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Commission on Dietetic Registration 2005-2007 Levels of Practice Study Executive Summary

Please send your comments regarding Advanced Practice to

Committee Charge

In 2004, the Commission on Dietetic Registration appointed an Advanced Level Dietetics Practice Audit Committee charged to conduct a study to identify and define levels of dietetics practice.

The committee met between 2005 and 2007 to draft the study survey instrument.  In spring, 2007 the committee contracted with an outside vendor to conduct cognitive interviews to further refine the survey instrument.  The survey was conducted between May-July 2007.

Study Objectives

  • To identify advanced practice in dietetics
  • To define advanced practice in dietetics
  • To provide a foundation for the development of a possible advanced practice credential

Research Approach – and Identification of Study Population(s)

  • Gather information on advanced credentials offered by other allied health professions
  • Identify a population of Advanced Level Practitioners (ALPs)
  • Select a separate scientific sample from the population of all other Beyond Entry Level (BEL) Registered Dietitians, registered 6+ years
  • Identify characteristics, qualifications, employment situations, and practice activities for both groups
  • Draft survey, conduct cognitive interviews, revise survey, conduct pilot test of survey instrument, and conduct survey
  • Conduct statistical analyses to discover variables that reliably discriminate between nominated ALPs and BELs
  • Evaluate practitioner interest in obtaining an advanced practice credential or recognition

Study Methodology

  • Establish criteria for advanced level practice nominations: These dietitians are recognized by their peers and the professionals who supervise their work for their expert knowledge base and complex decision-making skills and competencies. However, we are seeking dietitians with more than just specialized knowledge; rather we are looking for dietitians who have built on their specialized knowledge to acquire new practice skills and expand their practice. Often these dietitians function autonomously in their areas of practice. These dietitians may or may not be high profile in the profession or association.
  • April/May 2006: ADA Affiliate Presidents and ADA Dietetic Practice Group chairs asked to nominate Advanced Level Practitioners
  • The characteristics or functions of these dietitians may include
    • Integrate practice with research and education
    • Function with a high degree of professional autonomy and independent practice
    • Advanced skills in problem solving, decision-making and reasoning
    • Recognized as expert resources
    • Demonstrate global vision and initiative in approaching their practice
    • Advanced education and training in the form of fellowship, advanced degrees, and/or on the job training
    • Significant practice experience is essential for this higher level of skill development

Instrument Development

  • Survey instrument developed iteratively by Advanced Level Practice Audit Committee 2005-2007
  • Psychometric consultants review and refine survey instrument
  • Cognitive interviewing process conducted with 26 RDs selected from the study sample, to verify that activity statement interpretation was consistent with committee intent.  The committee revised the instrument based on the results of this process.
  • Pilot-test survey instrument using a sample of 100 ALPs and 100 BELs in May 2007 (61 responses).
  • Survey instrument refined and finalized based on pilot test results.
  • Final survey questionnaire of 13 pages, 77 activity statements, mailed June 2007.

Sampling Plan

  • 1,230* ALPs nominated, all surveyed
  • Scientific sample of BELs selected from remaining 56,492 RDs registered 6+ years
  • Random sample of 5,094* BELs
  • Oversample of 880 BELs with FADA and/or CDR specialty certifications (results analyzed separately)
  Population Sample Response Rate Margin of Error



  • Initial approach: correlational and contingency table analysis
  • Multivariate discriminant analysis: predict group membership (ALP or BEL) with linear function of selected independent variables
  • Logistic regression analysis: predict odds of ALP membership with linear function of selected independent variables
  • As a second step in the study analysis, several statistical models based on various dietetics practice segments/areas, (clinical, community, management, education/research, business), were developed in an effort to differentiate between ALPs, BELs, and entry-level practitioners. 


  • The absence of a nationally accepted and implemented standardized advanced level dietetics practice role, educational program, and vocabulary may have negatively affected the ability to discriminate between ALPs and BELs.  Without this common understanding and language, survey respondents may not have interpreted the activity statements as intended.
  • Item unreliability and self-reporting biases may have led respondents to inflate their degree of advanced practice, claiming participation in activities that they may not actually be involved with (or involved at the skill level asked about).
  • Even with explicit (practice oriented) criteria provided, many expert informants appear to have nominated Advanced Level Practitioners based more on professional accomplishment and stature than on observed advanced practice- does this study group truly represent advanced dietetics practice?
  • Whether employing attributes or activities, the models developed generally account for less than half the statistical variation observed-meaning there are clearly other factors in play that were not measured by this approach.


  • Overall the study results do not support the existence of a common thread of advanced level dietetics practice that crosses all practice segments/areas.  One survey instrument could not differentiate advanced dietetics practice.
  • None of the models developed as part of the second stage of analysis performed at the level required to meet current psychometric standards for the development of a certification program.
  • There is evidence that advanced practice in dietetics is differentiated by practice area. But uniquely assigning practitioners to one and only one practice area remains problematic, since most practice is in more than one area.
  • Activity statements related to advocating for resources, and conducting or managing research differentiate advanced level dietetics practice in all practice segments except education.  The latter is probably due to research being an expectation of those practicing in education.
  • Any advanced level practice credential that would be considered in the future would need to be related to a specific practice area.
  • Advanced level practice needs to be identified by task-supported data versus attributes, in order to adhere to sound psychometric practice and to meet CDR external accreditation standards.
  • Although the data was inconclusive, there is a suggestion that more ALPs have a CDR specialty credential (7%) versus the BELs (2%).  Further study would be required to document the relationship.
  • FADAs could not be distinguished from ALPs or BELs by their responses to activity statements.  However, they were distinguished by their attributes; especially for those practicing in an education setting.

Next Steps

  • Next study should be focused on a specific practice segment(s)/areas.  
  • Current practice segments/areas, (clinical, community, management, education/research, business), need to be reviewed and evaluated for their relevance to advanced level practice.
  • Future research efforts may need to employ additional or alternative methods for identifying advanced practitioners for study, as the nomination process employed in this research appears to have identified individuals based at least in part on characteristics/attributes other than those of dietetics practice.
  • A standardized advanced level dietetics practice role, educational program, and vocabulary should be established, disseminated, and widely accepted.
  • Different study methodologies could be considered to better assess critical thinking skills.
  • An article reporting the results of this study should be published in the Journal of the American Dietetic Association.
  • The results of this study should be considered as a topic for the CDR Forum at FNCE.