Expanding perspectives on professionalism in dietetics

Professionalism is highly regarded and valued in how dietitians practise, yet it has been a topic of limited scholarly research and discourse until recently within our profession.1, 2 While professionalism and professional practice have been articulated in broad terms in competency standards in Australia and internationally to support education of dietitians, it has been considered difficult to define and understand. Within dietetics education more specifically, teaching and assessing professionalism has been described as challenging and one of the hardest of the competency areas to assess, and has been associated with a discomfort articulated by educators because of the perceived subjectivity of professionalism.1-4 I propose this has been influenced and impacted by the way that professionalism has been considered within the context of the sociocultural and historical development of our profession. It is both timely and pertinent to consider new ways of understanding and applying dietetics professionalism as our profession evolves and expands into the 21st century, as highlighted by several papers in this issue of Nutrition & Dietetics. It is of value to strengthen and diversify our understandings and applications of professionalism within the profession moving forward. The historical development of the dietetics profession in Australia and other Western countries (New Zealand, Britain, Canada and the United States of America) over the past century has been founded in, and has privileged, scientific knowing. The scientific approach has informed research, education and practice and has provided solid and rigorous foundations for the profession to prosper and expand, and has ‘legitimised’ our profession within modern healthcare.5 However, it is important to consider that a scientific approach typically is aligned with positivist/post-positivist epistemologies (ways of knowing) and positioning (which includes viewing knowledge as objective, looking for a single truth, valuing objectivity, keeping distance etc.).6, 7 This influences ‘what’ is valued and taught in curricula, ‘how’ we are taught and learn, ‘what’ we come to value and privilege, and subsequently, ‘how’ we practice, socialise and acculturate others into the profession. The ‘what’ and ‘how’ of dietetics practice become important areas of focus. As other insiders in the profession have written, by privileging scientific approaches it limits our capacity to fully understand and appreciate ‘all complexities influencing nutrition in the social world’.6 The scientific paradigm has also impacted the ways in which professionalism has been approached in dietetics – with a desire for discrete definitions to apply across the profession, and for markers and measures of professionalism that are objective and easy to measure.1, 2 Dietetics professionalism does not fit neatly nor is easy to understand or apply when using a scientific approach. Perhaps aligned with medicine, definitions of professionalism have been described as being ‘grounded but also stuck in a background of Western, White, heteronormative view of society and the professions of the past’.8 Moving forward now and into the future, it is important to expand our understandings and applications of professionalism in practice, and approach it using an interpretive, rather than a scientific, lens. Professionalism cannot be neatly or succinctly defined, nor should we try to, if it is to have resonance and meaning across the diversity of dietetics practice. Professionalism is a socially constructed concept, it is multi-dimensional, and it changes across time and place, being influenced by culture and context.1, 2 While professionalism is a cornerstone of safe and effective healthcare and practice, it is important to acknowledge that dietetics professionalism means different things across the landscape of dietetics practice9 and the complex, social and uncertain worlds we work and learn within.10 If we are to expand and develop shared understandings of dietetics professionalism and to teach and manages lapses in professionalism, it is imperative that we create space and be open to discuss, debate, and interrogate our underpinning assumptions around dietetics professionalism.8 For example, white [middle class] norms have been the dominant reference standard for what is considered professional.11 Frameworks conceptualising professionalism in dietetics1, 2 can assist in guiding discussions to explore (and teach) professionalism, and to clarify and articulate professional expectations. We need to expect that professionalism will vary across the landscape of dietetics practice – dietetics professionalism in a rural community nutrition context will likely vary to professionalism expectations in an intensive care/high acuity context etc. Neither is more correct or ‘true’ (the scientific approach to viewing professionalism), rather professionalism needs to be ‘culturally compatible and emotionally intelligent to the needs of each society’.8 Invigorating conversations about professionalism in local and broader contexts, by engaging with a range of stakeholders, will support expanding perspectives and respect for diversity of practice. There is an emerging literature encouraging reflexivity and critical consideration of established ways of doing and being, towards a more diverse profession and considering the sociocultural aspects within the profession.5, 9, 12, 13 In this issue, the paper by Boak et