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Reflections on practice in dysphagia management: An influential new role paper is published

The lead author of the new role paper, “Defining the Role of the Dietitian in Dysphagia Assessment and Management,” shares why this paper is so important to her and many other dietitians.

HSJG.JPGJennifer Hemeon Garus is a professional dietitian and the Nova Scotia Dietetic Association’s executive director. She has practiced in a wide range of roles and settings, including long term care, an outpatient clinic, homecare, telehealth, private practice, public health, and industry. Jennifer applies her dietetic practice experience to her current role in professional regulation. Her interest in Dietitians of Canada’s new role paper overlaps with her role in professional regulation that addresses scope of practice issues and competencies in dietetic practice.


The recently published Dietitians of Canada role paper, “Defining the Role of the Dietitian in Dysphagia Assessment and Management,” was written to reflect the RD’s current role in this area. Work on the DC paper began early in 2014, with a review of the literature and other professions' role papers in dysphagia assessment.

With the draft versions of the paper having input from over 30 dietitians, this paper clearly reflects current practice across Canada. We, the contributors, used our “outside voice” to articulate what we wanted to share with those outside of the dietetics profession. We also wanted to express the value of interprofessional practice in dysphagia management, and ensure that other health professionals were aware that it is within a dietitian’s scope of practice.
“This document is important as it clarifies for RDs and other health professionals that the assessment and management of dysphagia is most certainly part of the RD’s scope of practice.” -Carole Chatalalsingh, College of Dietitians of Ontario
“This paper clearly articulates the breadth of dysphagia management activities that fall within the scope of practice of a dietitian, as long as that dietitian has the education and training required to ensure they are competent.” -Deidre Burns, Chair of the DC Dysphagia Assessment and Treatment Network
Despite being the lead author of this role paper, I relied heavily on the knowledge and collaborative efforts of peers and colleagues. I also relied on current literature and evidence, as I haven’t practiced in an area requiring dysphagia management for over 15 years. While writing the role paper, my impression was that some aspects of practice have advanced and changed since that time, while some have not.
Now, I want to use my “inside voice” to express my impression of how dysphagia management has changed over the past 15 years, and how these changes relate to the new role paper.

As a dietetic intern, over 20 years ago, I was exposed to the role of the RD in dysphagia management. I recall conducting nutrition screenings, referring to speech language pathologists (SLPs), and having input into the recommendations for texture modification. I also observed a modified barium swallow. The dietitian, even then, was a key part of the dysphagia care team.

As a new graduate, my internship experience helped to prepare me to work as the sole RD in a long-term care (LTC) facility and small hospital in rural Newfoundland. The closest SLP was 350 km away. Therefore, I relied on the skills I had learned during internship to successfully assess and manage dysphagia at this rural site.


Later, I also practiced in LTC facilities as a consultant in Ontario. Although the SLP was much closer, they weren’t employed within the LTC facilities and, as such, weren’t readily accessible. This is a context of dietetic practice that has not changed for many RDs. In some settings, dietitians are independently conducting clinical bedside swallowing assessments, as SLPs are hard to access. 

In my early years of practice, I found that it was essential to work closely with the food services department to ensure the correct texture and consistency of foods and liquids. This role paper stresses the value of the dietitian's involvement in dysphagia care from this lens.

While writing the paper, I also got the impression that there is an ongoing challenge with the use of terminology to describe the different levels of thickened liquids or food texture modifications. I look forward to the outcome of the current work to standardize dysphagia diet terminology. This will address the ongoing challenges associated with providing clients with the safest and most acceptable nourishment.

