LECTURE IN HONOUR

The 16th Constance Shearer Lecture,September 3, 2007A case for the role of dietetic support workers in New Zealand

INTRODUCTION

Constance Dorothy Shearer was only 46 years old when shedied in 1968. In her will, she made a bequest to the NewZealand Dietetic Association (NZDA) that was used to estab-lish the NZDA Education Trust and a lecture in her honour.

Constance Shearer gained her diploma in home science in1942, and taught at Wellington Girls College for four yearsuntil she undertook her dietetic training. Once qualified as adietitian, she worked for three years at Wellington Hospital,before being granted study leave to attend the University ofAlabama where she gained a BS in home economics. In1956, she was appointed Senior Dietitian, Wellington Hos-pital Board, a position she held until in 1965, she wasappointed Advisory Dietitian, Department of Health. Sheworked with a passion, and dietetics benefited from hertremendous vitality and energy.1 She had vision, enthusiasmand the ability to carry others along with her. Her variousroles in NZDA included Treasurer, Secretary, Vice President,President and Journal Editor.

BACKGROUND TO THE CASE

When dietetic resources are limited and there is an increas-ing demand for nutrition services, it is essential to thinklaterally about how to deliver effective dietary interventionsand professional expertise. This paper addresses a way dieti-tians can achieve their professional goals while being assistedin their more routine or background tasks by a new breed ofhealthcare assistant. By looking at other allied health profes-sions in New Zealand (NZ) and dietetics internationally, arole, scope of practice and training strategy for dieteticsupport workers is proposed.

In NZ, physiotherapy and occupational therapy profes-sionals are assisted by therapy assistants working under thesupervision of registered practitioners to provide specificphysiotherapy or occupational therapy treatments.

The NZ Society of Physiotherapists developed a guidethat defines the physiotherapy assistant, outlines roles,responsibilities and job descriptions specifically excludingtasks that must remain the clinical responsibility of thephysiotherapist.2

The NZ Association of Occupational Therapists does nothave an equivalent guideline, but a review of several health-care job descriptions for occupational therapy assistantsclearly identified their responsibility to the registered prac-titioner for all patient or client contact.

In these technical roles, there is an expectation of con-tinuing competence and ongoing professional developmentappropriate to the position. However, there is no formaltraining or career path.

In USA, registered dietary technicians (DTRs) were firstemployed in 1975. In 2003, they numbered over 4500 andworked in various settings.3

To become a certified and registered DT, a person com-pletes a two-year program from an American Dietetic Asso-ciation (ADA) accredited community college, after whichone must pass a national examination given by the Commis-sion on Accreditation for Dietetics Education (CADE).

Curricula for the programs are based on foundationknowledge and skills in eight content areas and 44competencies for entry level practice.

In the UK, in 1998, the British Dietetic Association (BDA)developed the concept of a person to ‘help’ dietitians. Ini-tially called a ‘dietetic helper’, the name was changed in 1999to ‘dietetic assistant’.4 The main objective of this role was toimplement nutrition plans prepared by dietitians for indi-viduals or populations.

The BDA produced a guidance document on roles,responsibilities and development of the dietetic supportworker.5 Reproduced in this document is the UK NationalHealth Service (NHS) nine-level career framework thatenables an individual with transferable, competency-basedskills to progress in a direction that meets workforce, serviceand individual needs. A dietetic support worker or techni-cian sits at level two or three, and a more highly qualifiedindividual––an assistant or associate practitioner––sits atlevel four. This latter level appears similar to the AmericanDTRs. Education of dietetic assistants in the UK is at levelthree and four of the National Vocational Qualifications levelthat seem similar to New Zealand Qualifications Authority(NZQA) unit standards.

In Australia in 1999, Milosavljevic and Patch reported ona project in Wollongong whereby roles, responsibilities andhierarchical reporting lines of traditional ‘diet aides’ (whohad no direct reporting line to dietitians but responsible todiet supervisors) were restructured.6 The resulting flattenedteam-based structure created closer relationships of

Presented at the Conference of The New Zealand Dietetic Association,Christchurch, September 2007.

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dietitians and clients with diet aides (who were renamed‘technical assistants’), and many positive outcomes fordietetic practice.

A further paper from Riddiford, Gazibarich andMilosavljevic surveyed New South Wales dietetic managerson the role of dietetic support staff, including diet supervi-sors and diet aides, diet technicians and nutrition anddietetic assistants.7 The authors recommended clearer roledelineation, further discussion about the appropriate title fordietetic support staff, their role, administrative and profes-sional lines of accountability and training requirements.

The Dietitians Association of Australia (DAA) has pro-duced a Scope of Practice––Support Staff in Nutrition andDietetic Services.8 This outlines titles for support workers innutrition (they are no longer called ‘technicians’), delegation,models of supervision and training requirements. The finaldraft of the document has recently been circulated forcomment among DAA membership, and is expected to beratified soon.

