HEALTH PROFESSIONS COUNCIL
RECOMMENDATIONS ON THE DESIGNATION
OF NUTRITION MANAGEMENT



Jim Chisholm, Member
Brenda McBain, Member
Dianne Tingey, Member

Application by the Pacific Society of Nutrition Management

October 2001


FOREWORD

This report is in response to an application by the Pacific Society of Nutrition Management for designation under the Health Professions Act, RSBC 1996, c. 183. Under the Health Professions Act, the Health Professions Council is a six-person advisory body appointed by the Government of British Columbia to make recommendations to the Minister of Health Planning about the regulation of health professions. This report is the result of an investigation of the profession of nutrition management by a three-member panel of the Health Professions Council.

CONTENTS

EXECUTIVE SUMMARY

I. APPLICATION AND PROCESS OF INVESTIGATION

A. GENERAL BACKGROUND
B. PROCESS OF INVESTIGATION

II. STATEMENT OF ISSUES

III. RECOMMENDATION

IV. RATIONALE FOR THE RECOMMENDATION

A. DEFINITION OF "HEALTH PROFESSION"

B. PUBLIC INTEREST CRITERIA
  1. Section 5(1): Risk of Harm Criteria
  2. Section 5(2): Discretionary Public Interest Criteria
  3. Conclusion Regarding Section 5(1) and 5(2) Criteria

 

APPENDIX A Summary of Responses to Nutrition Managers Application for Designation
APPENDIX B Pacific Society of Nutrition Management
Response of September 7, 2001 to the Council's Draft Report

EXECUTIVE SUMMARY

In its review of the application for designation of nutrition management, the Health Professions Council (Council) applied the Public Interest Criteria as directed by the Health Professions Act (HPA). The Council reviewed the information provided by the applicant Pacific Society of Nutrition Management (PSNM) and submissions made by respondents to the consultation phase of its investigation. No public hearing was conducted for reasons that will be set out in this report.

The Council first determined that the practice of nutrition management meets the definition of "health profession" set out in the HPA. The Council recognizes that the practice of nutrition management involves preventive and treatment health service functions in health care facilities to provide safe and nutritious food to the public.

The Council then reviewed the services provided by nutrition managers in light of the risk of harm criteria in Section 5(1) of the Health Professions Regulation (HPA Regulation). After reviewing the services performed the Council determined that the risk of harm associated with the practice of the profession is controlled by the level of supervision and regulation under which the profession is practised.

The Council found the criteria in section 5(1)(d)(i) and (ii) were to be the most significant in its recommendation not to designate nutrition management under the HPA:

  1. the degree to which the health profession is practised under the supervision of another person who is qualified to practise as a member of a different health profession
  2. The degree to which the profession is practised in a currently regulated environment.

The Council found that nutrition managers work as collaborative members of the health care team. They participate in decision making, and while not directly supervised by dietitians who are regulated health professionals, nutrition managers must follow guidelines and protocols written by dietitians when performing clinical patient care functions. In addition, the Health Act, the Community Care Facility Act and Regulations, and the federal Food and Drugs Act provide sufficient regulatory controls to safeguard the health of the public.

Next, the Council considered the supporting criteria listed in section 5(2) of the HPA Regulation and found the low membership numbers of the applicant PSNM a relevant factor in making its recommendation. Out of 500 practising nutrition managers, only 110, or less than 25 per cent, are members of PSNM. In view of the low number of nutrition managers represented by the applicant, it is the Council's view that section 5(2)(g) and (h) criteria have not been met. These two factors support the Council's decision not to recommend designation.

Therefore, the Council made the following recommendation to the Minister of Health Planning:

that the profession of nutrition management not be designated as a health profession under the Health Professions Act.

I.    APPLICATION AND PROCESS OF INVESTIGATION

A.    GENERAL BACKGROUND

The applicant Pacific Society of Nutrition Management (PSNM) was formed in 1969 as the Pacific Unit of Food Service Supervisors Association. It changed its name in 1993 to Pacific Society of Nutrition Management under the Society Act.

There is currently no legislation regulating nutrition management in Canada.

PSNM submits that there are approximately 500 nutrition managers (NMs) currently working in acute care, intermediate care and long term care facilities. Of those practising NMs, 110 are members of PSNM.

The applicant states its reason for requesting designation is:

designation of nutrition management will provide the public with safe and nutritious food and enable health care agencies and government to be cost effective in providing the public with quality care.

B.     PROCESS OF INVESTIGATION

PSNM submitted an application for designation of nutrition management as a self-regulating health profession under the HPA. The application was received on October 3, 1997.

The Council conducted an investigation pursuant to section 9 of the HPA. It met with the applicant on May 2, 2000 and made a site visit to the Kiwanis Care Centre on July 11, 2000. The Council also conducted a written consultation in September 2000.

The Council did not conduct a public hearing. Section 9(2)(d) of the HPA provides:

(2) Without limiting an investigation under this Act, the council may do one or more of the following for the purposes of the investigation:

    ...

(d) if the council considers the action to be in the best interests of the health profession association or the public, hold hearings the council considers necessary in a manner it determines.

Pursuant to section 9(2)(d) of the HPA, the Council determined that it could reach its conclusion without a public hearing.

II.     STATEMENT OF ISSUES

In accordance with the requirements of the HPA, the Council identified three issues involving the regulation of the practice of nutrition management. In assessing the public interest in the regulation of this profession, the Council considered:

  1. whether the practice of nutrition management meets the definition of "health profession" in section 1 of the HPA;
  2. the extent to which the practice of nutrition management may involve a risk of physical, mental or emotional harm to the health, safety, or well-being of the public according to section 5(1) of the HPA Regulation; and
  3. whether designation of a college of nutrition management would be in the public interest having regard to the criteria of sections 5(1) and 5(2) of the HPA Regulation.

III.     RECOMMENDATION

Pursuant to section 10(2) of the HPA, the Council recommends to the Minister of Health Planning:

that the profession of nutrition management not be designated as a health profession under the Health Professions Act.

IV.     RATIONALE FOR THE RECOMMENDATION

In order to proceed under section 10 of the HPA to recommend the designation of nutrition management, the Council must determine that the applicant's profession comes within the definition of "health profession" as set out in section 1 of the HPA and that designation is in the public interest pursuant to section 5 of the HPA Regulation.

A.     DEFINITION OF "HEALTH PROFESSION"

Section 1 of the HPA defines a health profession as:

. . . a profession in which a person exercises skill or judgment or provides a service related to

  1. the preservation or improvement of the health of individuals, or
  2. the treatment or care of individuals who are injured, sick, disabled or infirm.

Clearly, this is an extremely broad definition that encompasses many health-related services.

PSNM submits that:

The Nutrition Manager is a health professional who is uniquely trained to manage the provision of safe, nutritious food for the well being of the public. The Nutrition Manager utilizes their knowledge, skill and judgment to implement and translate therapeutic diets into food service standards/systems.

PSNM describes in detail the three principal roles of NMs: technician, supervisor and manager. These three roles are performed either in a clinical (technician) or administrative (supervisor and manager) capacity. PSNM describes the clinical and administrative capacities of NMs as follows:

Clinical
Nutrition Managers exercise judgment and skill when writing compound therapeutic diets. The Nutrition Manager visits clients for the purpose of collecting diet history, nutritional screening, counselling and charting in accordance with established standards and facility policies.

Administration
Nutrition Managers exercise independent judgment and skill in planning, organizing, directing, controlling and coordinating the areas of administration, human resources, food production and delivery to service the public. Nutrition Managers are responsible for the monitoring and supervision of the flow of food through production areas, from procurement to service, ensuring food safety and sanitation standards are met by implementing, monitoring and evaluating quality assurance programs and risk management programs to meet provincial regulations.

Thus, the clinical aspect of nutrition management typically involves the collection of information on a client's diet history, nutritional needs and food tolerances. The administrative functions of NMs are generally limited to monitoring, assessment, evaluation and interpretation of food safety and sanitation standards.

PSNM states that almost all NMs in BC work in acute care, intermediate and long term care facilities with a very small number working in commercial areas or as sole practitioners.

With respect to team practice, PSNM states that NMs function as members of the health care team, and they perform their functions and services independently or as part of a team, depending on the size and type of the facility. PSNM details the team practice as follows:

Nutrition Managers in acute care facilities and private practice interact with health care professionals as appropriate. Nutrition Managers and Registered Dietitian/Nutritionists are cooperative team members who provide facilities with the complete scope of nutrition/food services.

Nutrition Managers in community care facilities interact directly with other health care professionals including health care administrators, physicians, nurses, occupational therapists, speech and language pathologists, social workers, pharmacists, environmental health officers, and dietitians/nutritionists.

Nutrition managers, as independent members of the health care team, participate in the interdisciplinary team meetings (eg. Multidisciplinary care Conferences, Environmental safety and Sanitation Committees, Infection Control Committees, Regional Health Board Committees, Inservice Education Committees, and Facility Policy Development including implementation and evaluation.)

As a member of the health care team Nutrition Managers participate with dietitians in the development of facility policies and standards within the clinical services department.

