Jurisprudence Handbook

The Jurisprudence e-Learning Module is a component of the Nova Scotia Dietetic Association’s (NSDA) mandatory Continuing Competency Program (CCP).  The aim of the Module is to support dietitians to maintain a current understanding of the regulatory, provincial and federal requirements related to dietetic practice.  The legal principle ‘ignorance of the law excuses no one’ means that a person who is unaware of a law may not escape liability for violating that law merely because they were unaware. The Module provides dietitians with information related to laws, standards and guidelines that govern dietitians’ practice, such as the Professional Dietitians Act, standards and policies, the code of ethics, and provincial and federal legislation.


Self-regulation

In Nova Scotia, the dietetics profession is regulated according to the Professional Dietitians Act (1989). Health professions are regulated provincially, rather than nationally. The Nova Scotia Dietetic Association (NSDA) is the dietetic regulatory body in Nova Scotia. Dietetic practice is regulated in the public interest. Regulation assures the public that their practitioner is accountable for meeting regulatory requirements, and that there is somewhere for them to go if they experience poor quality care or harm that results from a dietitian’s actions. In contrast to non-regulated practitioners, regulated professionals are accountable to meet regulatory requirements based in legislation, regulations, standards of practice, a code of ethics, and policies.

To meet its mandate, NSDA follows a well-established regulatory framework. An act (also known as legislation or a statute), bylaws and policies direct the governance and operations of the organization. Government approves an act. Bylaws elaborate on statements within the act and are developed by the board of directors and approved by NSDA’s registrants. Policies elaborate on statements within the act or bylaws. Bylaws and policies can not contradict what is stated in the act, but further define and elaborate on the statements within the act.

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The act, bylaws and policies direct a regulatory body’s four core functions: registration, continuing competency, professional practice, and complaints. This Guide will now elaborate on the regulatory requirements related to each of the four functions.

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 Registration

Once licensed with NSDA, a registrant is authorized to use the titles dietitian or nutritionist in Nova Scotia. To use the titles and practice as a dietitian in another province, a dietitian must become registered in the other province. Dietitians practising in more than one province must be registered with the dietetic regulatory body in the province(s) where they practice. Dietitians can be registered in more than one province.

If practicing by electronic means (e.g. telephone, internet or email counselling), the dietitian must adhere to the Virtual Practice Policy. Some provinces require the dietitian to be licensed in the province where the client lives when practicing by electronic means. In Nova Scotia, dietitians registered with another provincial regulatory body may provide services by electronic means to Nova Scotians.

Dietitians must practice under the name registered with NSDA. To practice under a different name, the dietitian must provide evidence of the name change (e.g. marriage certificate). The database (also known as the register) must contain dietitians’ current information. A registrant's online profile can be updated through the Online Renewal System any time throughout the year.

Once a dietitian resigns from NSDA, they must apply to NSDA for reinstatement. If they are registered in good standing in another province at the time of application, they are eligible for reinstatement. If they are not registered with another provincial dietetic regulatory body at the time of application, the Registration Committee will assess eligibility for reinstatement. Upgrading may be required. If they have not written the Canadian Dietetic Registration Examination (CDRE), they will be required to write the CDRE.


 Protection of Title

NSDA serves and protects the public interest by protecting the profession’s professional titles, dietitian and nutritionist. Title protection enables the public to understand that those who use such titles have specific credentials, education, training, and continued competence approved by a regulatory body and is subject to the oversight of a regulatory body. Protected titles provide clarity to the public about the qualifications of the individual who is providing services.

Section 12(2) of the Professional Dietitians Act (1989) states : “A person not licensed under this Act who is not qualified for membership in the Association may not use any of the following titles or designations: "Dietitian" or "Dietician", "Dietitian-Nutritionist", "Nutritionist", "Professional Dietitian" or "Professional Dietician", "Professional Dietitian-Nutritionist", "Professional Nutritionist", "Dietetiste", "Dietetiste-Nutritionniste", "Dietetiste Professionelle", "Dieteticienne", "Nutritionniste" or the initials "P.Dt." or "Dt.P." either alone or in combination with other words, letters or descriptions.”

