Clinical Nutrition (1999) 18(6): 379-383

© 1999 Harcourt Publishers Ltd

SPECIAL ARTICLE

The role of the nutritional support dietitian in Europe

J. P. HOWARD*, C. F. JONKERS-SCHUITEMA t, U. KYLE*
*Bristol Royal Infirmary, Bristol, UK, tAcademic Medical Centre, Amsterdam, The Netherlands, CH6pital Cantonal,
Geneva Switzerland (Correspondence to: JPH, Head of Nutrition and Dietetic Services, Bristol Royal Infirmary,
Bristol BS2 8HW, UK)

Abstract--The European Community n o w supports the potential for professionals to practice in any of the
member states subject to recognized local standards of education and practice being achieved. However,
there is no agreed role for the nutritional support dietitian. This leads to an inconsistent and, sometimes,
fragmented approach to the nutritional management of patients throughout Europe. There is a need to
develop a common dietetic approach to nutritional support in order to raise awareness and rationalize
standards. This will help to optimize care to individual patients by fostering good practice, developing
effective communication and encouraging research.
Background: The role of the clinical dietitian varies widely throughout Europe - it tends to be more
highly developed in some countries than in others, which is a cause for concern among dietitians in
ESPEN. This appears to be caused by several factors including education, clinical awareness of the
benefits of dietetic support and access to adequate financial resources. The intention of this paper is to
focus on the key aspects of the role of the dietitian working in nutritional support. The educational
requirements of such a dietitian are outlined and these could be used as a preliminary guide for
institutions responsible for delivering undergraduate dietetic programmes. The overall intention is to
identify minimum educational standards for practice in this field throughout Europe. However, these
should be viewed as a baseline from which to proceed. They should also be perceived as a quality
standard for facilitating professional development, sharing clinical practice and enhancing patient
outcomes. This paper does not address issues of resource allocation.
Recommendations: a) There should be agreement about the key functions of the dietitian working in
nutritional support; b) There should be a common standard at first degree level for all dietitians; c) There
should be an identified programme of post-graduate study (both clinical and academic) leading to
specialization in nutritional support; d) There should be an innovative approach to providing clinical
support for emerging specialists; e) ESPEN should investigate the potential for developing an accredited
and integrated European dietetic standard in nutritional support. © 1999 Harcourt Publishers Ltd.

