Standards of Nutrition Care Practice and Professional Performance for Nutrition Support and Generalist Nurses

Nursing is the protection, promotion, and optimization of health and abilities; prevention of illness and injury; alleviation of suffering through the diagnosis and treatment of human response; and advocacy in the care of individuals, families, communities, and populations.1 Nutrition support nursing (NSN) is a professional nursing specialty that focuses on the protection, promotion, and optimization of nutritional health and functional abilities, prevention of nutrition-related illness and injury, alleviation of suffering through the diagnosis and treatment of nutrition-related human response, and advocacy in the care of individuals, families, communities, and populations with known or potential nutrition alterations. The historical development of the specialty of NSN focuses on 3 periods. The prespecialty period (1854–1960) highlights the development of the nutrition domain of nursing practice and role differentiation between the registered nurse and registered dietitian. The specialty period (1960–2000) highlights the birth of NSN as a specialty. The expansion period (2000–2015) highlights the contributions of NSN to expanding the science and practice of nutrition care to the discipline of nursing (including general and specialty nursing practice) and beyond. Key events are highlighted in the chronology in Table 1.234567891011121314–15 The American Society for Parenteral and Enteral Nutrition (ASPEN) has served as the professional home for NSN since 1976. ASPEN is a scientific society whose members are healthcare professionals—physicians, dietitians, nurses, pharmacists, other allied health professionals, and researchers—whose mission is to improve patient care by advancing the science and practice of clinical nutrition and metabolism. ASPEN envisions an environment in which every patient receives safe, efficacious, and high-quality nutrition care. NSN works collaboratively with other disciplines in a variety of settings along the continuum of care and across all developmental stages. Nutrition support (NS) nurses advocate resolving ethical issues of patients, colleagues, or systems involving nutrition support as defined by the Code of Ethics for Nurses With Interpretive Statements.16 The practice of NSN varies with the individual nurse's educational background, position, and practice environment. Due to the variation of NSN roles, clinical practice may not apply to all nurses as some may not practice in a patient care environment. The scope of practice includes but is not limited to direct patient care; consultation with other healthcare professionals; education of patients/caregivers, students, colleagues, and the public; participation in research activities and performance improvement; and administrative functions. Traditional roles for NSN include working as a member of an interdisciplinary nutrition support service or team. However, emerging NSN roles for the 21st century focus on 3 major areas: clinical practice, academia/research, and entrepreneur/industry, along with specialty emphasis in geriatrics, obesity, surgical specialties, wound ostomy care, pediatric or neonatal care, solid organ transplantation, and infection control.4 NS nurses have been leaders in providing interprofessional nutrition support education, long before the development of interprofessional education standards.17 Since NS nurses work collaboratively with other disciplines across the continuum of care, they play a pivotal role in providing formal and informal education to the interdisciplinary healthcare team. NS nurses interested in demonstrating a commitment to advancing one's knowledge and skillset can opt to obtain certification as a certified nutrition support clinician (CNSC).10 The certified nutrition support nurse (CNSN) credential was retired in 2012 as the National Board of Nutrition Support Certification ruled that due to the interdisciplinary aspects of nutrition support science and practice, one certification would be offered.10 NS nurses may hold a certification in related nursing specialties such as wound care, infusion therapy, vascular access, and home care, and they can also hold nutrition-related certifications such as diabetes education or lipid management. Although experts have called for more nutrition training in the health professions,14,18 the actual number of nutrition support nurses in the United States has decreased over time based on survey data of nurse members of ASPEN in the 1980s and repeated in 2002.4 Potential reasons for the decline in nurse members include decreased number of nurses working due to retirement and other reasons, the attrition of nutrition support teams, and the expanding roles of nutrition support nurses to include wound care, vascular access, and infusion nursing.4 Recent data derived from the ASPEN membership database demonstrate that the number of nurse members has remained relatively stable over the past decade. Of those nurses, 28% are nurse practitioners (NPs) and 38% are Master's prepared. The number of doctorally prepared nurses has tripled from 2002.4 Nine percent of the nurse members are international nurses, with several each from Canada, Belgium, Colombia, and