NSDA contacts those using the protected titles and advises them to cease using the title and apply to NSDA if they have the qualifications to be registered as a dietitian in Nova Scotia.


 Regulatory Tools

NSDA sets standards of practice to both support dietitians in their practice and regulate dietetic practice. Entrance standards ensure that those entering the profession practice in a competent1 and ethical manner. NSDA has established entry-level standards of practice (Integrated Competencies for Dietetic Education and Practice) and standards of ethical practice (Nova Scotia Code of Ethics for Professional Dietitians). Standards of practice describe competent, collaborative, ethical and safe practice in a broad manner to be applicable to dietitians in multiple practice areas and settings. Yet standards are sufficiently specific to set the standard against which performance can be measured in a complaints process (NSCMLT, 2016).

Additional regulatory tools that serve to regulate and support practice include policies, position statements and practice guidelines. Dietitians are accountable to know and comply with standards and policies. Standards and policies direct practice and define the overall requirements and expectations for dietitians when performing a specific activity. Guidelines are recommendations endorsed by the NSDA board of directors.

1Competence - the ability to integrate and apply the knowledge, skills and judgement required to practise dietetics safely and ethically in a designated role and practice setting and includes both entry-level and continuing competencies (Dietitians Act, 2009).

Below is a table that outlines regulatory tools and provides examples of relevant documents and examples. 

Regulatory Tool Relevant Documents Examples
Standards of Practice                                            Integrated Competencies for Dietetic Education and Practice
Nova Scotia Code of Ethics for Professional Dietitians
A dietitian shall involve the patient and/or alternate decision maker in all decisions related to the nutrition care process.
Position Statement Use of Social Media in Practice
Position Statement on the Recommendation, Endorsement, and Sale of Products
Dietitians must be honest, transparent, objective, and use an evidence-based approach when recommending, selling or endorsing products or product lines.
Policy Virtual Practice Policy
Extension of Continuing Competency Program Submission Due to Illness
Dietitians providing or offering to provide services via electronic means across borders must inform clients of the jurisdiction(s) where they are registered and limitations of e-practice.
Guidelines Documentation Guidelines
Guidelines for Self-Employed Dietitians and Nutritionists 
A dietitian documents an interaction with a client within 24 hours.

 

 

 

 

 

 

 

 

 

Reference:  The Nova Scotia College of Medical Laboratory Technologists (2016). Professional Practice for Medical Laboratory Technologists in Nova Scotia.


 Code of Ethics

A dietitian accepts the obligation to protect clients, the public, and the profession by upholding the Code of Ethics. The Code of Ethics for Professional Dietitians is a statement of the ethical commitments of dietitians to those they serve. It has been developed by dietitians for dietitians. It outlines the numerous roles played by dietitians and the ethical standards by which dietitians are to conduct their practice. It gives guidance for decision making, serves as a means of self-evaluation, and provides a basis for feedback and peer review. This code outlines what professional dietitians must know about their ethical responsibilities, informs other health care professionals and the public about ethical commitments and fulfills the responsibilities of a self-regulating profession.

The Code of Ethics addresses ethical principles, including:
- client-centred practice
- confidentiality and privacy
- duty to report
- consent1
- professional boundaries
- appropriate and secure documentation, and
- conflict of interest2

1Consent – agreement to allow something to happen
Informed consent – the person fully understands what they agree to 
Express consent – consent that is given very clearly and definitively
Implied consent – not expressed definitively, but communicated by word or action.
2Conflict of interest – occurs when, in the mind of a reasonable person, a dietitian has a personal interest that could improperly influence their professional judgement (Steinecke and CDO, 2015).