Although the role paper was written using our “outside voice” for our interprofessional colleagues, the paper is also very meaningful to RDs for many reasons:
“This is a landmark document to support Canadian dietitians in dysphagia practice. Glad to see it come to life after many years of hard work by many committed individuals!” - Peter Lam, Dietitians of Canada member
“Dietitians across the country have varying opinions on their role in dysphagia assessment and treatment. Many are independently assessing patients/clients with dysphagia; others are simply implementing the textures recommended by other members of the health care team. With such variety in roles and expectations, it is difficult for practitioners to understand their role. This paper has clarified the dietitian’s role and will support dietitians to work to their full scope with respect to dysphagia management.” -Deidre Burns, Chair of the DC Dysphagia Assessment and Treatment Network
“This document is important to dietitians as it responds to managing high risk dietetic activities and advancing dietetic practice in dysphagia management. It also describes the dietitian’s role in the context of interprofessional practice.” -Carole Chatalalsingh, College of Dietitians of Ontario
“This paper was collaboratively developed and reviewed by dietetic experts in several practice areas. It represents a valuable move forward for the profession as a whole to ensure that individuals with dysphagia receive the best and safest care.” – Angela Cuddy, Dietitians of Canada member
In the past 15 years, practice expectations have changed. In every province in Canada, it is within the professional scope of dietetic practice to conduct clinical bedside swallowing assessments. There are formal learning opportunities available for dietitians to move beyond screening, and to achieve the advanced level of knowledge and skills required to effectively care for clients with dysphagia. 
I’m looking forward to working with the Alliance of Canadian Dietetic Regulatory Bodies to develop the advanced level competencies for dysphagia assessment and management, which will help to further support and regulate practice in this area.

I hope to elicit your comments and reactions on the definition of the RD's role in dysphagia assessment and management, as well as how dietetic education and practice can further advance in our clients’ best interest.

As Kimberley says so well below, this role paper is the result of many dietitians collaborating to help advance our practice in this area.
“As the founder of the DC- Dysphagia Assessment and Treatment Network (DAT-N), it is very professionally rewarding to reflect on the passion and drive of our members and the trajectory of their work since 1997. Seeing our vision come to fruition is incredible and many years of dedication and hard work should be celebrated. DAT-N leaders have been pioneers in enhancing our role on dysphagia treatment to where it is today. This is a very influential paper and I'm thrilled to see it published and endorsed by the experts in Canada.” – Kimberley Butt, Dietitians of Canada member

Editor’s note: Has DC’s new role paper inspired you to learn more about this important area of dietetic practice?

Be sure to check out the “Don’t choke on it... just feel it!” session on Saturday, June 6th at the upcoming National Dietitians of Canada Conference. Participants will develop new skills for performing bedside assessments. The workshop speakers, Isabelle Germain, PhD(c), DtP and Michel Sanscartier, MSc, DtP, are extremely knowledgeable in this area – don’t miss it! 

Also, be sure to register for the “Charting new ground: Interprofessional approaches to dysphagia management 2-day workshop in Toronto this October.

I hope to see you at the conference in Quebec City next week! Please share any thoughts, comments or questions below.

  1. Vivian--agreed. If this is the case, and RDs are to be one with SLPs in management in dysphagia, a curriculum 'overhaul' would be required for RD schooling. Poster graduate education MUST include, neurological functioning and anatomy, anatomy and physiology of the head, neck and throat, motor speech disorders, vocal/voice issues, to name a few. Has this been considered and are Colleges and Universities willing and able to do this? Has this been considered?
  2. AS an SLP, I am aware there are limited SLP resources. I think the best plan is to continue to request SLP resources. I work with an RD on my team for dysphagia assessments. I see the need for RDs to manage more when it comes to dysphagia, my only worry is that so much is missed with just a clinical assessment. Thicker is not always better. How is RD training changing to embrace using the words swallow assessment - anatomy of the ear, nose and throat, training in MBS? The college states ability to predict risk of pneumonia, how are RDs calculating that risk? I see a role for us all, and unless those in the front lines continue to advocate for SLP services, they will not appear. The lack of SLP and CCAC services in LTC is horrible, but SLPs alone cannot change that. Not just for dysphagia, but communication needs unmet in these areas where many live a number of years.

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