Clinical tasks are only performed in isolation once the facility policies and procedures are cooperatively established.

In the Council's view, NMs undoubtedly perform health service functions in providing safe and nutritious food in care facilities. The Council is satisfied that the profession of nutrition management meets the definition of "health profession".

B. PUBLIC INTEREST CRITERIA

When examining an application for designation the Council considers the public interest criteria set in section 5(1) and (2) of the HPA Regulation. The section 5(1) criteria relate to risk of harm and must be considered by the Council while the section 5(2) criteria are discretionary and may be considered by the Council.

1. Section 5(1): Risk of Harm Criteria

Section 5(1) of the HPA Regulation states:

5.(1) For the purposes of s.10(1) of the Act, the Council must consider the extent to which the practice of a health profession may involve a risk of physical, mental or emotional harm to the health, safety or well being of the public, having regard to

  1. the services performed by practitioners of the health profession,
  2. the technology, including instruments and materials, used by practitioners,
  3. the invasiveness of the procedure or mode of treatment used by practitioners, and
  4. the degree to which the health profession is
  5. practised under the supervision of another person who is qualified to practise as a member of a different health profession, or
  6. practised in a currently regulated environment.

a) Section 5(1)(a): the services performed by practitioners of the health profession

PSNM does not propose a scope of practice statement but submits an open-ended list of proposed scope of practice which consists of the following 14 detailed items:

  1. Manage and/or supervise food service systems to provide quality and cost effective nutrition services including budgeting, purchasing and continuous quality improvement.
  2. Implement, monitor and evaluate Sanitation and Safety Standards.
  3. Formulate, implement, evaluate and review policies and procedures.
  4. Manage and/or supervise all aspects of human resources within the nutrition and food services including labour relations within the collective agreements.
  5. Develop menus, standardize recipes and write modified diets.
  6. Use of current computer technology to manage various aspects of food service and nutrition management.
  7. Conduct research of food service preparation, delivery systems and facility design.
  8. Act as a liaison with all other departments and industry related personnel.
  9. Participate in the development of and implement nutritional care plans based on nutrition assessments.
  10. Interpret the nutritional needs of clients into an acceptable cultural, social, and spiritual context.
  11. Act as a resource and provide information to the public on basic principles of food and nutrition, and the practical application of those principles.
  12. Participate in planning, coordinating, implementing, and evaluating health promotion programs.
  13. Devise, present and follow up food and nutrition service education programs for food service staff, care staff and others.
  14. Maintain awareness of community resources and identify and evaluate community needs so that appropriate responses may be made.

The applicant states that the following areas of practice require nutrition management expertise:

  1. Translate therapeutic diets and nutritional care plans into food services and production standards;
  2. Manage and/or supervise food service and delivery systems within health care facilities;
  3. Implement, monitor and evaluate sanitation and safety standards;
  4. Implement therapeutic diet into menus; and
  5. Assess the (preliminary) nutritional status to determine the need for therapeutic diets in the absence of the dietitian. (this would not preclude a physician licensed under the Medical Practitioner Act from performing services as a physician.)

With respect to risk of harm, PSNM states that the following patient risks may occur when nutrition management is practised in an incompetent, unethical or impaired manner:

Food Poisoning
Biological, chemical or physical contamination may render food unsafe for consumption. Inadequate supervision in food production, handling, receiving and storage may cause food inborne illnesses. Improper chemical storage may also put clients at risk.

Allergic Reaction to Food
Inadequate diet writing, product knowledge, meal delivery and food distribution supervision may result in a client receiving harmful or inappropriate meal items.

Choking
Clients may choke as a result of inappropriate food textures and/or a misunderstanding of such conditions as dyshphasia.

The Council accepts that there is a significant risk of harm involved in the practice of nutrition management. The Council finds that the services performed by NMs are preventive in nature.

b) Section 5(1)(b) and (c): the technology, including instruments and materials, used by practitioners, and the invasiveness of the procedure or mode of treatment used by practitioners

PSNM does not enumerate specific technologies nor does it cite procedures that could be considered invasive. No specific devices or equipment were identified. The Council concludes that NMs do not conduct invasive procedures.

c) Section 5(1)(d)(i): the degree to which the health profession is practised under the supervision of another person who is qualified to practise as a member of a different health profession

PSNM quotes from the CSNM Accreditation Manual (Manual) which states that NMs function under the general supervision of a qualified dietitian. The Manual does not require on-site supervision. The Manual also states that NMs may be indirectly supervised through facility or government standards. PSNM also states that in long term care, NMs work independently in sole charge of food service departments.

In its investigation the Council learned that there are various manuals used in the workplace, some of them authored solely by dietitians. The policy and procedure manual titled Food and Nutrition for Quality Care: a Policy and Procedure Manual used by the Vancouver/Richmond Health Board, was edited by a dietitian. It has contributing authors who are both dietitians and NMs. BCDNA dietitians authored, among others, the sections that govern clinical and patient care functions and have direct accountability for those functions.

The issue of supervision of NMs was also discussed at great length by several respondents.

BC Dietitians' and Nutritionists' Association (BCDNA) submits that NMs do not independently exercise skill or judgment, or provide a clinical nutrition service to individuals. In the area of nutritional care, dietitians are responsible for establishing and developing standards, policies and procedures. Under the supervision of dietitians, NMs assist in implementing nutritional care plans.

Similarly, the College of Dietitians of Alberta (CDA) submits that NMs practise independently in limited circumstances, only under established policies and procedures and in controlled institutional settings.

Kathleen Quinn, Executive Director of Dial-A-Dietitian, submits that in large hospital settings, the scope of duties, training and supervision of a nutrition manager working as a dietitian's assistant are the responsibility of a registered dietitian.

Christine Chou, a Registered Dietitian, submits that in adult continuing care facilities, the Adult Care Regulations of the Community Care Facility Act require a registered dietitian to complete and evaluate nutritional care plans for all residents. She submits it would be irresponsible and unsafe for NMs to take on clinical nutrition responsibilities without the direction and supervision of a dietitian. Chou also states that dietitians write and review therapeutic diet manuals. They translate diet orders into individualized nutrition care plans, while NMs provide the technical support in ensuring the food is prepared and served.

Another individual submission, from Deanna Tan, a Registered Dietitian employed by the Simon Fraser Health Region, states that NMs have adequate training to do only administrative duties the PSNM describes in its application. Ms. Tan believes that NMs do not have adequate training to perform the clinical roles they describe. Ms. Tan states that this will inherently put residents of long term care facilities at risk. She believes that NMs are able to screen a resident at risk, but then the resident should be referred to a registered dietitian.

Dietitians of Canada (DC) submits that NMs perform responsibilities generally under the supervision of a registered dietitian. NMs are trained to assist in the implementation of care plans by writing therapeutic menus according to documented care plans developed by a dietitian. Under the direction of a dietitian, NMs participate in the evaluation of client intake and acceptance of nutrition intervention. Under the direction of a dietitian and according to established procedures, NMs may participate in nutrition counselling, but they are not trained to provide nutrition counselling on complex therapeutic diets. DC further states that NMs' responsibilities would be highest in acute care settings where they work more independently. However, the Community Care Facility Act - Adult Care Regulations clearly indicate that a registered dietitian must develop, document, review, monitor and revise the nutrition care plan in facilities with 25 or more residents.

BC Dietitians' and Nutritionists' Association (BCDNA) states that NMs are trained to do a basic diet history (record of patient eating habits) and list of food preferences. It states that in a few facilities NMs have been delegated the task of explaining simple diets such as mild salt restriction.

d) Section 5(1)(d)(ii): the degree to which the health profession is practised in a currently regulated environment.

The Adult Care Regulations (Regulations) govern food service operations in community care facilities. The Regulations establish minimum standards for nutrition care plans, including the primary role of dietitians at facilities with 25 or more residents. The Regulations also set criteria for food preparation and service, the provision of eating aids and supplements, menu planning, and monitoring of residents' weight patterns and nutrition needs.

Public health protection programs, including the Food Premises Regulations under the Health Act set out a number of requirements that food service operations must meet. Public health officers monitor and enforce the Food Premises Regulations. A permit for a food premise is issued annually by the health inspector after a full inspection.

Information received during the Council's investigation indicates that public health officers rely on the professional skills of NMs to administer the requirements of the Food Premises Regulation and the Hazards Analysis Critical Control Points program. The federal government also administers health protection programs through its Health Protection Branch of Health Canada which administers the federal Food and Drugs Act. Inspectors of the Health Protection Branch examine domestic and imported food products and ensure their safety for consumption. Finally, each health care food service operation has detailed policies and procedures to ensure food safety and nutritional quality to clients.

The BC Dietitians' and Nutritionists' Association (BCDNA) states that in the area of food service systems, current legislation exists to protect the public, i.e., the Food Premises Regulation under the Health Act and the Community Care Facility Act. This legislation regulates activities by NMs which are carried out in compliance with the policies and procedures of health care facilities developed by dietitians and health care facility administration. BCDNA feels that additional regulation of these activities under the HPA would not enhance public protection. The applicant points out that NMs also contribute to the development of facility policy and procedure.