Resource for information on ethical principles: College of Dietitians of Ontario Jurisprudence Handbook

Ethical principles are also addressed in legislation.  Below is a table that outlines the ethical principles addressed in legislation. 

Ethical Principle Relevant Act or Policy
Duty to Report                                                                                                                                            

The Health Protection Act addresses mandatory reporting of adult abuse, physical, emotional, or sexual abuse, or neglect of an adult; an adult living in dangerous circumstances and unable to protect him or herself.

The Adult Protection Act (section16) provides a means whereby adults who lack the ability to care and fend adequately for themselves can be protected from abuse and neglect by providing them with access to services which will enhance their ability to care and fend for themselves or which will protect them from abuse or neglect.

The Children and Family Services Act(sections 23, 24 and 25) protects children from harm. It includes mandatory reporting of child abuse, emotional, or sexual abuse, or neglect of a child.

Protection for Persons in Care Act (section 5): Health care providers are responsible to protect vulnerable clients and report any concerns they may have in relation to the treatment of a client.

Confidentiality and Privacy                                             

Nova Scotia Personal Health Information Act (PHIA) governs the manner in which personal health information may be collected, used, disclosed and retained within the health care system in Nova Scotia. It provides a framework that strikes a balance between the protection of personal health information and the collection, use and disclosure of personal health information within (by) the health care sector to deliver and improve health care services.

The Personal Information Protection and Electronic Documents Act (PIPEDA) is the federal privacy law for private-sector organizations. It sets out the ground rules for how businesses must handle personal information in the course of commercial activities.

The Freedom of Information and Protection of Privacy Act (FOIPOP) focuses on public bodies being fully accountable to the public while protecting the privacy of individuals. It sets out mandatory requirements relating to personal information held by public bodies and requires that public bodies protect the confidentiality of personal information, and the privacy of the individual who is the subject of that information.

Consent

Nova Scotia Personal Health Information Act (PHIA)

Personal Directives Act (section 18): Health care providers are required to ensure they seek and receive informed consent from the appropriate person and consult with the appropriate decision maker when developing care plans.

The Hospitals Act addresses capacity and consent.

 

 


Privacy and Confidentiality

Clients trust their health care providers to protect their privacy and to keep their medical records confidential. The Nova Scotia Personal Health Information Act (PHIA) lays out the expectations of health care providers. All information encountered about a client is confidential, including birthdate, address, information they share during their service, medical history, and even the fact that they were a client at a particular clinic or hospital. Information can be shared with other members of the client’s health care team.

PHIA’s definition of a custodian includes a regulated health care professional or a person who operates a group practice of regulated health professionals. A district health authority and the Isaak Walton Killam Health Centre are custodians. To be a custodian under PHIA, those individuals or organizations listed in the Act (section 3(f)) must also have custody or control of the personal health information. Custodians have specific responsibilities to the individuals whose information they hold. Refer to the Toolkit for more information about these duties.

The PHIA Toolkit’s chapter on CONSENT, CAPACITY, AND SUBSTITUTE DECISION-MAKERS addresses the concept of circle of care.

The following are examples of a breach of patient privacy:
-Accessing medical information about a friend or family member without a professional reason to do so.
-Informing a colleague or friend that someone they know has had an encounter of any kind with the health care system.
-Asking someone about their visit to an emergency department or clinic after learning of their visit through one’s professional role.
-In a professional capacity, requesting personal information that is not required.

The storage of personal information in an electronic age presents unique considerations. Travelling with personal information also presents a risk of a breach of privacy. The following are precautions which may be taken to prevent a breach.
-Encrypt data on electronic devices; safeguard encryption keys
-Enable password protection on electronic devices; safeguard passwords
-Avoid use unsecured WiFi networks
-Avoid the use of public computers to access sensitive data
-Use locks and keys whenever possible
-Avoid working in public places where others can view information
-Avoid carrying personal information outside of the workplace
-Avoid downloading documents to personal public computer / use of i-cloud/Google Drive or private server
-Email – use confidentiality signature/privacy statement, secure email, not using personal email for work, reply to messages rather than initiating email, password protected email and attachments.