THE NZ SITUATION

Professional vacancies exist in NZ, with dietitians workinglong hours and clients not seen in a timely manner. Manydietitians find that they are doing tasks that could be donereliably by appropriately trained, supported and superviseddietetic support workers.

Current literature on allied healthcare support workersallows the NZ dietetic profession to capitalise on the expe-rience of others. Chambers, in her 2003 PG Dip Diet (Otago)practicum, questioned whether there was a role for dieteticassistants in clinical dietetics.9 This study, based inAuckland, concluded the affirmative.

Auckland District Health Board Home Healthcare dieti-tians set up and piloted the first of a new breed of dieteticsupport worker (dietetic therapy assistant). The first DistrictHealth Board to advertise and appoint a dietetic therapyassistant for the community home health team was CountiesManukau. The raison d’être for this role was to support thedietitian by doing the initial screening and data collection,such as anthropometry, following up on nutrition care planssuch as enteral feeding (using a specially developed tem-plate) and collecting generic client information for triagingpurposes.

Of vital importance is who holds the ‘duty of care’ fordietetic intervention? Ultimately, the registered professional,the dietitian, must always ensure that any intervention issafely completed.

WHAT TASKS COULD DIETETICSUPPORT WORKERS DO?

Dietetic support workers could support or enhance the workof a dietitian in many situations.

A food service management dietitian may spend hoursdoing menu audits where a menu is assessed against well-established standards. The auditing part of the process,where action is measured against well-documented stan-

dards, could be accomplished by a dietetic support worker,leaving the dietitian to draw conclusions and make recom-mendations so that the client can meet the requirements ofNZ Health and Disability Sector standards.

Providing basic nutrition information is another legiti-mate task. With appropriate training, dietetic supportworkers would be capable of educating patients abouthealthy eating, particularly relating to lifestyle diseases, oncethe dietitian has developed the nutrition care plan.

With the high risk of malnutrition in older people,especially in residential care, nutrition screening is an in-creasingly critical tool identifying those at risk. It has beenrecommended that every person entering long-term, acuteor primary health care be screened for nutritional risk.10

Because well-designed and validated screening tools arestandard documents, it does not require a dietitian to admin-ister. Where contracts require dietitians to see all residents ina care facility, residents could first be screened by the dieteticsupport worker and those at high risk referred quickly to thedietitian for assessment and intervention.

Similarly, in the community where often dietetic servicesare stretched, the initial screen and collection of basicanthropometric and biochemical data done by a dieteticsupport worker would conserve valuable resources. InAuckland, where a dietetic support worker had beenemployed, the dietitian reported:

This has improved the quality of service we’re offering tothe client. We’re meeting their needs sooner. We’ve alsoreceived a recent update on our productivity, and at themoment, we’re 104% over contract. The dietitians aretaking on additional responsibilities in specialist roles; weare now producing our newsletter more easily; we’ve gota research project underway; we’ve got a [dietetic services]coordinator able to do her job; we’re doing morein-service training sessions and updates, and workingin a more multidisciplinary environment than we’ve beenable to do before.9

In hospital food services aiming to be more service-focused, such as the Medirest ‘Catering to You™’ program,catering associates (Medirest brand food service workers)could be up-skilled to provide individual advice to patientsrequiring dietary modification or instruction. Cases wherepatients need to make dietary changes could be assisted bya dietetic support worker, and dietary services would beenhanced without the direct input of a dietitian. Appropri-ately trained catering associates would also be capable ofdoing initial inpatient nutrition screening as previouslydescribed.

EDUCATIONAL OPPORTUNITIES

Currently, there is no specific training for allied healthsupport workers in NZ. The NZQA system has generic unitstandards in communication and basic nutrition and foodtechnology, including food safety. NZ physiotherapy andoccupational therapy services decry the dearth of training,and organise this themselves for their assistants.

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Last year, the Health Workforce Advisory Committee pro-duced a discussion paper––‘Care and Support in the commu-nity setting’.11 A key issue highlighted was improving thetraining of home-based support services workers to ensurethat NZ had a qualified and sustainable support servicesworkforce. While this focused on aged care and disabilitysupport environments, there is an opportunity for the dieteticprofession to work within the training plan and developmodules to meet specific needs of dietetic support workers.

Career Force, the Community and Social ServicesIndustry Training Organisation, recently announced a newnational Foundation Certificate for personal care workers.The plan is to develop this into a full national qualification.Career Force has developed a career pathway with a stair-cased approach to qualifications, similar to the British NHSpathway mentioned earlier.

The National Certificate is set at level three, and is basedon generic compulsory core competencies.

After achieving core competencies, a student opts forelective competencies known as knowledge or skill ‘clusters’depending on his/her area of interest, client group or worksetting. Already planned are knowledge clusters in palliativecare, vision and hearing, restorative work, arthritis, epilepsy,intellectual disability, brain injury. Nutrition/Dietetics wouldfit well into this model.

Competency statements would need to be developed,based on tasks the dietetic support worker would beexpected to perform, and evidence would be required toshow that the entry level dietetic support worker coulddemonstrate competence in all of these.