The Hospital Employees' Union (HEU) supports regulation of food service operations and enforcement of standards for nutrition care in the interest of public safety. However, it does not believe that regulating nutrition supervisors and technicians is necessary to achieve those public safety goals. HEU believes that the public interest is protected by the current regulatory framework which includes the Adult Care Regulations, public health protection regulations, Hazards Analysis Critical Control Points program, accreditation requirements, quality assurance programs, workplace policies and procedures, and regulation of dietitians. HEU outlines the current regulatory environment with respect to the functions of food service supervisors/technicians and managers, including the Adult Care Regulations, public health protection, Health Protection Branch, workplace policies and procedures, training and clinical resources. HEU believes that the current regulatory framework provides reliable protection of the public interest. It does not believe that the PSNM request for designation under the HPA is either substantiated or widely supported. Thus, it strongly recommends rejection of this application.

Dietitians of Canada (DC) submits that NMs are not presently involved in a practice that creates a risk to the public. DC states that legislation such as the Health Act exists to provide protection to the public regarding food and workplace safety. DC also states that medical health officers and environmental health officers monitor food service establishments and enforce the http://www.qp.gov.bc.ca/statreg/stat/S/96433_01.htm Food Premises Regulations as well as municipal by-laws relating to food service establishments.

The Council is satisfied that nutrition management is practised in a currently regulated environment that is sufficient to provide adequate safeguards for the public.

2. Section 5(2): Discretionary Public Interest Criteria

When examining the services of the health profession being considered for designation under the HPA the Council must consider the section 5(1) criteria above. The Council may also consider the section 5(2) criteria. While consideration of the section 5(2) criteria is not mandatory, the practice of the Council has been to consider all of the section 5(1) and (2) criteria.

Section 5(2) of the HPA Regulation states:

(2) The Council may also consider the following criteria:

  1. the extent to which the health profession has demonstrated that there is a public interest in ensuring the availability of regulated services provided by the health profession;
  2. the extent to which the services of the health profession provide a recognized and demonstrated benefit to the health, safety or well being of the public;
  3. the extent to which there exists a body of knowledge that forms the basis of the standards of practice of the health profession;
  4. whether members of the profession are awarded a certificate or degree from a recognized post-secondary educational institution;
  5. whether it is important that continuing competence of the practitioner be monitored;
  6. the extent to which there exists within the health profession recognized leadership which has expressed a commitment to regulate the profession in the public interest;
  7. the likelihood that a college established under the Act would be capable of carrying out the duties imposed by the Act, having regard to factors which in the view of the council may affect the viable operation of the college;
  8. whether designation of the health profession is likely to limit the availability of services contrary to the public interest.

a) Section 5(2)(a): Profession has demonstrated that there is a public interest in ensuring the availability of regulated services

While there is currently no specific regulation of NMs, their services are practised in a regulated environment. In the Council's view the information provided by the applicant does not demonstrate that ensuring availability of self-regulated nutrition management services is in the public interest.

Licensed Practical Nurses Association of BC (LPNABC) states that the applicant did not indicate how self-regulation would be in the public interest.

b) Section 5(2)(b): the extent to which the services of the health profession provide a recognized and demonstrated benefit to the health, safety or well being of the public

The Council concludes in light of the information provided by the applicant that the profession does provide a recognized and demonstrated benefit to the health of the public.

c) Section 5(2)(c): the extent to which there exists a body of knowledge that forms the basis of the standards of practice of the health profession;

In Canada training for nutrition management requires completion of a two-year study of normal and therapeutic nutrition, food service systems management, human resource management, financial/business management and communications.

There are several training programs and two home study programs in Canada. The Canadian Society of Nutrition Management (CSNM) is the official review board for accrediting institutions of learning that meet its admission standards. CSNM recommends 1000 to 1200 hours of academic study and 160 to 200 hours of practical experience.

BC's Langara College has been offering Nutrition and Food Service Management program since 1970. PSNM has provided the curriculum outline for the Langara College Nutrition and Food Services Management program. The program was accredited by the Canadian Society of Nutrition Management (CSNM) in 1998.

Members of PSNM must meet the requirements for membership with CSNM, as follows:

  • Completion of a CSNM approved two-year college program in Nutrition and Food Service Management, or
  • completion of an approved distance study course in Nutrition and Food Service Management, with 1875 hours supervisory experience, plus successful completion of the CSNM examination, or
  • completion of a program that differs from those listed above, subject to approval of the Board of Directors of CSNM, but including studies in diet therapy, human nutrition and 1875 hours supervisory experience and successful completion of the CSNM examination.

Once any of the above requirements is completed, an applicant can apply and be a member of CSNM. Since 1989, anyone who graduates from a two-year approved program more than two years prior to the date of application with CSNM will be required to write the CSNM entrance examination.

PSNM submits that the Dietetic Technician program and the Certified Dietary Managers program in the United States are comparable to Canadian programs. Training programs obtained in the United States qualify for membership with CSNM and PSNM. Training programs in the United Kingdom qualify for the eligibility to write the CSNM entrance examinations and can lead to membership with PSNM.

The Council is satisfied that there is a uniform body of knowledge that could form the basis of standards of practice of the profession of nutrition management and that CSNM is actively developing standards for uniform practice. These standards are national competency standards for education and training and also are used to develop uniform job descriptions for entry level practice.

d) Section 5(2)(d): Whether members of the profession are awarded a certificate or degree from a recognized post-secondary educational institution

In British Columbia Langara College offers a two year (21 months) Diploma Program allowing graduates to become members of the CSNM. The program is designed to provide graduates with entry level competencies enabling them to work in health care facilities, contract catering services, educational facilities, private practice and education. The program content is kept current with the cooperation of professionals working in the industry who serve on the Advisory Committee. A British Columbia Grade XII or equivalent, or eligibility for Dean's Admission is required.

CSNM members who have been practising three or more years are eligible to apply for certification. This program enables a current member to attain a higher degree of professional proficiency, which includes years of varied experience, educational courses and the passing of a Certified Nutritional Manager (CNM) examination. Upon successful completion of the CNM examination, the member may use the initials CNM and the designation Certified Nutrition Manager after his or her name.

e) Section 5(2)(e): Whether it is important that continuing competence of the practitioner be monitored

The Council recognizes that it is always important to monitor continuing competency of practitioners in any profession where a risk of harm to the public is present.

The PSNM Bylaws require a number of continuing education points for continued membership in good standing. Guidelines for achieving the required continuing education are established by the Board of Directors of the PSNM as adopted by the general membership body.

f) Section 5(2)(f): the extent to which there exists within the health profession recognized leadership which has expressed a commitment to regulate the profession in the public interest

PSNM has represented the profession since 1969. PSNM, formerly known as the Pacific Unit Food Service Supervisors' Association until 1993, was incorporated under the Society Act on March 14, 1984. Since that time, it established a Code of Ethics, Constitution and Bylaws. These were revised in April 1997. Through its Bylaws, PSNM establishes membership requirements, including mandatory continuing education programs. It has a process in place for investigation and discipline of its members. An administrative hierarchy exists which sets out the duties and functions of the Board of Directors, the officers of the PSNM and the standing committees. The Bylaws also include a system for their amendment.

g) Section 5(2)(g): the likelihood that a college established under the Act would be capable of carrying out the duties imposed by the Act, having regard to factors which in the view of the Council may affect the viable operation of the college

The applicant has confirmed that only 110 of an estimated 500 practising NMs are members of the PSNM. Its revenues consist of membership fees. It also received a subsidy from the CSNM in 1997.

h) Section 5(2)(h): whether designation of the health profession is likely to limit the availability of services contrary to the public interest

Membership with PSNM is voluntary. Its membership includes less than 25 per cent of all NMs. Given the small number of NMs who are members of the applicant society it is unclear if the remaining majority of NMs would qualify for membership in a college.

However, the applicant states that to the best of its knowledge the approximately 400 non-members would qualify for membership in a college based upon similar education and training. In that case services would not be limited.

Designation under the HPA could result in limited availability of nutrition management services if education and training become an issue. In that regard, designation would not be in the public interest.

3. Conclusion Regarding Section 5(1) and 5(2) Criteria

The Council has reviewed the information gathered during the investigation in light of the public interest criteria. The Council concludes that the risk of harm in the practice of nutrition management is currently managed by the legislative requirements of the Health Act, the Community Care Facility Act, and the federal Food and Drugs Act. In addition, NMs' clinical practice follows guidelines and protocols written by dietitians who are members of a regulated health profession. Should this regulatory environment change it is possible that the public would be at risk.

With respect to the criterion in section 5(2)(g) the Council notes the small number of practising NMs who are currently members of PSNM and does not view designation under the HPA as viable at the present time. In addition, it is uncertain whether designation would result in limited availability of services because the qualifications of those NMs who are not members of the applicant are not known.