Brazil. As far as certification, 28% are certified, either in nutrition support or in other areas such as critical care or infusion nursing. There was a large variety of job titles reported by the nurses, including clinical educators, nurse practitioners, nutrition support clinicians, managers, and university professors. Specialty areas as reported include Nutrition Support/Clinical Nutrition (30%), Other (30%), Adult and Pediatric GI (16%), Surgery/Critical Care/Trauma (9%), Infusion Therapy (5%), and Pediatrics/Cardiology/Geriatrics/Internal Medicine/Weight Management (6%). Employment settings included 48% in hospital settings, 24% other, 12% in home care, 8% in a university setting, and 8% in industry. ASPEN defines a standard as a "benchmark representing a range of performance of competent care that should be provided to assure safe and efficacious nutrition care."19 It outlines in detail professional responsibilities as they relate to patient assessment, education, care plan development, implementation, clinical monitoring, evaluation, and professional issues. ASPEN publishes discipline-based standards (eg, physician, dietitian, nurse, or pharmacist) and practice-based standards (eg, adult hospitalized patients, pediatric hospitalized patients, home care, and long-term care). ASPEN has published NSN standards for over 30 years. However, due to the recent national call to action to revisit the crucial role that health professionals, including nurses, play in promoting nutritional health and well-being across the life span14,18 and the incorporation of malnutrition as a national goal,20 the NSN Standards of Practice Taskforce advocated for the introduction of differentiated levels of nutrition-related nursing practice. The 2016 standards are adapted from the framework presented in the American Nurses Association's Nursing: Scope of Standards of Practice, 2nd Edition.21 The audience for the standards includes the generalist registered nurse (RN), the advanced practice registered nurse (APRN), and the NS nurse specialist who is either an RN or an APRN. Nutrition is an important concept of nursing practice. Nutrition is found in 1 of 13 domains of practice and is defined as "the activities of taking in, assimilating, and using nutrients for the purposes of tissue maintenance, tissue repair, and the production of energy."21 The RN and APRN practice across the continuum of care and are responsible for incorporating the nutrition domain into nursing practice. While the ANA's Standards of Professional Nursing Practice provide the "authoritative statements of the duties all registered nurses are expected to perform competently,"22 this document demonstrates, where applicable, the context of the "nutrition domain" for the RN or APRN who is not an NS nurse specialist. The NS nurse is either an RN or APRN who is competent and practices in the specialty of nutrition support. This nurse specialist incorporates this body of knowledge into clinical practice regardless of setting and synthesizes the multidimensional aspects of nutrition and the varied individual responses to nutrition as influenced by age, sex, culture, or socioeconomic status. ASPEN has developed these standards as general guidelines for the NS nurse specialist (RN and APRN) and the generalist nurse (RN and APRN). These standards represent an update of a similar 2007 set of standards from ASPEN.23 The application of these standards and competencies in any individual case should be determined by the individual's position, education, practice environment, and the best judgment of the nutrition support nurse. Competencies are presented for each standard in Tables 2 and 3. While the list of competencies is not exhaustive, the competencies provide evidence of suggested compliance with the corresponding standard.22 The Standards of Practice represent a range of competencies that should be provided by any RN, APRN, or NS nurse (within or outside the context of a formal nutrition support service or team). The application of standards in any individual case should be determined by the best judgment of the nurse. The standards are presented in the most generic terms possible. The details of patient care are left to the discretion of the individual RN, APRN, NS nurse, healthcare professionals, nutrition support services or teams, or institution. The standards aim to ensure sound and effective nutrition care for patients in all healthcare settings in need of nutrition support therapy. These standards of practice for nurses do not constitute medical or other professional advice and should not be taken as such. The information presented in these standards is not a substitute for the exercise of judgment by the healthcare professional, which takes precedence over these standards. These standards have been developed by the ASPEN Nurses Standards Revision Task Force, reviewed by the ASPEN Clinical Practice Committee and nutrition support nurse content experts, and approved by the ASPEN Board of Directors. These standards shall be used in conjunction with the previously published ASPEN Clinical Guidelines, Standards, Position Papers, and other Board-approved documents, which can be accessed at the ASPEN Documents Library: http://www.nutritioncare.org/Clinical_Practice_Library/. The