al.14 outlines the need for cultural shifts and change, and for reinvention within the profession. Their paper presents an insightful exploration of the future of nutrition and dietetics in Australia and New Zealand, and relevant workforce implications. This includes descriptions of expanding and future dietetics roles and capabilities required for moving forward including curiosity, creativity, empathy, embracing and harnessing diversity, cultural safety and disrupting expertise.14 These capabilities are aligned with contemporary dietetics professionalism and necessitate expanding paradigms and ways of thinking, educating and being. Similarly, other papers in this issue, by Blair et al.,15 Croxford et al.,16 Kelly et al.17 and Kirkegaard et al.18 all speak to an expanding requirement to more explicitly educate graduates in the ‘art’ of practice – equipping nutrition and dietetics graduates for employability in diversifying roles, in navigating uncertainty and complexity, and developing the critical capabilities Boak et al.14 describe. This will require ongoing cultural change (and involve learning and unlearning), and philosophical shifts within the profession. Cultural change and attention to sociocultural factors are required across the profession beginning with the education of our future dietitians.9, 19, 20 Sociohistorical systems of educating dietitians in Australia have developed predominantly through the scientific paradigm, and have been influenced by colonialism and the profession's dominant middle-class, white, female history.5, 14 New education approaches are required in dietetics education; where space is created for critical pedagogies and discourse, and a ‘re-privileging’ of the art of dietetics practice. We need to stop referring to the more complex aspects of practice as ‘soft skills’ – rather invest in conversations and critical inquiry, unpacking and exploring these more complex and nuanced aspects of practice, and develop shared understandings and respect for difference. This requires humility and reflexivity at an individual level, and disruption of power and established hierarchy within education practices and systems more broadly. Examples of dietetics curricula content to support critical inquiry include teaching and learning about colonisation, anti-racism, gender and gender diversity, disordered eating, weight, and exploring implicit and explicit bias. Further, we need to be including and/or amplifying lived expertise and perspectives within dietetics education programs. For example, asking patients and other healthcare consumers about their perspectives of dietetics professionalism. Are we on the same page? Critical analysis can be further applied and integrated into our education and practice – for example, reviewing the narratives represented in our content and assessment – do they champion diversity? It is also important to critically reflect on and consider our terminology and language, our behaviours, and sociocultural practices in university and workplace settings. What are the hidden messages we are transmitting? Are we actively supporting or hindering professional socialisation and transitions? We need to foster a professionalism in dietetics that reflects an internal set of values, including being embracing of diversity, and an authentic commitment to social and racial justice; rather than being something that is performative and externally motivated.11 It seems there are numerous influences and signals, including the supporting evidence published in this issue of Nutrition & Dietetics, indicating that now is an important time for reinvention and cultural change within our profession looking forward into the 21st century. This is essential if we are to expand, fulfilling new roles moving forward, and truly meeting the needs of our diverse population. Boak et al.14 and others have highlighted that significant cultural shifts and change are required within the profession and while complex interventions are required to support cultural change, this begins with developing a professional culture of learning and comfort with uncertainty. It is easy to become overwhelmed with the complexity of it all, but the impetus and capacity for change begins with every one of us at a personal and individual level and we need to work together in our local contexts to support cultural shifts. It is up to us as members of the profession, to be reflexive and commit to change. This is an active process, expanding our perspectives and practice, and challenging historical ways of doing and being as we embrace more interpretive and critical approaches and step into conversations in some of these more complex spaces. This includes shifting our focus more to the art of practice, and paying more attention to the sociocultural factors within our profession and our education systems, including how we support transitions and socialisation into the profession.9 It seems particularly apt to consider expanding professional perspectives in the year that the profession lost one of its great pioneers, Peter Williams OAM, who wrote about the ‘limits to what is regarded as acceptable difference’ in the profession only a decade ago.21 To fully embrace diversity moving forward, the profession ‘must reckon with its historical roots and step forward’5 and expand the limits on what has been considered ‘acceptable difference’. This requires reinvention and reshaping our ways of thinking, doing and being.

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