The Council considered the option of a joint college for nutrition management and one or two related health professions to be a practical solution to the problem of viability. Had the applicant formed an alliance with a related health profession such as dietitians or environmental health officers/public health inspectors the Council would have considered a joint college to be a viable option. A college with different categories of registrants is contemplated in section 19(1)(I) of the HPA. There are also precedents for colleges with two or more categories of registrants including the College of Dental Surgeons of BC and the College of Traditional Chinese Medicine Practitioners and Acupuncturists. In addition, the Council has recommended two categories of registrants for a College of Medical Laboratory Technologists.

In a college where both categories of registrants are health professionals there would be modification to the scope statement or possibly two separate scope statements. Members of such a college may or may not have the same or any reserved acts.

Among the respondents to the Council's consultation letter only the Canadian Society of Nutrition Management (CSNM) supports, without qualification, designation of nutrition management. BC Nurses' Union (BCNU) supports designation of NMs under a modified version of the College of Dietitians as recommended by the Council in its 1999 report Recommendations on the Designation of Dietetics.

In light of the reasons identified in the previous paragraphs, the Council has concluded that designation of nutrition management under the HPA should not be recommended.

The Health Professions Council recommends that the profession of nutrition management not be designated as a health profession under the Health Professions Act.

APPENDIX A
SUMMARY OF RESPONSES TO NUTRITION MANAGERS APPLICATION FOR DESIGNATION

PROFESSIONAL ASSOCIATIONS/SOCIETIES

1. British Columbia Dietitians' & Nutritionists' Association (BCDNA)
2 page submission from Darlene Ravensdale, Chair, Legislation Committee, June 2, 1998

Note that BCDNA made a subsequent submission at #8.

BCDNA makes reference to its public hearing where the applicant PSNM made a presentation. BCDNA disagrees with the information the applicant provided at the public hearing. It states that Nutrition managers (NMs) are not trained to do the following:

  • design, calculate and administer any of the therapeutic diets requested by dietitians
  • design other therapeutic diets
  • nutrition assessment

BCDNA states that NMs are trained to do a basic diet history (record of patient eating habits) and list of food preferences which might be called "screening". It further states that NMs are expected to use diet and menu patterns designed by the dietitian or diet manuals, to set out appropriate food items. BCDNA states that in a few facilities NMs are delegated to explain simple diets such as mild salt restriction.

BCDNA stresses the importance of recognizing the academic and practical training limitations for NMs, and realising that their actual role is quite different from the role the applicant depicted at the BCDNA public hearing. BCDNA feels that many of the applicant's statements would not be endorsed by the majority of persons working as food service supervisors/diet technicians. It is estimated that only about 10 individual NMs are actually working in therapeutic dietetic areas in BC.

BCDNA appends documents regarding the formal education and internships/practicums of programs in BC which prepare dietitians/nutritionists and those that train NMs. The attachments are:

  • Canadian Society of Nutrition Management (CSNM) Entry Level Competency Based Standards for Nutrition Managers;
  • CSNM Entry Level Competencies for Nutrition Managers from the Capital Health Region;
  • Nutrition and Food Service Management Department - Program; and
  • FNMT/FSNM Programs.

BCDNA also notes that the Adult Care Regulations for licensing of facilities require a dietitian to develop the Nutrition Care Plan.

Reserved acts
Per the Resolution of its Board of Directors on May 29, 1998, BCDNA does not support the applicant's position that they should be given a shared scope of practice for the eight high risk diets that the BCDNA is requesting as reserved acts.

2. The BC Psychological Association (BCPA)
1 page e-mail from Dr. Jean Stewart, Chair, Health Professions Council Task Force, October 13, 2000

BCPA does not wish to respond to this application.

3. Association of Dental Surgeons of British Columbia (BCADS)
1 Page letter from Jocelyn Johnston, Executive Director, October 25, 2000

BCADS has no comments concerning this application.

4. BC Medical Association (BCMA)
1 page letter from Dr. Dan MacCarthy, Director of Professional Relations, October 11, 2000

BCMA states that the information is insufficient for it to respond, particularly the lack of a proposed scope of practice statement from the applicant.

5. Licensed Practical Nurses Association of BC (LPNABC)
1 page letter from Sheila Wilkinson, President, November 22, 2000

Scope of practice
LPNABC notes that the applicant did not propose a scope of practice statement. It states that the statement provided by the applicant does not adequately describe its role and function. It also states that the applicant has not indicated how self-regulation would be in the public interest.

Reserved acts
LPNABC states that there is no indication of significant risk of harm if the applicant has no reserved acts.

Reserved titles
LPNABC states that the proposed reserved titles appear to have been taken from union classifications instead of from a professional classification. It further states that the proposed title does not distinguish members of PSNM from anyone else performing their functions.

6. BC Nurses' Union (BCNU)
2 page submission from Patricia Shuttleworth, Vice-President, November 22, 2000

BCNU proposes that it is in the best interest of the public and the applicant if NMs were regulated by a modified version of the college that was proposed by the Council for dietitians and nutritionists in August 1999. BCNU suggests that given their small numbers, NMs are more likely to succeed in their quest for self-regulation if they join forces with dietitians and nutritionists to create a single college.

Scope of practice
In its spirit of proposing a modified version of what the Council recommended as the college for dietitians and nutritionists, BCNU states that some refinements may have to be made to the Council's recommended scope of practice for dietitians and nutritionists to accommodate NMs. BCNU states the changes are likely to be nominal because there appears to be a substantial overlap in the scopes of practice of the two professions.

Reserved acts
BCNU states that only dietitians would be able to provide services that fall within the reserved acts recommended by the Council in its August 1999 application report on dietetics and nutrition.

Reserved titles
BCNU proposes that those members of the new combined college who perform more clinical or therapeutic functions than food service and delivery functions should be called "Dietitians", while those who provide food service or delivery and related administrative functions could use the title "Nutritionist", or a narrower title such as "Nutrition Manager" to distinguish them from dietitians.

7. The Dispensing Opticians Association of BC (DOABC)
1 page letter from Ilona Rule, Executive Director, November 29, 2000

DOABC feels it does not have the expertise or knowledge required to comment on this application.

8. BC Dietitians' & Nutritionists' Association (BCDNA)
3 page submission from Anna Bozac, President, December 7, 2000

BCDNA proposes that NMs not be designated as a self-regulating health profession because there is no substantial risk nor harm to the public. BCDNA bases this proposal on the definition of "health profession" under the Health Professions Act (HPA), the fact that the applicant did not provide a proposed scope of practice, the applicant's acknowledged practice limits, and the lack of reserved acts.

BCDNA further states that membership with the PSNM has been on the decline since its application with the Council. It estimates that 99 per cent of NMs working in the health care sector manage and/or supervise food service operations. The two general areas of work are food service systems and implementation of nutritional care, as evidenced by the Canadian Education Program for Nutrition Managers Accreditation Manual, published by the Canadian Society of Nutrition Managers (CSNM). BCDNA states that in the area of food service systems, current legislation exists to protect the public, i.e., the Food Premises Regulation, the Health Act, and the Community Care Facility Act. This legislation regulates activities by NMs carried out in compliance with the policies and procedures of health care facilities which are developed by dietitians and health care facility administration. BCDNA feels that additional regulation of these activities under the HPA would not enhance public protection.

Next, BCDNA states that in the area of nutritional care, dietitians are responsible for establishing and developing standards, policies and procedures. NMs do not independently exercise skill or judgment, or provide a clinical nutrition service to individuals. Under the supervision of dietitians, NMs assist in implementing nutritional care. Dietitians develop the resources under which NMs perform their work, in the presence or absence of a dietitian.

In sum, BCDNA advises the Council about the high cost of regulation. It also states that since dietitians are responsible for nutritional care NMs are not in a position to directly cause harm to the public.

Reserved acts
BCDNA notes the lack of proposed reserved acts by the applicant. It refers to the Council's recommendation to grant dietitians and nutritionists "designing, compounding and dispensing therapeutic diets where nutrition is administered through enteral or parenteral means." BCDNA states that, as with other activities in the area of nutritional care, dietitians will develop the policies and procedures related to enteral nutrition and will supervise NMs in the implementation of these activities.

Reserved titles
BCDNA states that there is no well established reserved title for the applicant, and that the proposed reserved titles do not reflect NMs' areas of work in food service supervision and management. BCDNA states that inclusion of the term "nutrition" is misleading and will lead to further confusion with the scope of practice of dietitians.

REGULATORY BODIES

9. The College of Dental Hygienists of BC (CDHBC)
1 page letter from Nancy Harwood, Registrar, October 3, 2000

CDHBC makes no comment on this application.

10. College of Dental Surgeons of BC (CDSBC)
1 page letter from Evelyn McNee, Registrar, November 22, 2000

CDSBC opposes designation of NMs as a self-governing profession under the HPA. It believes there is insufficient risk of harm to the public to warrant designation of NMs. It also states that the field of nutrition management can be very subjective, making it difficult to establish valid criteria for unethical or impaired practice of nutrition management. CDSBC believes that Health Canada's regulations sufficiently protect the public's food source because their criteria for doing so are constantly being evaluated and improved.