Key words: dietitians' education; dietetic responsibility;
nutritional support; dietetic role; nutritional support educa-
tion; multidisciplinary nutritional support
Introduction
Dietitians attending ESPEN conferences have long ex-
pressed concerns about inconsistencies in the dietetic role
throughout Europe. This paper is an initial step in redressing
these inequalities and represents the particular views of
those dietitians attending the 18th ESPEN Congress in
Geneva (1996). These views were endorsed by delegates at
the 19th ESPEN Congress in Amsterdam (1997).
Clinical nutrition is a fundamental component of general
clinical care as well as acute and chronic disease manage-
ment. The speciality of clinical nutrition relies on trained
A pre]iminary report on behalf of the Dietitians' Group of the European
Society of Parenteral and Enteral Nutrition.
379
practitioners to assess the nutritional status of patients,
define their nutritional goals and recommend strategies to
achieve and maintain these goals.
Malnutrition has potentially serious clinical sequelae and
is frequently not diagnosed when patients are admitted to
hospital. Furthermore, it is often unrecognized as the clini-
cal course of treatment progresses (1).
Changes in technology, clinical practice and resource
allocation have combined to highlight the unique role of the
dietitian as an essential member of any team offering advice
about nutrition. Assessing nutritional status must, therefore,
be a core component of all clinical practice in order to pre-
vent the development of malnutrition and its consequences,
and should be performed on all patients considered to be
suffering from or at risk of developing nutritional deficien-
cies regardless of where this occurs.
For the purposes of this report, nutritional support is
defined as the means of helping patients to meet all their
nutritional needs both in hospital and in the community. The
provision of food is always the first therapeutic option and
380 THE ROLEOF THE NUTRITIONALSUPPORTDIETITIANIN EUROPE
should be the first consideration for all patients (2-7). In
addition, nutritional support includes the concept of support-
ing others to help patients meet their nutritional needs (8).
The role of the dietitian working in nutritional support has
several aspects - these include clinical practice, research/audit
and quality assurance as well as management. The dietitian
will be involved in all of these functions to some extent
although some of the management aspects may be under-
taken by the head of a dietetic service.
The need to maintain competence to practice is a core
requirement of continuing professional development for any
clinical dietitian. Knowledge of advances in nutritional sup-
port with concurrent skills development are fundamental to
effective practice and these can be acquired either on a uni-
or multi-professional basis.
Functions and responsibilities of the clinical dietitian in
nutritional support
Scope of practice
The role of the dietitian has developed dramatically during
the last 50 years. The original need to prepare modified food
for patients with specific diseases, e.g. diabetes, renal failure,
has expanded into an advisory/educational role which, in
turn, is increasingly focused on evidence based practice.
Nowadays, dietitians in general are experts in the practi-
cal application of nutritional sciences to the treatment of
patients in hospital and in the community (9). A fundamen-
tal aspect of dietetic practice is the singular ability of the
dietitian to translate complex clinical nutritional concepts
into simple everyday language coupled with acceptable
strategies for implementing nutritional change.
Clinical practice in nutritional support
The dietitian working in nutritional support is responsible
for specific aspects of clinical management (Table 1). These
attributes do not constitute an exhaustive description of the
dietetic role. They are, however, an established starting
point from which to clarify individual dietetic responsibili-
ties in line with local practices and resource allocation. The
need for the dietitian to maintain current knowledge of
developments in product specifications, changes in techno-
logy and advances in clinical practice is fundamental (11).
In addition, the dietitian can only be successful if there is
effective collaboration with many other people including
Table 1 Clinical responsibilities of the nutritional support dietitian
• To assess nutritional intake and nutritional status (12, 14, 15)
• To advise clinical colleagues of actual or potential nutritional
deficiencies (10-13)
• To develop nutritional care plans for identifiedpatients (11-14)
• To participate in the design, implementation and monitoring of
nutritional support at all stages. This includes transitional feeding as
well as the provision of nutritional support at home (11-14, 16)
• To provide appropriate nutritional education for health care
professionals as well as for patients, their families and carers
(11-14, 16)
clinicians, nurses, pharmacists, patients and their relatives -
preferably within a nutritional support team setting (10-15).
Research and audit in nutritional support
Clinical practice is constantly changing in response to new
knowledge and technological development. New knowl-
edge, in turn, is generated by dietitians becoming involved
in clinical research to demonstrate the benefits of changing
practice in identified groups of patients (5, 17-19). Dieti-
tians have a crucial contribution to make to the accumula-
ting wealth of evidence based practice and participation in
such initiatives should be viewed as an important part of the
dietitian's clinical role as well as underpinning continuing
professional development (20, 21).
Audit is part of quality assurance and a central component
of clinical governance. This is an imperative, and well-
conducted projects will highlight good practice and help to
identify where sub-optimal practice can be improved (22-25).
Agreed standards for service provision can then be identi-
fied and these will help to ensure safe and effective practice
for particularly vulnerable groups of patients. Projects that
are patient-focused and designed to improve clinical effec-
tiveness are, usually, best undertaken on a mulfiprofessional
basis. Dietetic input and support are intrinsic to success.
Management
The nutritional support dietitian is not, usually, a manager.
However, strong management support is essential if nutri-
tional intervention is to be successful. This will help to
ensure a clear operational framework and will facilitate
many important working relationships (Table 2).
Safe dietetic practice depends on clear identification of
potential risk coupled with a comprehensive limitation
strategy. It also relies upon 'dietitians being trained in cur-
rent aspects o f nutritional support in order that they remain
up-to-date, competent and safe to practice'(11). The need
for continuing training and education is well-documented
(8, 11, 26-28). Finally, the dietetic manager should play a
key role in rationalizing service provision across all areas o f
care to ensure consistency and an appropriate response to
identified patient needs.
Table 2 The role of the dietetic manager in nutritional support
• To identify and allocate resources. This includes stafftime and
identifying budgets for feeding solutions, delivery systems, etc.
• To develop appropriate formularies, thereby helping to ensure safe
practice, a consistent approach to nutritional support and cost effective
purchasing of feeding solutions, delivery systems, etc.
• To plan and resource explicit continuing professional development for
dietetic staff working in nutritional support to ensure that they maintain
up-to-date kowledge and skills in relevant areas of dietetic practice
• To liaise with other Heads of Departments who have an important role
in the provision of nutritional support including catering managers and
treasurers as well as directors of pharmacy and nursing services in order
to establish and maintain effective nutrition advisory groups
• To consult with organizations involved in purchasing dietetic services
(whether this is in the hospital or the community) to ensure that
adequate provision is made for nutritional support services irrespective
of where they are delivered

