in practice included: participation in continuing education and access to educational information and programming, as well as personal support and feedback.³

It is important for dietitians to know their strengths and skills. Being unaware of competence gaps tends to lead to overestimation of knowledge and skills, potentially leading to risk of harm. Completing the self-assessment in the CCP prompts you to become aware of risk areas you might want to address and identify knowledge and skills to develop or enhance. Identifying your resources (e.g., colleagues, mentors) or lack thereof gives you a plan to address your personal and professional risks in the interest of public protection. Ensure you are evaluating yourself on an ongoing basis and undergoing any necessary professional development.

1. College of Dietitians of Ontario (2014). A Framework for Managing Risk in Dietetic Practice. Retrieved from https://www.collegeofdietitians.org/resources/professional-practice/workplace-issues/a-framework-for-managing-risk-in-dietetic-practice.aspx; accessed January 18, 2021.

2. College of Dietitians of Ontario (2014). High Risk Activities in Dietetics. Retrieved from https://www.collegeofdietitians.org/resources/professional-practice/survey-provides-insight-into-high-risk-activities.aspx; accessed January 18, 2021.

3. Takahashi, SG, Nayer M and St. Amant L. Connecting Theory and Practice: exploring the risks and supports to the Competence of physiotherapists. Overview Report (2017). Retrieved from https://www.collegept.org/docs/default-source/default-document-library/overview-report—connecting-theory-and-practice.pdf?sfvrsn=3bb7cfa1_4; accessed January 18, 2021.

4. Canadian Medical Protective Association (CMPA). The aging physician. Maintaining competence and practising safely. Retrieved from: https://www.cmpa-acpm.ca/en/advice-publications/browse-articles/2016/the-aging-physician-maintaining-competence-and-practising-safely; accessed January 11, 2021.

5. Administrative Errors: Technical Series on Safer Primary Care. World Health Organization (WHO). 2016. Retrieved from: https://www.who.int/publications/i/item/9789241511674; accessed January 18, 2021.

6. Horsley, T., J. Grimshaw, and C. Campbell, Policy brief – Investing in Europe’s health workforce of tomorrow: Scope for innovation and collaboration. Creating Conditions for Adapting Skills to New Needs & Lifelong Learning. European Observatory on Health Systems and Policies and the Health Evidence Network of WHO/Europe. 2010.

7. Final Report of the APA Task Force on the Assessment of Competence in Professional Psychology. American Psychological Association. 2016. Retrieved fro: https://www.apa.org/ed/resources/competency-revised.pdf; accessed January 18, 2021.

8. Lee, Nancy-Jane. (2010). An evaluation of CPD learning and impact upon positive practice change. Nurse education today. 31. 390-5. Retrieved from: https://www.researchgate.net/publication/49656607_An_evaluation_of_CPD_learning_and_impact_upon_positive_practice_change; accessed January 18, 2021.