11. College of Dietitians of Alberta (CDA)
3 page submission from Lynda Heyworth, Registrar, December 19, 2000

CDA states it regulates the practice of dietetics in Alberta under the Registered Dietitians Act, and will be proclaimed under Alberta's new HPA.

Regarding risk of harm to the public, CDA states that it may be useful for the Council to determine whether the applicant has developed the structure and regulatory mechanism required for self-regulation, and whether it has the resources to sustain a regulatory college. CDA believes that the high cost of regulation needs to be balanced with the real benefit to the public of regulating practice.

CDA states that the information provided by the Council indicates that NMs practise independently in limited circumstances, only under established policies and procedures and in controlled institutional settings.

Finally, CDA notes that the stated limitations to practise and the lack of reserved acts do not indicate the potential for significant harm to the public. It suggests that the practice of nutrition management does not need to be regulated under the HPA.

Scope of practice
CDA proposes that an accurate scope of practice would include statements provided by the applicant, as follows: "primary responsibility is to promote nutritional health through the provision of safe and nutritious food", the phrase "assess and administer food service systems", and "They function in positions as technicians." CDA further states that NMs manage or supervise food service systems in clinical settings, in the hospitality industry, or in other settings the profession might identify.

With respect to practice limits, CDA states that the applicant has clearly stated the limitations in that NMs are not qualified to:

  • perform clinical assessments;
  • develop therapeutic diet standards;
  • develop clinical nutrition care plans; and
  • practice independently.

Reserved acts
CDA states that given the practice statements and limitations in the application, this profession would not perform any reserved acts.

Reserved titles
CDA states that the titles "Nutrition Technician", "Nutrition Manager", and "Certified Nutrition Manager and Supervisor" do not accurately describe the practitioner or the service that NMs provide, and they do not distinguish NMs from other nutrition practitioners.

OTHER ORGANIZATIONS/INDIVIDUALS

12. Certified Dental Assistants of BC (CDABC)
1 page letter from Marlene Robinson, Executive Director, September 15, 2000

CDABC does not wish to participate in nor comment on this application.

13. Sydney Massey, Registered Dietitian/Nutritionist and Nutrition Educator, Nutrition Education BC Dairy Foundation
1 page submission from, November 22, 2000

Reserved titles
Massey is concerned with the proposed reserved titles. She feels that the inclusion of the term "nutrition" in the applicant's proposed reserved titles would confuse the public since the registered dietitians/nutritionists who practice as a nutrition educators use that term. Also, Massey states that the title "Community Nutritionist" is used by the registered dietitians/nutritionists who practice in public health.

14. Cayla Runka, Registered Dietitian/Nutritionist
1 page e-mail, November 22, 2000

Ms. Runka makes an identical submission as Massey, submission #13.

15. Anne Swann, Registered Dietitian/Nutritionist, Vancouver/Richmond Health Board
2 page facsimile, November 23, 2000

Ms. Swann makes an identical submission as Massey, submission #13.

16. Stephanie Staus, Registered Dietitian/Nutritionist
1 page e-mail, November 23, 2000

Ms. Staus makes an identical submission as Massey, submission #13.

17. Judy Toews, Registered Diteitian/Nutritionist
1 page e-mail, November 23, 2000

Ms. Toews makes an identical submission as Massey, submission #13. She adds that it would seem logical for PSNM members to call themselves "Dietary" or "Dietetics Managers".

18. Deborah Leach
1 page e-mail, November 23, 2000

Ms. Leach makes an identical submission as Massey, submission #13, above.

19. Carol Murphy
1 page e-mail, November 27, 2000

Ms. Murphy makes an identical submission as Massey, submission #13.

20. Dial-A-Dietitian Nutrition Information Society of BC
2 page submission from Kathleen Quinn, Executive Director, December 1, 2000

Scope of practice
Dial-A-Dietitian states that NMs are food service managers or food service supervisors. They may also assist the dietitian in noting the client's food preferences, ability to chew or swallow, and the collection of special diet orders. Dial-A-Dietitian states that it is the dietitian who is the professional responsible for the clinical assessment of clients' nutrient needs as determined by their medical conditions and medications, and ensuring nutritional care and medical diet standards and procedures are in place. Dial-A-Dietitian includes a chart of procedures that food service managers and dietitians' assistants perform.

Dial-A-Dietitian further states that in large hospital settings, the scope of duties, training and supervision of a dietitian's assistant are the responsibility of a registered dietitian. In small long-term care settings, a dietitian would be hired as a consultant to provide guidance to the food service staff in nutritional health concerns for the protection of the residents or clients of the institution. Dietitians would provide standards of nutrition care.

Reserved titles
Dial-A-Dietitian states that the title "Nutrition Manager" may confuse the public in describing the professional and the services being provided. The title does not adequately reflect the primary role of food service manager, and could be confused with services performed by dietitians and nutritionists. It suggests that the titles should be "Food Service Manager" or "Food Service Supervisor" if the NMs perform food management duties, and the titles "Dietitian's Assistant" or "Dietetic Services Assistant" or "Dietary Technician" if the NMs perform duties within the process of food selection to meet specific medical diet specifications as per standards, procedures and guidelines determined by the dietitians. Lastly, Dial-A-Dietitian states that the term "nutrition" should not be reserved as per the Council's earlier recommendations for other professions.

21. Christine Chou, Registered Dietitian/Nutritionist
2 page submission, December 11, 2000

Ms. Chou urges the Council to reconsider the PSNM's application to the same college as dietitians and nutritionists. She supports NMs in forming their own college but a separate one from the dietitians' and nutritionists' college.

Ms. Chou states that although NMs and dietitians work in similar fields the training of the two professionals is very different. NMs have two years technical training whereas dietitians undergo a four-year baccalaureate degree program followed either by a 40 week plus hospital based internship or masters degree. Thus, the scope of practice of NMs is more limited as they lack basic courses required for the dietetic degree. Courses taken towards the NMs' diploma are not transferable towards the nutrition and dietetic program.

Ms. Chou further states that because NMs do not study biochemistry, microbiology, human physiology, pharmacology, statistics and research design, or food chemistry, their knowledge of the interaction between food and health is limited. NMs receive basic training to understand the role of therapeutic diets, perform basic screening and interpret non-complex diet orders such as low sodium and heart healthy. Ms. Chou states that NMs are not trained to interpret laboratory results, analyze food and drug interaction, perform clinical assessment, or review medical charts - skills necessary in developing and evaluating nutritional care plans. Nor are NMs likely skilled in enteral/parenteral feeding or dysphagia (swallowing disorders).

Ms. Chou also states that in adult continuing care facilities, the Adult Care Regulations require a registered dietitian/nutritionist to complete and evaluate nutritional care plans for all residents, and it would be irresponsible and unsafe for NMs to take on clinical nutrition responsibilities without the direction and supervision of a dietitian.

Next, Ms. Chou states that dietitians write and review therapeutic diet manuals. They translate diet orders into individualized nutrition care plans, while NMs provide the technical support in ensuring the food is prepared and served.

Ms. Chou feels that incorporating NMs into the same college as dietitians and nutritionists would confuse the public, and make it unclear as to the role each has towards ensuring the nutritional health of the residents in care and their scope of practice.

Ms. Chou feels that many of the statements were vague and misleading, i.e.,

responsibility may include various degrees of participation in assessing, implementing and evaluating nutritional care plans depending on the facility policies and procedures.

Ms. Chou states that one could argue that nurses, cooks and care aides also have varying degrees of responsibilities in the nutrition care planning yet it is unquestionable that it would be inappropriate for them to form part of the dietitians' college.

22. Jeri Manley, Registered Dietitian/Nutritionist, Central Vancouver Island Health Region
1 page facsimile letter, December 11, 2000

Ms. Manley makes an identical submission as Massey, submission #13, above.

23. Deanna Tan, Licensing Nutritionist for Community Nutrition Council - Standing Committee on Licensing
2 page submission, November 20, 2000

Ms. Tan states that the Standing Committee on Licensing represents the majority of nutritionists in BC. The Committee also investigates complaints with respect to nutrition and food service issues, and it is thus familiar with the practices of dietitians and NMs.

Scope of practice
According to the Community Care Facility Act, Adult Care Regulations, Ms. Tan believes the following scope of practice for NMs is appropriate:

  • Management and/or supervision of food services;
  • Participation in the development of (food services) policies and procedures;
  • Development of menus, including modified diets;
  • Liaison with other caregivers;
  • Co-ordination of food procurement;
  • Maintenance of safety, sanitation and security in food distribution and preparation;
  • Participation in care planning;
  • Participation in the quality improvement program; and
  • Participation in staff education regarding food services.

Ms. Tan states that the following should not be included in the scope of practice of NMs:

  • Development of therapeutic menus;
  • Nutrition assessments;
  • In-services on therapeutic diets;
  • Nutrition counselling of clients;
  • Development, documentation, monitoring and evaluation of nutrition care plans;
  • Development of clinical nutrition policies and procedures.

Reserved titles
Ms. Tan states that the titles for NMs should be "Food Service Supervisor", "Certified Food Service Supervisor", or "Certified Diet Technician". It advises that the term "nutrition" should not be part of any title because it may confuse the public, it does not reflect the scope of practice of NMs, and it was not recommended by the Council for dietitians in their reserved titles.

