Restricted Activities

Restricted Activities are elements of the Dietitians’ scope of practice that present a significant risk of harm and are reserved to those professionals specifically qualified to perform them.

The Restricted Activities are:

  • RA-A Design, compound or dispense therapeutic diets where nutrition is administered through enteral means.
  • RA-B Design therapeutic diets where nutrition is administered through parenteral means.
  • RA-C Administer a substance to a person by instillation through enteral means.
  • RA-D Administer a substance to a person by instillation through parenteral means.

Interpretive Guide: Restricted Activities. Last Updated April 2022.

As a registrant, you may register for Restricted Activities anytime through online services.

Q1: How do I apply for Restricted Activities?

Refer to the Restricted Activities section of the website for more information. You can register for Restricted Activities anytime. Restricted Activities expire yearly on March 31st.

 

Log in to your CDBC account. You will be able to select which Restricted Activities are applicable to you. During renewal, this page consists of a check box associated with each Restricted Activity that will be available to registrants. The accessibility of those check boxes will be determined by whether you have been registered previously with those Restricted Activities.

 

For example, a registrant renewing with Restricted Activities A,B,C, will be able to select each check box upon renewal. A registrant who has never been registered with Restricted Activities (or who might have A, but need B/C at renewal), will have to complete an embedded checklist (and pay a one-time administration fee of $27) before gaining access to the check box(es) for the newly registered Restricted Activities. The process of providing a verification of competence during registration/renewal will no longer be required and has moved into the annual CCP requirement as part of goal development and achievement.

 

If you anticipate requiring Restricted Activity A now and possibly B/C later on, please note that you will be charged the $27 fee again. However, in annual renewal, if you plan to renew with your existing Restricted Activities (no additions), you will NOT be charged the administrative fee again

Q2: Do I need to be registered with Restricted Activity (RA) “A” if I have a patient who is able to drink enteral nutrition products independently?

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

Q3: What are the implications of registration with a Restricted Activity without feeling practice ready? How can I become competent to register with Restricted Activities?

You must be practice ready before providing any Nutrition Support. As stated in the CDBC Code of Ethics (Principle 3) and Standards of Practice (2, 3), it is your duty to ensure safe, competent and ethical practice. If you are not confident you can practice restricted activities safely, you must refrain from registering with and practicing restricted activities. If you have already registered with an RA and don’t feel practice ready, due to lack of confidence, experience, or opportunity to practice, you must inform your employer of the situation and look for solutions to address the risks of this situation (for example, refer the patient to a health professional who can safely practice the RA while you seek learning opportunities to solidify your competence and confidence to practice the RA).

It is your responsibility to take steps to ensure practice readiness as you are liable for this practice if you are registered with Restricted Activities. To determine your readiness to register, refer to the Restricted Activities Interpretive Guide on this page. Bullet points under each Restricted Activity indicate the competencies associated with that specific Restricted Activity

If you are ready to register with a Restricted Activity, you can proceed to registration by logging into your profile.

If you are not ready to register with a Restricted Activity, you must take steps to ensure practice readiness. Refer to the Q6 below to understand options you have prior to registration with Restricted Activities.

Q4: I need Restricted Activity B, but I can’t confidently check off all the competencies. Can I register with Restricted Activity B? (IDPN example included)

It is important to stress that all PN competencies should be established before registering with Restricted Activity B. The CDBC Restricted Activity B competencies are embedded in the Restricted Activities Interpretive Guide, on page 4. It’s possible and understandable that you may not practice all PN competencies in your workplace, depending on your role and responsibilities.

An example is that of Intradialytic Parenteral Nutrition (IDPN) when using a pre-prepared formula for which RDs need to adjust the rate and monitor tolerance (does not involve PN calculations and design aside from rate of administration).

For this example, you’ll find several of the competencies are stated in a general manner that would be inclusive of IDPN, for example:

  • Appropriately identifies indication for PN with ability to weigh risks and benefits
  • Identifies type of PN formulation available to the worksite,
  • Accurately identifies published guidelines and designs PN recommendations consistent with published guidelines,
  • Proactive in PN problem solving, includes monitoring and analyzing changes in the PN patient, including complications, and adjusting PN as needed,
  • Accounts for insulin administration in designing PN and weaning of PN,
  • Ability to judge when situation has turned from chronic to acute, or stable to critical,
  • Collaborates with other team members/practitioners with regards to PN,
  • Confidence in own PN skill level,
  • Acquires new skills and knowledge related to PN, as applicable.

 The CDBC PN competencies and the Standards of Practice may guide important components to cover in an IDPN training session, in addition to your Health Authority’s policies and procedures for IDPN.

 In the case of IDPN, as it is considered along the same vein as PN, you may only practice and have competence with a subset of the CDBC’s PN competencies. This means that Restricted Activity B is required to practice with patients on PN, including those receiving IDPN.