PHIA outlines the procedure to follow if there has been a privacy breach.

PHIA focuses on the collection, use, disclosure, retention, disposal and destruction of personal health information. The Toolkit provides essential information for custodians of healthcare information.

Reference: The Nova Scotia College of Medical Laboratory Technologists (2016). Professional Practice for Medical Laboratory Technologists in Nova Scotia.

 


Consent for Treatment

Health care professionals must continually communicate with patients and patients must continue to willingly consent to their care. Without this, there is no informed consent. Informed consent must be ongoing.

Consent should be obtained from clients or substitute decision-makers whenever dietitians are recommending a nutritional therapy (e.g. therapeutic diet, tube feeding or TPN). While a signed consent form from a client may be desirable, it is not necessary. What really matters is that there is evidence that a client was given the necessary information and provided consent. Simply recording the fact that consent was obtained after a discussion with a client, and it appeared to the dietitian that the consent was genuine and informed, is often sufficient. Both a signed consent form and a dietitian's note in a chart documenting consent are legally recognized ways of demonstrating that actual consent was obtained. Dietitians should also consult organizational policies to determine if there are any facility protocols for documenting consent.

The role of the practitioner is to provide information and make recommendations that will enable clients to make informed decisions. A dietitian must be sensitive to and respect any wishes from a client to withdraw consent. However, withdrawal of consent should be informed. The client should reasonably understand the foreseeable consequence and risks to withdrawing consent and be informed of alternatives to the proposed treatment.

PHIA addresses consent for the collection, use and disclosure of personal health information in Nova Scotia.

References: The College of Dietitians of Ontario (2015). The Jurisprudence Handbook for Dietitians in Ontario (pg. 75) and The Nova Scotia College of Medical Laboratory Technologists (2016). Professional Practice for Medical Laboratory Technologists in Nova Scotia.

 


Conflict of Interest

A conflict of interest is anything that could affect one’s impartiality in practice, or tempt one to compromise their professional ethics. It occurs when an individual or organization is involved in multiple interests where one could possibly influence the other. It is the appearance of a conflict of interest that matters. A dietitian’s intentions and actions may be entirely honorable, but if others perceive that there is a conflict of interest, then there is one.

Potential situations where a dietitian may be tempted to put someone (e.g. self or friend) other than the patient first:
-Using personal status or influence for gain (e.g. endorsement of a friend’s service)
-Conferring a benefit (e.g. referral to a friend’s service)
-Receiving a benefit (e.g. receiving a gift from a sales representative)
-Selling products for profit (see Position Statement on the Recommendation, Endorsement and Sale of Products).
-Interactions with clients that go beyond professional duties raises the possibility that the dietitian is receiving a benefit for something offered or taking unprofessional advantage of their position (e.g. using a client’s personal belongings)
-Incentives (e.g. coupon)
-Personal beliefs or convictions (e.g. treating a client differently because of religious or moral belief)

A conflict of interest may be managed through DORM. DORM is an acronym that describes safeguards used to manage a conflict of interest. Some conflicts should not be managed through DORM, but avoided all together.

Disclosure
-Openness and transparency with the client or relevant other(s) about the nature of the conflict and of any potential benefit.
Options
-Providing a client with options to ensure an informed choice.
Reassurance
-Reassuring the client that their choice will not impact the quality of services you provide.
Modification
-A modification may remove or reduce the potential for conflict.

References: CDO Jurisprudence Handbook (chapter 9) and The Nova Scotia College of Medical Laboratory Technologists (2016). Professional Practice for Medical Laboratory Technologists in Nova Scotia.