24. Deanna Tan, Licensing Nutritionist, Simon Fraser Health Region
4 page submission, December 11, 2000

Ms. Tan makes an itemized submission, as follows (underlined page and item references refer to the applicant's application for designation):

Clinical roles, page 4
Ms. Tan states that NMs have adequate training to do only administrative duties the PSNM describes in its application. She states that the following skills the applicant claims as NMs' clinical roles cannot be obtained by simply taking extra courses: assessing, developing, implementing and evaluating nutrition care plans, providing nutrition information and writing modified diets. She believes that NMs do not have the adequate training to do the clinical roles that they describe. Ms. Tan states that this will inherently put the residents at risk. She believes that NMs are able to screen a resident at risk, but then the resident should be referred to a registered dietitian.

Part V, 26. Reasons for Designation page 15
Ms. Tan states that the roles of NMs and dietitians are too different to realize PSNM's request to form a joint college with registered dietitians. She reiterates her belief that NMs should not have a clinical role.

28 Proposed professional titles page 16
Ms. Tan states that the following proposed reserved titles are misleading and too broad in scope: "Nutrition Manager", "Certified Nutrition Manager", "Nutrition Technician", and "Nutrition Supervisor". Ms. Tan states that the term "nutrition" implies there is a strong clinical aspect to the work of NMs. Allowing NMs to use a title with the term "nutrition" would confuse the public as to what their role is. Ms. Tan states that the more administrative duties that the applicant has described suggests the following more appropriate reserved titles: "Certified Food Service Supervisor", "Certified Food Service Manager", or "Certified Diet Technician".

29 Proposed scope of practice

  • Ms. Tan states that NMs can develop menus and standardized recipes and texture modified diets, but they cannot write therapeutic diets. Ms. Tan explains that "modified diets" is a vague term that would cover both therapeutic and texture-modified.
  • Ms. Tan states that NMs cannot develop, fully implement, nor interpret nutritional needs of clients.
  • Ms. Tan states that NMs are not qualified to give out nutrition information.
  • Ms. Tan states that health promotion programs are beyond the scope of NMs.
  • Ms. Tan states that food service education is within NMs' scope but not nutrition education.

30 Proposed practice limits
Ms. Tan finds this passage completely contradictory as the applicant's entire application is based on its proposal to do clinical assessments, therapeutic diets, and its request to develop nutrition care plans.

31 Proposed exclusive scope of practice
Ms. Tan believes that the applicant is blurring the role of NMs versus the role of dietitians. The latter must assess and make the crucial decisions regarding assessing, developing and evaluating care plans, whereas the former play roles in helping to implement and monitor.

Finally, Ms. Tan makes a general comment and states that she finds certain parts extremely vague: "responsibilities include various degrees of participation in assessing, developing, implementing and evaluating nutritional care plans" means that NMs can go far beyond their capabilities as "various degrees" can refer to all or none. Ms. Tan stresses that NMs cannot assess, develop or evaluate but can assist in implementing and monitoring.

25. Christine Chou, Registered Dietitian/Nutritionist, South Delta Health Unit
2 page facsimile letter, December 12, 2000

This is the same as submission #21.

26. Hospital Employees' Union (HEU)
7 page submission from Chris Allnut, Secretary-Business Manager, December 13, 2000

HEU supports the regulation of food service operations and the enforcement of standards for nutrition care in the interest of public safety. It does not believe that regulating nutrition supervisors and technicians is necessary to achieve those public safety goals. HEU believes that the public interest is protected by the current regulatory framework which includes the Adult Care Regulations, public health protection regulations, Hazards Analysis Critical Control Points program, accreditation requirements, quality assurance programs, workplace policies and procedures, and regulation of dietitians.

HEU states that in its own consultation with food service members and servicing representatives, it appears that there is no wide support for the application, and in fact many do not even know the application for designation under the HPA was made. HEU states that it seems that the PSNM is not exercising recognized leadership.

HEU further states that the application lacks depth and clarity in terms of the recommended parameters for food service supervisors, technicians, and managers. HEU notes that the applicant failed to define the scope of practice or the reserved acts appropriate to NMs. HEU states that there seems to be no compelling argument or evidence to recommend regulation of this profession.

HEU also believes that it is difficult to understand how unionized food service supervisors and technicians could be combined with out-of-scope managers under a category titled "nutrition managers". Responsibility and authority of the two groups are very different, and the title "manager" is inappropriate for the majority of candidates encompassed by the PSNM proposal.

Lastly, HEU notes the omission of food service supervisors/technicians and managers in the review of dietetics' designation in BC and in the health professions regulation of other provinces. Dietitians did not request the inclusion of supervisors/technicians and managers in their application for designation under the HPA.

HEU concludes by outlining the current regulatory environment with respect to the functions of food service supervisors/technicians and managers, including the Adult Care Regulations, public health protection, Health Protection Branch, workplace policies and procedures, training and clinical resources. HEU believes that the current regulatory framework provides reliable protection of the public interest. It does not believe that the PSNM request for designation under the HPA is either substantiated or widely supported. Thus, it strongly recommends rejection of this application.

OTHER MINISTRIES IN BRITISH COLUMBIA

27. Ministry of Health, BC Ambulance Service (BCAS)
1 page letter from Paul Gotto, Executive Director, September 27, 2000

BCAS has no comment on this application.

28. Cariboo Community Health Services Society (CCHSS)
3 page submission from Allison Ruault, Executive Director, December 6, 2000

CCHSS consulted with registered dietitian nutritionists across the region to assist in preparing its response.

Scope of practice
CCHSS states the appropriate scope of practice for NMs is documented in the Canadian Education Program for Nutrition Managers Accreditation, and the Community Care Facility Act, Adult Care Regulations. CCHSS cites the scope of practice from the first document, as follows:

The practice of food services supervision incorporates basic knowledge and skills in the coordination and management of operations in food and nutrition services for the purpose of meeting and maintaining quality and cost effectiveness. Practice encompasses food service systems and may include nutritional care of clients. Responsibilities are performed in compliance with standards established by the government, dietetic profession and health care facility administrator.

Reserved titles
CCHSS states that the appropriate titles should be "Food Service Supervisor", "Certified Food Service Supervisor", or "Certified Diet Technician". CCHSS states that the titles are most consistent with NMs' scope of practice and reflect existing titles in the workplace. It further states that use of the term "nutrition" will be confusing to the general public.

29. Simon Fraser Health Region Food and Nutritional Services (SFHRFNS)
1 page submission from Phil Skillman, Regional Director, December 13, 2000

SFHRFNS states that membership of the PSNM is not comprised of managers in the true sense of the word but rather supervisors and diet technicians. SFHRFNS states it would be difficult for it to support any initiative that would further restrict the number of supervisors and diet technicians. It states that there is currently a province wide shortage of supervisors and diet technicians. It also states that it is highly doubtful that the Hospital Employees' Union would support additional requirements or forced association with PSNM. Finally, SFHRFNS states that while food and nutrition supervisors and diet technicians are an important component of its overall operation, they are however a reasonably small group by percentage in comparison to the staff they supervise. The majority of their work is spent on administrative and not clinical, direct patient care tasks, as might a clinical dietitian. SFHRFNS states that their small membership may be an obstacle to maintaining a college specific to this group of health care employees.

Reserved acts
SFHRFNS notes the lack of proposed reserved acts and states it is unusual for a designated health profession to not have reserved acts since they are the benchmarks that distinguish a health profession.

Reserved titles
SFHRFNS prefers the titles "Food and Nutrition Technician" and "Food and Nutrition Supervisor". It also notes the term "nutrition" as being in the public domain.

OTHER PROVINCES

30. Northwest Territories Health and Social Services (NWTHSS)
1 page letter from Bronwyn Watters, Director, Policy, Planning and Human Resources, October 10,2000

NWTHSS states that it currently has no regulatory responsibility with the practice of nutrition management. It is unprepared to offer any comments.

31. New Brunswick Health and Wellness (NBHW)
1 page letter from Christy Shaw, Legislation Development, Planning and Evaluation Division, October 12, 2000

NBHW states that nutrition management is a profession not identifiably practised in its province and therefore, cannot make a comment on this application.

32. Ontario Ministry of Health and Long-Term Care (OMHLT)
1 page letter from Donna Segal, Acting Executive Director, October 6, 2000

OMHLT states that a response to this application should come from the Integrated Policy and Planning Division of this ministry. It indicates it will forward the Council's correspondence to Mary Beth Valentine, Director of the Program Policy Branch, and Marilyn Wang, Manager of Integrated Policy and Planning Division.

33. Quebec Office des Professions (QOP)
2 page submission from André Contant, Research Director and Coordinator, December 5, 2000

The submission is in French.

34. Yukon Health and Social Services (YHSS)
2 page submission from Bruce McLennan, Deputy Minister, December 11, 2000

YHSS states that it does not regulate nutrition management, nor is it planning to do so in the near future.

