Q1: What is the CDBC interpretation of ‘evidence-informed/ evidence-based practice’? How can a registrant be sure to meet this requirement in practice?
The College of Dietitians of BC is mandated to “establish, monitor and enforce standards of practice to enhance the quality of practice and reduce incompetent, impaired or unethical practice amongst registrants…” (Health Professions Act, s. 16(2)(d)).
CDBC Standard of Practice # 13 states: “A Dietitian seeks information and incorporates an evidence-informed approach to their practice.” This Standard of Practice applies to all areas of dietetic practice, not only clinical nutrition.
Quality care consists of care that is patient-centred, scientifically based, population outcomes based, refined through quality improvement and benchmarking, individualized to each patient, and compatible with system policies and resources.
The CDBC defines evidence-based or evidence-informed dietetic practice as the integration of the most reliable and available research evidence with dietetic expertise and client values. Evidence-informed dietetic practice involves balancing the evidence, data and professional judgement with client interests and needs for optimal care outcomes.
Q2: What is considered to be appropriate and relevant research evidence and how would an RD identify this in the multitude of nutrition publications available online?
The College of Dietitians of Ontario developed a five-step evidence-based practice framework and a free online workshop to help Dietitians evaluate and identify scientifically-sound evidence to formulate recommendations to clients.
There are also several other resources available to Dietitians on evaluating, rating and selecting scientifically-sound evidence. Here are examples of helpful resources:
- Practice-based Evidence in Nutrition (PEN)
- Cochrane Collaboration and Training:
- Johns Hopkins Medicine Evidence Based Practice Center.
Selecting the most reliable, appropriate and relevant evidence does not mean that dietitians cannot consider other type of evidence and data. It means that dietitians are expected to appraise the information and determine how it should be considered within the individual context of their client. Dietitians should be able to understand the strengths, limits and applicability of the data they review so they can ensure informed decisions by their clients too.
Q3: Why is evidence-informed practice important?
With the plethora of medical and nutrition information available on the Internet today, the public has greater access to nutrition material and research more than ever before. Yet, the public has little way of knowing what nutrition information is reliable, accurate, credible or unbiased. Within the Dietitian-client relationship, there is a power imbalance where the Dietitian is the expert. Clients trust and rely on the RD’s knowledge to manage and improve health conditions that are influenced by nutritional choices and habits. Evidence-based practice relies on the use of effective and proven strategies that improve client outcomes, and therefore enhances the RD’s credibility with clients and interprofessional colleagues. Evidence-informed practice may also improve client adherence to recommendations by proposing the appropriate treatment from the start, as opposed to several trials & errors over time. Potentially, using the most reliable and available evidence can also optimize the use of healthcare system resources (i.e., the right treatment is offered at the right time, by the right person).
The College acknowledges that in the field of nutrition and dietetics, evidence and data is often limited or considered to be poor/low level quality. This doesn’t mean that dietitians cannot practice in an evidence-based manner. Considering the overall body of evidence, its quality and applicability for each client is what makes an evidence-informed practice.
Q4: What are examples of evidence-informed practice?
Determine that the nutrition recommendations are:
- Within dietetic scope and the individual RD scope of practice. If recommendations are not within dietetic or personal scope of practice, take steps to ensure:
- the client is referred to another health professional who is authorized to address the topic or recommendation with the client;
- you are informed by a subject matter expert, who can refer you to scientifically sound evidence, to address the topic or recommendation with the client.
- Based on the overall scientific body of evidence available for a given topic/product. Make sure recommendations are:
- selected from current, unbiased and credible sources of scientific information (e.g., research, systematic reviews, practice guidelines, systematic analysis of clinical experience, quality improvement data, expert knowledge and skills);
- based on appropriate methodology, design and statistical analysis to support the findings;
- inclusive of all relevant studies. Balance positive and negative clinical outcomes. Appraise the quality of study design, as opposed to only selecting studies that may support RD view (or that of the client).
- not solely based on personal opinion and/or belief.
- Accurate and clear (not misleading).
- Explain the implications of recommendations if the overall body of evidence is limited, inconclusive, not well researched, or not based on replicable, generalizable studies. What does this mean for the client? Are there any potential impacts (physically, mentally, financially, socially)? Are there any alternatives?
- Addressing your client’s nutritional health priorities, needs and interests. This aspect of evidence-based practice includes considering a client’s preferences, beliefs and values based on their social determinants of health (culture, gender, race and racism (First Nations, Métis and Inuit, black people and other oppressed groups), income, education, childhood experiences, environment, access to healthcare, etc.)
- Addressing your own biases, beliefs, behaviors, power and privilege that may affect your interpretation of the evidence, data and information and therefore affect your client’s outcomes.
- Including information on potential benefits and risks, within the client’s context, to ensure informed consent/decision making.
- Using evidence-informed language adapted to the literacy of your audience such as: “the overall scientific evidence suggests…” or “the scientific literature I reviewed on this topic suggests…” Evidence-informed practice is not flawless. Nutritional science literature is published at a pace that is challenging for individual Dietitians to keep up with. That being said, evidence-informed practice also means being able to adapt, revise and change your recommendations, as new science becomes available that highlights different results than previously found. Ask yourself if the information you are sharing is contributing to your clients’ and the public’s trust in your ability to provide objective, independent and evidence-informed dietetic services.
Q5: My client would like me to counsel him on a diet for which there may be limited or inexistent support in research.
It is unethical for a dietitian to recommend any nutrition care plan for which there is either a lack of evidence, is not supported by the science or involves a risk of harm. It is important to distinguish what your recommendations are versus the client’s wishes. In the situation described above, it is expected that after conducting your assessment, you would advise the client on your own recommendations and the potential risks and benefits of the diet, describing the state of the evidence to support the diet. The client may choose to pursue the diet despite the lack of evidence that it works or other risks. In this case, it is important to observe Standard of Practice #12: “A Dietitian provides quality professional services that reflect the unique needs, goals, values and circumstances of the client.”
If you are unable to counsel the client in his/her desire for a diet due to ethical concerns, or if teaching the diet is outside of your personal scope, you may refer to policy QAC-06 Right to Refuse Treatment. This policy mandates that you “(1) inform the client of your concerns, (2) give reasonable notice of termination of treatment and, (3) offer alternative options to ensure that the client’s nutritional care needs are being met.” Regardless of whether you counsel the client or refer the client to another dietitian for diet counseling, it is important to document the encounter thoroughly, based on the CDBC Standards for Record Keeping.
Q6: Can the CDBC provide guidance with respect to specific clinical practice questions?
No. The mandate of the CDBC is to protect the BC public by regulating Dietitians to practice safely, ethically and competently. Refer to the CDBC Mission and Value Statements. For specific practice questions, an RD is encouraged to refer to colleagues with expertise in the area of interest, peer-reviewed publications such as PEN (Practice Based Evidence in Nutrition) and Cochrane, UpToDate, Dietitians of Canada , ASPEN, ESPEN and other scientifically sound sources of information.