standards are divided into 2 sections: Standards of Practice and Standards of Professional Performance, in congruence with the American Nurses Association's Nursing: Scope and Standards of Practice, 2nd edition.22 The Standards of Practice include assessment, diagnosis, outcomes identification, planning, implementation (including coordination of care, health teaching and health promotion, consultation, and prescriptive authority), and evaluation.22 An introduction to these 6 standards is provided below, and the associated competencies are detailed in Table 2. Assessment is the cornerstone of nursing practice. Nurses collect comprehensive data, including nutrition data, pertinent to the patient's health.22 A nursing diagnosis is a clinical judgment about individual, family, or community responses to actual or potential health problems/life processes. A nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable. The North American Nursing Diagnosis Association has developed nursing diagnoses, and many are nutrition related.21 While many professions have their own set of diagnoses, nurses should practice at the top of their scope by using the nursing diagnoses. Nurses identify expected outcomes for a plan individualized to the patients and their family or caregiver requiring nutrition interventions (including dietary enhancements or restrictions, parenteral and/or enteral nutrition, and associated access devices) during an episode of care.22 Planning focuses on developing prescribed strategies and alternatives to attain expected outcomes.22 Nurses collaborate with other healthcare professionals, the patient, and caregiver(s) in the development of an individualized care plan that includes nutrition-related strategies and outcomes.22 The nutrition care plan is age, developmental, culturally, and ethnically appropriate.22 The optimal nutrition care plan utilizes resource-efficient and economic care to keep the patient comfortable and appropriately nourished and hydrated.22 The plan also keeps the patient, caregiver(s), and healthcare professionals knowledgeable about the nutrition process and ongoing goals. Implementation focuses on execution of the identified plan and includes coordination of care delivery, health teaching, and health promotion.22 Evaluation focuses on appraising the patient's progress toward attainment of outcomes.22 The nurse collaborates with members of the healthcare team, including the nutrition support team, the patient, and caregivers, to monitor and evaluate the patient's clinical condition, including the effectiveness and appropriateness of nutrition therapy as well as access devices, and progress toward attainment of expected outcomes. The Standards of Professional Performance include ethics, education, evidence-based practice and research, quality of practice, communication, leadership, collaboration, professional practice evaluation, resource utilization, and environmental health. An introduction to these 10 standards is provided below, and the associated competencies are detailed in Table 3. Nurses at all levels are expected to practice ethically,22 in accordance with the Code of Ethics for Nurses With Interpretive Statements.16 Ethical principles are very important when initiating or commencing parenteral or enteral nutrition support. In addition to the Code of Ethics for Nurses,16 ASPEN's Ethics Position Paper24 should also be used to guide practice related to specialized nutrition support. Education refers to the nurse's attainment of knowledge and competence that reflects current nursing practice.22 For all nurses, current nutrition therapies and the nurse's role in nutrition screening and assessment can be incorporated into the requisite knowledge and competence for practice. Nurses at all levels are expected to integrate evidence and research findings into practice, including nutrition evidence and research.21 Nurses at all levels are expected to contribute to quality nursing practice, which includes nutrition-related nursing practice.22 Nurses at all levels are expected to communicate effectively in a variety of formats in all areas of practice.22 Effective communication is essential for the nutrition support nurse when serving as a consultant, collaborating with the nutrition support team, and interacting with patients, caregivers, and policy makers. Nurses at all levels are expected to demonstrate leadership in the professional practice setting and the profession.22 Nurses at all levels are expected to collaborate with the patient, family, and others in the conduct of nursing practice, including nutrition-related aspects of nursing practice.22 Nurses at all levels are expected to evaluate their own nursing practice in relation to professional practice standards and guidelines, relevant statutes, rules, and regulations, including those related to nutrition.22 Nurses at all levels are expected to utilize appropriate resources to plan and provide nursing services that are safe, effective, and financially responsible, including nutrition-related nursing services.22 Nurses at all levels are expected to practice in an environmentally safe and healthy manner, including the provision of nutrition-related care activities.22

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