Resources: Conflict of Interest and RD Practice (CDO) and Conflict of Interest in Dietetic Practice: How to Handle Competing Interests (CDO)

 


 Scope of Practice

Regulated professions define their profession’s scope of practice1 in legislation. Standards of practice also describe the dietetic scope of practice.

Both standards of practice (ICDEPs) and standards of ethical practice (code of ethics) state that dietitians must practice within their individual scope of practice2 and recognize and address situations beyond personal capacity by consultation, referral or further learning (ICDEP 1.04).  A professional’s scope of employment is set by the employer.

Practice Illustration: A public health nutritionist delivers presentations at family resource centres on general nutrition guidelines. A member of the public asks the nutritionist a question about her infant who has gastrointestinal reflux. Replying to this question is within the professional scope of practice, but the nutritionist does not have the current knowledge to provide nutrition counselling for this scenario. It is also not her employer’s expectation for her to provide one-on-one counselling for medical conditions. This is an example of a scenario that is within the dietetic scope of practice, but not the dietitian’s individual or employment scopes of practice.

It is essential to recognize when an activity is out of one’s individual scope of practice and refer to another qualified health care professional.

It is essential to understand the scopes of practice of interprofessional team colleagues, respect where they overlap with the dietetic scope of practice, and collaborate effectively to provide optimal patient care.

Practice Illustration: A dietitian works within a primary health care clinic with a speech language pathologist (SLP), physician and physiotherapist. The dietitian’s client is reporting signs of dysphagia. The dietitian does not have current knowledge or skills to perform a bedside swallowing assessment, although the SLP has the ability. Although this activity falls within the dietetic scope of practice, the dietitian must refer her client to the SLP and collaborate with the SLP to develop, implement and monitor the nutrition care plan.

There are activities that health professionals perform that are considered within the public domain. These are activities that non-regulated professionals may perform. For example, providing information about healthy eating guidelines, taking a person’s blood pressure, or measuring a person’s height and weight.

Practice Illustration: A dietitian with recent experience practising in an acute care hospital as a clinical dietitian accepts a position as a continuing care coordinator. Clients often ask questions about nutritional concerns. Whereas the dietitian has the current knowledge and skills to answer clients’ nutrition-related questions, it is not within her job description. This is an example of the activity falling within both individual and professional scopes of practice, but not within the employment scope of practice.

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1 Professional scope of practice - Scope of practice of the profession - the roles, functions and accountabilities that dietitians are educated and authorized to perform (Dietitians Act, 2009).

2 Individual scope of practice - the roles, functions and accountabilities that an individual is educated and authorized to perform (Dietitians Act, 2009).

Note: The Dietitians Act (2009) was approved in 2009, but is not yet in effect.


Continuing Competency

The Continuing Competency Program (CCP) is a regulatory tool to support dietitians to maintain and enhance their competence to practice dietetics. The CCP was developed to reflect NSDA's vision, mission and values. The primary responsibility for maintaining competence rests with the dietitian, as outlined in the Code of Ethics for Professional Dietitians, however employers and the regulatory body are also accountable. Dietitians’ initial training is thorough and rigorous; lifelong learning is essential for maintaining competence and keeping abreast of changes applicable to an individual’s practice. The purpose of the CCP is not to determine whether a dietitian is competent; it is a proactive approach to continuing competence1 to promote safe, ethical and competent practice through lifelong learning.

Relevant publications:
Extension of the Submission of the Continuing Competency Program Due to Illness
Continuing Competency Program Toolkit


Complaints

NSDA addresses complaints made about a dietitian’s practice. The Act and policies prescribe a process to address the complaints fairly and objectively. Complaints may address incompetence1, incapacity2, or misconduct.

Standards of practice describe competent, collaborative, ethical, and safe practice applicable to dietitians in multiple practice areas and settings. Standards set the minimum expectation which performance can be measured in a complaints process.

Upon receipt of a written complaint, NSDA informs the dietitian about the complaint and requests a written response. The complaint is investigated. Unless the complaint is deemed frivolous or vexatious, the complaint is assessed by the NSDA board of directors. The Board oversees and facilitates an evidence-based, objective, fair, and timely complaints process.