The way in which all these tasks are undertaken can vary
from the formal and specifically identified role of the clini-
cal nutritional support dietitian to more informal and ad hoc
advice offered by many generalist dietitians. This highlights
the need to strive for a minimum standard for dietitians
working in nutritional support in Europe. The need for a
common approach to dietetic education in general has
already been recognized by the European Federation of the
Associations of Dietitians (EFAD) and several recommen-
dations have been made based on information collected
from the member countries (29, 30). However, these relate
to general organizational arrangements rather than an inte-
grated curriculum proposal.
Proposed qualifications and educational requirements
for the nutritional support dietitian
There should be a common standard at first degree level for
all dietitians. This should include courses in nutrition, diete-
tics, physiology, biochemistry and psychology. Knowledge
of clinical medicine, pharmacology, microbiology, ethics
and sociology are essential. Additionally, dietitians need to
develop skills in audit, education, basic research techniques
and effective communication. These courses should all in-
corporate a common and defined approach to the provision
of nutritional support.
The dietitian working in specialist areas of nutritional
support, e.g. bums, renal disease and haematology should
have further qualifications, including:
• A minimum of 2 years' full time experience in general
clinical areas, e.g. general medicine, general surgery,
critical care. This should, ideally, include some work on a
rotational basis under the supervision of a senior nutri-
tional support team dietitian.
• Additional relevant post-registration training obtained by
attending formally accredited educational programmes,
by undertaking practice based research or by participating
in other, equivalent, continuing educational opportunities,
e.g. ESPEN Advanced Nutrition Course, PEN Group
Clinical Update Course (British Dietetic Association).
Work-based training and development for the
nutritional support dietitian
Many dietetic programmes in Europe have not, hitherto,
included a practical nutritional support component. There-
fore, most dietitians have had to enhance their competence
by relying on work-based training and continuing educa-
tion programmes. This is when the mentoring process can
prove invaluable as an adjunct to more traditional learning
strategies.
Mentoring can function in a variety of ways and these can
be adapted to suit the particular needs of each individual
(31-34). Mentors can either be assigned to a mentee or,
preferably, selected by the mentee.
CLINICAL NUTRITION 381
Distance mentoring
It is often helpful to gain clinical experience in a different
environment, thus bringing relevant examples of the best
practice back to the local unit. In some cases it may be more
appropriate to spend time at a centre where there is recog-
nized expertise in the area of nutritional support. The mentor
might be an established nutritional support dietitian but
could, equally, be another clinician. The placement could be
organized as an entity or on an intermittent basis.
Local mentoring
An experienced dietitian or a physician will often be well-
placed to work with and support a dietitian who is develop-
ing their role in nutritional support. Informal discussion and
demonstration will help to clarify the clinical decision-
making process in the context of the dietetic role. Ideas can
be explored in a 'safe' environment thus protecting the
emerging specialist. It is also important to test any such
learning with a range of different professionals thus en-
suring an informed approach to the subject.
In either case individual dietitians can select the modality
best suited to them but the main objective should be to
improve their clinical skills in assessing, evaluating, deliver-
ing and monitoring nutritional support. It will be important
to reflect on their unique dietetic attributes and to determine
how these can best be deployed in a multiprofessional
approach to nutritional support.
A possible role for ESPEN in establishing a standard
approach to the function of the nutritional support
dietitian