It is also pertinent to consider possible changes in practice over time. For example, in situations where you are covering the absence of a colleague, in a casual role, or where workload support is required, you may have to move from an area where only IDPN is used, to an area where general PN practice is needed. In that case, you are expected to be current with and practice all PN competencies.

If the dietitian determines that they are not current and safe to practice all PN competencies, they may want to refer to the Risk Management Q&A to think about:

  • What are the risks of only focusing my practice and on IDPN and maintaining IDPN Restricted Activity B competencies only?
  • Would my practice require that I maintain other Restricted Activity B competencies?
  • Can I easily refresh Restricted Activity B competencies I haven’t practiced for a while?
  • Do I have resources (learning modules, PN support dietitians etc.) available to me to support this?
  • Do I have workplace requirements regarding Restricted Activity B that I’m required to satisfy?
  • Am I in a supervisory/mentoring capacity with a dietetic student or newly hired dietitian who may be expecting me to provide a comprehensive learning experience?

Ultimately, if you are registered with Restricted Activities, it is your responsibility to ensure that you are capable of providing care for clients requiring EN/PN, such that the EN/PN competencies are satisfied.

Q5: The CDBC used to have a list of courses I could take to become eligible to register with Restricted Activities. How can I prepare myself to register with the Restricted Activity(ies) I require?

If you require registration with Restricted Activity(ies) and have deemed that you need education/support to ensure competence in any area of the Restricted Activity (as outlined in the Restricted Activity Interpretive Guide on this section of the website, you need to select appropriate education/training that will satisfy those requirements.

While there are no more set courses approved by the College to complete, you may certainly still select a course from this list (not exhaustive):

  • National Board of Nutrition Support Certification (NBNSC) established by ASPEN
  • Dietitians of Canada, Learning on Demand, Critical Care Nutrition
  • Basic 5 workshops (run by Jan Greenwood: jkgreenwood3@gmail.com)

You may find that your workplace has access to online modules and case studies for enteral nutrition-related activities. You may also access on-the-job training or job shadowing. For these, there is no set curriculum, nor is there a set number of hours necessary to be deemed competent. You are encouraged you to find a colleague who is registered with the Restricted Activity you require and request mentorship. You may have opportunities for job shadowing, or case studies, and ultimately have the experience of practicing some enteral nutrition care on patients, which is overseen by your colleague, practice educator or practice leader.

After undertaking additional education/practice support, you must be able to confirm your competence in all tasks listed in bullet points under the Restricted Activity in the Restricted Activity Interpretive Guide. You can also access this same webpage to review step-by-step instructions for how to register with Restricted Activities. To understand how registration with Restricted Activities will affect your CCP, please see the CCP section of the website, specifically ‘Self Assessment Relative to Standards of Practice’.

Q6: To practice enteral nutrition, are both Restricted Activities (RAs) A and C required?

This depends on the nature of the enteral nutrition practice. For information distinguishing Restricted Activities A and C, refer the CDBC’s Interpretive Guide: Restricted Activities.

It is common for RDs to have RA “A”, but not be registered to practice “C” since such RDs may never be involved in physically administering an enteral feed or teaching enteral feeds. However, RDs with RA”C” must also have RA”A” since the RD cannot physically administer or teach administration of an enteral feed, without also having the baseline knowledge, skills, abilities and judgment for enteral nutrition encompassed by RA “A”

Q7: What if I register with a restricted activity but don’t practice it?

Your annual CCP will reflect your Restricted Activity registration. You must include a learning report based on the Restricted Activity and provide activities and outcomes in order to satisfy your CCP. If you are not practicing with Restricted Activities, but are registered with them, you must maintain your competence by including them in your annual CCP. See the CCP section of the website for more information related to Restricted Activities and your annual CCP

Q8: What if I was on maternity leave last year and did not renew my restricted activities, but I want them when I return to practice?

Because you are not currently registered with Restricted Activities, they will not appear readily on your renewal. However, you are able to register for Restricted Activities anytime. Restricted Activities expire yearly on March 31st.

If you need help to register to practice Restricted Activities, please see the question above: How do I apply for Restricted Activities?

Q9: What if I change my mind and want to register with restricted activities after registration renewal?

You can register with Restricted Activities anytime. Please see the Restricted Activities section of the website.

Q10: I am a temporary registrant and will register with restricted activities for the first time. Do I need my supervisor or employer to sign off on it?

No, not for the College registration. Employers may have additional requirement for practicing restricted activities depending on their organizational requirements, whether it is a specific training or an assessment by a more experienced colleague. As registrant of the College, you are expected to recognize the limit of your personal scope of practice and know about practice readiness. If your practicum has not provided a lot of exposure with restricted activities and you are unsure if you would be able to practice them safely on your own, do not register with Restricted Activities. Registering with Restricted Activities without sufficient competencies represents a serious risk to the public.

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