YHSS poses two questions: 1) where a dietitian is also a nutrition supervisor or manager, would he/she also be required to belong to this society, as well as a provincial dietitian's association and/or Dietitians of Canada? 2) should there be a concern that this process is about trying to classify food service supervisors and/or dietary technicians into a society with responsibilities that are outside of their expertise?

Scope of practice
YHSS comments that NMs function as members of the health care team. However, they do not perform clinical tasks independently and are not referred by dietitians to clients in need of nutritional care unless they are registered dietitians employed as NMs.

YHSS also states that the Council's letter provides contradictory information in the limits of practice and the scope of practice statement. Under the first heading, NMs are not qualified to perform clinical assessments nor develop therapeutic diet standards. But under the second heading, NMs assess and administer food service systems as well as the nutritional care of clients. YHSS explains that assessing and administering the nutritional care of clients implies that NMs are responsible for clinical assessments which is a critical role in the nutritional care of clients. YHSS states that NMs are not qualified to do so unless they are registered dietitians working as NMs.

Next, with respect to limitations imposed on the performance of services by NMs YHSS states that responsibility for the nutritional care of clients does not fall within NMs' scope of practice, but the provision of such services is within a dietitian's scope of practice. YHSS comments that although the policies and procedures of select facilities may permit NMs an independent performance of tasks, the provision of a self-governing profession with different levels of responsibility within a provincial regulatory framework could create difficulty in regulating that practice.

Reserved titles
YHSS states that all of the proposed reserved titles are probably appropriate as they are similar and fall within the same category.

ADDITIONAL SUBMISSIONS

35. Dietitians of Canada (DC)
3 page submission from Janice Macdonald, regional Executive Director, BC Region, December 11, 2000

DC at this time does not support the application by PSNM to be regulated as a health profession in BC, for the following reasons:

  • NMs in BC are not presently involved in a practice that creates a risk to the public. DC states that legislation such as the BC Health Act exists to provide protection to the public regarding food and workplace safety. DC also states that medical health officers and environmental health officers monitor food service establishments and enforce the Health Act Food Premises Regulations as well as municipal by-laws relating to food service establishments.
  • NMs perform responsibilities generally under the supervision of a registered dietitian/nutritionist. NMs are trained to assist in the implementation of care plans by writing therapeutic menus according to documented care plans developed by a dietitian. Under the direction of a dietitian, NMs participate in the evaluation of client intake and acceptance of nutrition intervention. Under the direction of a dietitian and according to established procedures, NMs may participate in nutrition counselling, but they are not trained to provide nutrition counselling on complex therapeutic diets. DC further states that NMs' responsibilities would be highest in acute care settings where they work more independently. However, the Community Care Facility Act - Adult Care Regulations clearly indicate that a registered dietitian/nutritionist must develop, document, review, monitor and revise the nutrition care plan in facilities with 25 or more residents.
  • Competency standards and accreditation of nutrition management have been in place for a short period of time. In 1990, the first competency standards was developed and adopted by the Canadian Society of Nutrition management and the Canadian Dietetic Association. The first program was accredited about five years ago.
  • The profession is currently not large enough to support a college.

Scope of practice
DC states that since the applicant did not propose a scope of practice it is not proposing one either. It states that NMs are typically involved in operating diet office computer software, obtaining food preferences and diet histories from clients, supervising nutrition clerks and foodservice assistants, supervising patient tray assembly, participating in the implementation of nutrition care plans, designing meal patterns, giving basic diet advice to nursing and other staff, and completing nutrition screening assessment.

Reserved titles
DC recommends titles that the public would clearly understand and that reflect the practice. It believes that the proposed reserved titles do not reflect the practice, are not well established and thus, not well understood by the public. The title "Nutrition Manager" has been in use in Canada for less than 10 years and is not consistently used by practitioners in this field. DC also states that the term "nutrition" could be misleading to the public as this profession mostly deals with food service systems as noted in its accreditation standards. DC notes that in the US, "Dietetic Technician" is used under the American Dietetic Association, but in Canada the title is not well established and the practice of the dietary technician is focused on clinical nutrition.

36. The Canadian Society of Nutrition Management (CSNM)
2 page submission from Janet Milner, Executive Director, December 18, 2000

CSNM states that its members are charged with ensuring both National and Provincial Food and Nutrition Standards and Regulations are met. One of its major objectives is to assure incorporation of the knowledge and skills in nutrition and food service management into the basic minimum curriculum of training programs across Canada. CSNM also notes that the majority of Directors of the programs are registered dietitians and nutritionists.

Scope of practice
CSNM states that no limitations should be imposed on the performance of services as listed on the accompanying document.

Reserved acts
CSNM states that it makes no comment or requests at this time.

Reserved titles
CSNM states the proposed reserved titles indicate adequate representation of actual functions to the public.

RESPONSES TO THE COUNCIL'S DRAFT REPORT

37. Deanna Tan, Licensing Nutritionist, Simon Fraser Health Region
3 page submission, July 31, 2001

Ms. Tan clarifies two sections of the Council's draft report.

First, she refers to the summary of her initial submission found in this Appendix:

Another individual submission, from Deanna Tan, a Registered Dietitian employed by the Simon Fraser Health Region, states that NMs have adequate training to do only administrative duties the PSNM describes in its application. Ms. Tan believes that NMs do not have adequate training to perform the clinical roles they describe. Ms. Tan states that this will inherently put residents of long term care facilities at risk. She believes that NMs are able to screen a resident at risk, but then the resident should be referred to a registered dietitian...

Ms. Tan clarifies her statement to indicate that NMs have adequate training to do only foodservice or non-clinical duties.

Ms. Tan explains that the CNC-SCL does not represent the majority of nutritionists in BC, but rather, the majority of nutritionists who monitor, inspect and investigate complaints related to food and nutrition within residential care facilities.

38. College of Dental Hygienists of British Columbia (CDHBC)
1 page submission from Nancy Harwood, Registrar, July 23, 2001

CDHBC has no comment regarding the Council's draft report.

39. Pacific Society of Nutrition Management (PSNM)
6 page submission from Flo Dolega, Government Relations Chair, September 7, 2001

PSNM has requested that its response to the draft report be included in the final report of the Council. Please see Appendix B for the full text of this submission.

APPENDIX B
Pacific Society of Nutrition Management
Response of September 7, 2001
to the Council's Draft Report

Re: RECOMMENDATIONS ON THE DESIGNATION OF NUTRITION MANAGEMENT
Draft report for the 30-day consultation.

We would like to thank the Health Professions Council for their service and recognition of our accomplishments.

Here are the sections of the draft document "Recommendations on the Designation of Nutrition Management" that we would like to correct, clarify and comment.

1. Under the Public Interest Criteria we offer some clarification with respect to the various manuals used included policy and procedure manuals.

B. PUBLIC INTEREST CRITERIA c) Section 5(1)(d)(i): the degree to which the health profession is practised under the supervision of another person who is qualified to practice as a member of a different health profession "PSNM quotes from the CSNM Accreditation Manual (Manual), which states that NMs function under the general supervision of a qualified dietitian. The Manual does not require on-site supervision. The Manual also states that NMs may be indirectly supervised through facility or government standards. PSNM also states that in long-term care, NMs work independently in sole charge of food service departments, management of staff and facilities, but the process and standards come from the Manual and Community Care Facility Act Regulations. In its investigation the Council learned that BCDNA authored the policy and procedure manual, which directs NMs' clinical and patient care functions."

There are various manuals used in the work place, some of them authored solely by BCDNA but the policy and procedure manual May 1999 Titled FOOD AND NUTRITION FOR QUALITY CARE: a policy and procedure manual was co authored by the BCDNA and Nutrition Managers. In addition a number of Dietitians and Nutrition Managers representing various facilities were consulted in finalizing the content of the Manual.

1a Also under this section " the degree to which the health profession is practised under the supervision of another person who is qualified to practice as a member of a different health profession."

"BCDNA submits that NMs do not independently exercise skill or judgment, or provide a clinical nutrition service to individuals."

While the Dietitians as a profession develop the resources under which the NMs do their work, the need for Nutntion Managers to independently exercise knowledge, skill and judgment is paramount, for the provision of safe, nutritious food For that part of our profession that includes clinical only duties, our situation is better expressed by the College of Dietitians of Alberta (CDA) "NMs practice independently in limited circumstances, only under the established policies and procedures in controlled institutional settings".

"The BCDNA states that in the area of food service systems, current legislation exists to protect the public, i.e., the Food Premises Regulation, the Health Act, and the Community Care Facility Act."

"This legislation regulates the activities by NMs, which are carried out in compliance with the policies and procedures of the health care facilities developed by dietitians and health care facility administration."

We clarify that it is also a function of the Nutntion Manager (as per job description) to participate in the development and formulation of facility policies and procedures.

2. Below is the section of the Community Care Facility Act Adult Care Regulations as it applies to Nutrition Managers.

d) Section 5(1)(d)(ii): the degree to which the health profession is practiced in a currently regulated environment.