First degree level
• To suggest/recommend core subjects/topics for inclusion
in the dietetic curriculum.
• To identify common guidelines for basic nutritional support
(which is a core component of general dietetic practice).
Table 3 Proposal for a clinical internship in nutrition support
• Supervisors should be member physicians/surgeons/dietitians of ESPEN
who work within a multiprofessional team context
• The internship should be for a period of 6 months (full time) or for an
equivalent period on a part-time basis
• The intern should be expected to develop competence in all aspects of
nutritional assessment and evaluation as well as being able to plan
treatments and monitor patients with a wide range of pathologies in
both an acute and a chronic setting. Familiarity with the provision of
nutritional support at home would also be expected
• The intern should be expected to attend and pass an appropriate course
with both theoretical and practical components in nutritional support
which would be organized/formally recognized by ESPEN. An
examination would add significant credibility to this award
• Certification should be awarded following this process after which the
dietitian could apply for identified prescribing privileges using agreed
protocols. This should be constructed in such a way that would protect
experienced dietitians who are currently undertaking specific clinical
duties. These duties could include such tasks as passing enteral feeding
tubes, taking blood samples, assessing swallow and prescribing
parenteral nutrition
 382 THE ROLE OF THE NUTRITIONAL SUPPORT DIETITIAN IN EUROPE
Post-graduate level
• To identify the basic requirements for a dietitian working
in specialized areas of nutritional support.
• To establish a register of appropriate, formal courses for
dietitians wishing to gain accreditation in nutritional sup-
port.
• To publicize regular specialist dietetic meetings through-
out Europe for dietitians working in nutritional support.
• To identify hospitals/dietitians prepared to offer place-
ments to dietitians wishing to gain experience in nutri-
tional support.
Future options
• To formalize the ESPEN education programme, thereby
enabling accreditation.
• To liaise with colleges of nutrition and dietetics and other
academic institutions to develop formally recognized
advanced courses/qualifications at European level. A
combination of distance-learning strategies and formal
examination should be considered.
• To explore the possibilities of establishing a register of
institutions/requirements for undertaking higher degrees,
e.g. MSc, PhD.
• To investigate the practicalities of introducing a clinical
'internship' scheme (Table 3). This would involve formal
supervision by identified member physicians of ESPEN
within their local multiprofessional nutritional support
team.
• To identify and formalize the dietetic prescribing privi-
leges associated with the provision of nutritional support.
Note: These suggestions are intended to be used as guide-
lines rather than as prescriptive definitions.
Conclusion
Many dietetic skills are unique and cannot be undertaken by
members of other professions. An effective nutritional sup-
port service relies heavily on dietetic expertise to optimize
patient care. However, standards of practice for dietitians
working in nutritional support vary significantly throughout
Europe. There is a political as well as a clinical imperative
to reconcile these differences. This preliminary report iden-
tifies the role of the nutritional support dietitian, which has
already been realised in some countries in Europe (35).
ESPEN is in a unique position to encourage a more stan-
dardized approach by supporting the recommendations
which have been made.
Acknowledgements
We would like to thank all the dietitians who have contributed to this
document - in particular those who attended the ESPEN Congress in
Geneva and also Mrs Ann Micklewright, former Chairman BDA PEN
Group, UK and Ms Carole-Anne McAtear, Chairman BDA PEN Group
UK. We would also like to thank Ms Katrin Saner for typing the
manuscript.
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Submission date: 16 August 1999 Accepted: 2 September 1999
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