Practice illustration:  

Mrs. Jones sent a written complaint to NSDA about a dietitian named Sally. Mrs. Jones was concerned about the nutritional care Mr. Jones received while admitted for respite in a long-term care facility. While at the facility, Mr. Jones developed an infection and lost weight over a period of two weeks. She believed the dietitian did not develop a nutrition care plan that would have provided enough nourishment.

NSDA sent the written complaint to Sally and asked for a written response. The competencies of care were identified that Sally may have failed to meet.

Assess nutrition-related risks and needs
Develop nutrition care plans.
Manage implementation of nutrition care plans
Evaluate and modify nutrition care plan as appropriate.

NSDA obtained and reviewed Mr. Jones’ medical chart, and interviewed Mr. and Mrs. Jones, and the patient’s physician.

The investigation revealed that the nutrition care assessment and care plan were appropriate, and that the dietitian had appropriately monitored and evaluated the intervention. The dietitian had documented her actions to address that the patient failed to consistently receive the high energy high protein nutritional supplements as ordered.

A panel of the NSDA board of directors who had never worked with Sally nor had any potential bias, assessed the investigation’s findings. They did not find Sally to be incompetent in her practice. The facility was advised of the findings and recommendations to the facility were made.

A written decision was provided to both Mrs. Smith and Sally that outlined the reasons for the board’s decision.

1 Incompetence - the display of lack of knowledge, skill or judgement in the respondent's care of a patient or delivery of dietetic services that, having regard to all the circumstances, rendered the respondent unsafe to practise at the time of such care of the patient or delivery of dietetic services or that renders the respondent unsafe to continue in practice without remedial assistance (Dietitians Act, 2009).

2 Incapacity - the status whereby a respondent, at the time of the subject-matter of a complaint, suffered from a medical, physical, mental or emotional condition, disorder or addiction that rendered the respondent unable to practise with reasonable skill or judgement or that may have endangered the health or safety of patients (Dietitians Act, 2009).


Federal and Provincial Legislation Relevant to Dietetic Practice

In addition to the legislation sited thus far within the Module, there is other federal and provincial legislation that relates to the practice of dietetics.

Federal Legislation

The Controlled Drugs and Substances Act describes how the Canadian Government controls certain drugs, their precursors, and other substances. The Act details eight Schedules.

The Food and Drug Act authorizes Health Canada to establish standards for safety and nutritional quality for all food items sold in Canada to protect Canadians against products that make false nutrition related claims through inaccurate packaging, labelling and advertising. The need for sanitary production, preparation, preparation and storage facilities is also addressed. Ensuring accurate labelling allows dietitians to trust that their clients are consuming safe nutritious foods and that the nutritional information on the label can be used as part of their counselling. The Canadian Food Inspection Agency enforces this Act.

The Canadian Human Rights Act was established to extend the law to ensure that all individuals should have an opportunity equal with other individuals to make for themselves the lives that they are able and wish to have and to have their needs accommodated, consistent with their duties and obligations as members of society, without being hindered in or prevented from doing so by discriminatory practices based on race, national or ethnic origin, colour, religion, age, sex, sexual orientation, gender identity or expression, marital status, family status, genetic characteristics, disability or conviction for an offence for which a pardon has been granted or in respect of which a record suspension has been ordered.

Provincial Legislation

The Occupational Health and Safety Act is legislation based on the assumption that employees and contractors share the responsibility of safe workplace environments with the employer or owner of a workplace. The Act establishes workplace health and safety standards.

The Workers Compensation Act (2005) provides a legal framework for the administration of the Workers' Compensation Board's prevention, return to work, assessment and compensation programs.

Nova Scotia Labour Standards set out the minimum employment rules that employers and employees must follow. The Standards set out rules specific to recruitment and hiring.