There is value in having support workers genericallytrained to maintain as much flexibility as possible withinallied health groups, and to reduce costs of establishingseparate training programs. To assess the need for traininghealthcare support workers in NZ, Career Force recentlyheld a two-day Pan Sector meeting where employers, healthprofessionals, trainers and trade unions brainstormed roles,responsibilities, scopes of practice and competencies forallied healthcare support workers.

THE WAY FORWARD

The provision of comprehensive dietetic services to thepeople of NZ is a strategic goal for NZDA. To achieve thiseffectively, the profession needs allies, and being proactive indeveloping these allies gives a greater chance of achievingthis goal. Dietetics is a small profession; this is likely to bethe case in the foreseeable future, and dietitians must be incontrol of their future direction.

The development of a new role for dietetic supportworkers in an already cash-strapped health service is a sig-nificant undertaking. The profession must think laterallyabout how it can provide a more cost-effective service thatplaces dietetic services where they need to be.

It is recommended that an NZDA working group be estab-lished to investigate the development of a role for dieteticsupport workers, job descriptions, areas of work, competen-cies, education and a guide for practice. Clearly defining and

differentiating scopes of practice for dietitians and dieteticsupport workers is a critical first step in any attempt tointroduce another level of dietetic skill.

CHALLENGES FOR THE NZDA

If a new category of staff is developed to support the profes-sional function of dietitians, there must be appropriatebackup, otherwise they will feel isolated and poorly sup-ported. The ADA was criticised for not integrating dietarytechnicians into its organisation.

Other challenges include honing dietitians’ skills in del-egation and supervision, critical if a role for dietetic supportworkers is developed. Dietitians will need to be prepared tocontribute to support workers’ basic education (acting asworkplace assessors or moderators), and to provide for theircontinuing education so that they will be equipped to serveclients well. Dietetic support workers, to become an inte-grated group in the NZ health service, will need activesupport and encouragement from dietitians.

CONCLUSION

This paper has summarised the state of play with regard todietetic support workers in NZ, and may serve as a stepping-off point for more discussion and action. The time is right tobe thinking how dietitians can make best use of their limitedprofessional resource when there is a growing need forservices. Already, Auckland-based community and homehealthcare dietetic services have taken the initiative byemploying dietetic support workers, and have shown that itcan work.

The key to success will be the development of a compre-hensive set of guidelines for those tasks that can be passeddown the line, so that professional dietetic practice and dutyof care are not compromised and the client’s expectation ofbest practice is met or exceeded.

Julian Jensen, MS (Kans) NZRDConsultant, Dietetic and Foodservice Management

Christchurch, New Zealand

REFERENCES

1 New Zealand Dietetic Association. Constance Dorothy Shearer1922-68. J N Z Diet Assoc 1968; 22: 7.

2 Grbin M. The Physiotherapy Assistant––Roles and Responsibilitiesof the Physiotherapy Assistant, the Supervising Physiotherapist andthe Employer. Wellington: NZ Society of Physiotherapists Inc,2005.

3 American Dietetic Association. Dietetic Technicians and Their Rolewithin the Profession of Dietetics. Chicago, IL: American DieteticAssociation, 2003. (Cited 17 Jul 2007.) Available from URL:http://www,eatright.org/cps/rde/xchg/ada/hs.xsl/governance_5088_ENU_HTML.htm

4 The British Dietetic Association. Briefing paper on DieteticAssistants. November, 1999. (Cited 27 Jul 2006.) Availablefrom URL: http://www.bda.uk.com/dietetic-assistants.html

J. Jensen

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5 BDA Joint Professional Development and Education WorkingGroup. Guidance Document on the Roles, Responsibilities andDevelopment of the Dietetic Support Worker. Birmingham: BritishDietetic Association, 2006.

6 Milosavljevic M, Patch C. Restructuring to improve access todietetic services at no extra cost. Aust J Nutr Diet 1999; 56:81–5.

7 Riddiford S, Gazibarich B, Milosavljevic M. What is the role ofdietetic support staff? A survey of dietetic managers in NewSouth Wales public hospitals. Aust J Nutr Diet 2000; 57: 215–9.

8 Dietitians Association of Australia. Scope of Practice––SupportStaff in Nutrition and Dietetic Services. Canberra: Dietitians Asso-ciation of Australia, September 2007.

9 Chambers H. Is There a Role for Dietetic Assistants in New ZealandClinical Dietetics? Dunedin: University of Otago PG Dip DietPracticum, 2003.

10 European Nutrition for Health Alliance. Malnutrition within anAgeing Population: A Call to Action. European Nutrition forHealth Alliance: London, 2005. (Cited 5 Aug 2007.) Availablefrom URL: http://www.european-nutrition.org

11 Health Workforce Advisory Committee. Care and Support in theCommunity Setting––Discussion Paper. Wellington: Ministry ofHealth, 2006. (Cited 18 Jul 2007.) Available from URL: http://www.hwac.govt.nz/publications/care-and-support-in-the-community-setting.htm

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