"The Community Care Facility Act Adult Care Regulations (Regulations) govern food service operations in community care facilities. The Regulations establish minimum standards for nutrition care plans, including the primary role of dietitians at facilities with 25 or more residents. The Regulations also set criteria for food preparation and service, the provision of eating aids and supplements, menu planning, and monitoring of residents' weight patterns and nutrition needs."

This section of the Community Care Facility Act Adult Care Regulations (Regulations) govern food service operations in community care facilities as it relates to Nutrition Managers states the following.

Supervisor of food services in facilities with 50 or more residents.

7.2 (1) For the purposes of this section, a supervisor of food services must be

(a) A nutrition manager who has membership in the Canadian Society of Nutrition Management,
(b) A person who is eligible for membership in the Canadian Society of Nutntion Management, or
(c) A registered dietitian-nutritionist.

(2) A licensee of a facility with 50 or more persons in residence must obtain the services of a supervisor of food services to ensure adequate management of food services.
[en BC Reg 22/97, s 2]

3 Under Section 5(1)(d)(n) we would like to clarify the following.

d) Section 5(1)(d)(ii): the degree to which the health profession is practiced in a currently regulated environment.

"Public health protection programs, including the Food Premises Regulations under the Health Act set out a number of requirements that food service operations must meet. Public health officers monitor and enforce the Food Premises Regulations. The health inspector issues a permit for a food premise annually after a full inspection.

Information provided by the applicant indicates that in some instances public health officers no longer perform full inspection but rather rely on the professional skills of NMs to administer the requirements of the Food Premises Regulation and the Hazards Analysis Critical Control Points program."

Regarding Public Health Inspectors The applicant did not provide this information However individual Nutrition Managers are expected (by the Health Dept) to interpret the requirements of HACCP into a Food Safety Plan best suited for use in their particular establishment as per the regulations.

4 Under Section 5(2) Discretionary Public Interest Criteria we offer the following corrections.

c) Section 5(2)(c): the extent to which there exists a body of knowledge that forms the basis of the standards of practice of the health profession;

"In Canada training for entry into nutrition management profession requires completion of a two-year study of normal and therapeutic nutrition, food service systems management, human resource management, financial/business management and communications.

PSNM submits that the Dietetic Technician program and the Certified Dietary Managers program in the United States are comparable to Canadian programs. Training programs obtained in the United States qualify for membership with CSNM and PSNM."

The Dietetic Technician programs in the USA are now called Dietetic Technician Registered program.

The Certified Dietary Managers program is a one-year program and is not comparable and does not qualify for membership in the CSNM.

5 Under Section 5(2)(g) we offer the following clarification.

g) Section 5(2)(g): the likelihood that a college established under the Act would be capable of carrying out the duties imposed by the Act, having regard to factors which in the view of the Council may affect the viable operation of the college.

"The Applicant has confirmed that only 110 of an estimated 500 practicing Nutrition Managers are members of the PSNM. Its revenues consist of membership fees. It also received a subsidy from the CSNM in 1997."

There has been a change in the number of members since 1997. PSNM bylaw revision now includes mandatory National membership The Provincial chapter's membership decreased from 180 to 110 Some Nutrition Managers opted to pay only one membership fee and because membership in the CSNM is now a requirement under the Adult Care Regulations, the result was an increase in the National membership from 90 to 206 Looking at the obvious difficulties that have arisen the National Society is considering a combined membership fee.

6 Under Conclusion Regarding Section 5(1) and 5(2) Criteria.

"In a college where both categories of registrants are health professionals there would be modification to the scope statement or possibly two separate scope statements as well as recommendations about reserved acts, if any, granted to either category."

Had the Dietitians followed through and supported a joint college there is a process to define our roles. We thank the council for stating the facts.

"Among the respondents to the Council's consultation letter only the Canadian Society of Nutrition Management (CSNM) fully supports designation of nutrition management BC Nurses' Union (BCNU) supports designation of NMs under a modified version of the College of Dietitians as recommended by the Council in its 1999 report Recommendations on the Designation of Dietetics."

We note Christine Chou's support for our designation.

22. Christine Chou, Registered Dietitian/Nutritionist 2 page submission, December 11, 2000
"Chou urges the Council to reconsider the PSNM's application to the same college as dietitians and nutritionists. She supports NMs in forming their own college but a separate one from the dietitians' and nutritionists' college."

7. Appendix SUMMARY OF RESPONSES TO NUTRITION MANAGERS APPLICATION FOR DESIGNATION

As respondents are quoted in your report, we are obliged to clarify and correct any misperceptions and assumptions.

Without listing each response it is clear that some respondents have interpreted our application as if we represent ourselves as Dietitians, or that if we had a college with or without the Dietitians, that some how we would be comparable.

We did not at any time state that we are trained, perform or are capable of performing the clinical duties and responsibilities of a Dietitian.

We have clearly explained our role in clinical nutrition. For your records we submit another role delineation (clinical nutrition only) that was conducted in 1998.

We have also clearly explained our role in food service management. We thank the council for not interpreting our application as anything more than was presented.

7a Appendix #22

22. Christine Chou, Registered Dietitian/ Nutritionist
"Chou likens the situation to the training of a nurse's aide versus a degree nurse." (In an attempt to illustrate the difference between a NM and a Dietitian).

Training of a Nurse Aide is 6 months; a Nutrition Manager has 2 years of education. The level of professional expertise/ responsibility of a Nutrition Manager and that of a Nurses Aide are not even remotely comparable and it is entirely inappropriate and misleading to use this comparison to describe the difference between a Dietitian and a Nutrition Manager.

7b Appendix #23

Deanna Tan, Licensing Nutritionist, Simon Fraser Health Region
4 page submission, December 11, 2000.

"Tan states that the roles of NMs and dietitians are too different to realize PSNM's request to form a joint college with registered dietitians. She reiterates her belief that NMs should not have a clinical role.

29 Proposed scope of practice page 16
#5: Tan states that NMs can develop menus and standardized recipes and texture modified diets, but they cannot write therapeutic diets. Tan explains that "modified diets" is a vague term that would cover both therapeutic and texture-modified.

#9 and 10: Tan states that NMs cannot develop, fully implement, nor interpret nutritional needs of clients.

#11: Tan states that NMs are not qualified to give out nutrition information.

#12: Tan states that health promotion programs are beyond the scope of NMs.

#13: Tan states that food service education is within NMs' scope but not nutrition education.

30 Proposed practice limits
Tan finds this passage completely contradictory as the applicant's entire application is based on its proposal to do clinical assessments, therapeutic diets, and its request to develop nutrition care plans.

31 Proposed exclusive scope of practice
Tan believes that the applicant is blurring the role of NMs versus the role of dietitians. The latter must assess and make the crucial decisions regarding assessing, developing and evaluating care plans, whereas the former play roles in helping to implement and monitor.

We feel that the above noted respondent misinterpreted our submission. Under the circumstances, Tan's submission is entirely out of context and we were surprised to see it included in the draft.

7c. Appendix #26

26. Hospital Employees Union (HEU)

7 page submission from Chris Allnut, Secretary-Business Manager, December 13, 2000

"HEU states that in its own consultation with food service members and servicing representatives, it appears that there is no wide support for the application, and in fact many do not even know the application for designation under the HPA was made. HEU states that it seems that the PSNM is not exercising recognized leadership."

Our members have contacted us regarding their consultation and stated they did not feel support by HEU in the consultation process.

7d. Appendix # 9

9. Simon Fraser Health Region Food and Nutritional Services (SFHRFNS) 1 page submission from Phil Skillman, Regional Director, December 13, 2000.

"SFHRFNS states that membership of the PSNM is not comprised of managers in the true sense of the word but rather supervisors and diet technicians."

The majority of our members are managers and/or department heads.

8 Discussion around the titles.

The Nutrition and Food Service Management 2-year diploma program is centered on food as nutrition. It is not training for the general hospitality industry. There are separate courses offered in various Provinces for the commercial application of food services. The service we provide is not food for an occasional night out of fine dining, or the fast food meal for the hurried consumer. It is food for nutrition served to the same people day after day We are in the business of providing nutrition to a very vulnerable clientele, the sick, the elderly, the very young, and any person in an institutional setting with very limited personal choices.

Given our other duties in Long Term Care, including the procurement of human and material resources, responsibility for departmental budgets, labour relations, training and evaluation of staff etc the correct title would be Manager, not Supervisor. While not all our members have a position as a Manager, management is a key element of our education and a position many of us hold in our professional life.

Just as the Dietitians went to great lengths at the hearing to descnbe the variety of positions and responsibilities open to their members the same holds true of Nutrition Managers It would be most helpful to all concerned in the business of public health services to recognize fully the part that each discipline plays.

Nutntion Manager is a professional title not a Job description. There is an extensive list of job descnptions used in the workplace, however if you are looking for the professional applicant that is trained specifically for these job descnptions, then you are looking for a Nutrition Manager.

We request that our clarifications and responses be included in your final published report.

Thank you for this opportunity to respond the draft report for the Recommendations on the Designation of Nutntion Management, Draft Report for the 30-Day Consultation.

Sincerely,
Mrs Flo Dolega, CNM
Government Relations Chair,
Pacific Society of Nutrition Management