By Liz Roper, Chief Dietetic Technician
With ever increasing caseloads, how do we help our Registered Dietitians meet the demands on their service? Are Dietetic Technicians the answer and how does their role fit in within your service?
How did this role first come about?
Nottingham University Hospitals (NUH) NHS trust is one of the largest acute NHS Trusts in the UK with over 1900 staff, 90 wards and 1700 beds across its sites.
We have developed our department over the years and historically included band 5, band 6 and band 7 dietitians. Approximately 450-500 dietetic job vacancies a month appear on NHS Jobs showing that dietitians are in high demand. Dietetic caseloads have changed, primarily because people are living longer and present with multiple dietetic/nutritional issues. This means that patients will often require close monitoring and a great deal of input of expertise from our registered members of staff.
Our key performance indicator (KPI) states that 90% of patients should be seen by a member of the dietetic team within 48 hours of receipt. Like many dietetic departments we have struggled to employ Dietitians and although we had Dietetic Assistants in post, we realised there was a clear gap where support staff could work autonomously providing a robust level of patient care.
The department decided to explore new ways of working and the Dietetic Technician role was developed and has been embedded into our dietetic structure since 2014.
Our support team now comprises of 7.4 whole time equivalent (WTE) Dietetic Technicians, 5.0 WTE Dietetic Assistants and 4.0 WTE Dietetic Administrators.
Chief Technicians
In addition to the 7.4 WTE Dietetic Technicians, we have two Chief Technician roles within the department. One that specialises in catering, nutrition, and hydration for patients and sits on the food and menu groups. The other Chief Technician leads on the implementation of purchasing and ensuring timely procurement of nutritional products, in addition, leads the team of support workers.
Training
Training for Dietetic Technicians is provided in-house and includes tutorials, shadowing and directed study all using a training framework and a set of locally agreed competencies all formulated by our Registered Dietitians. The Professional Competency Passport is the tool used to complete the training once competency has been achieved for all professional competencies relevant to the named Dietetic Technician; the final assessment is completed and placed within the Dietetic Technicians Professional Portfolio as a record of their achievement and current competence.
In addition, they are required to complete the ‘Care Certificate’ and we expect them to complete this within a year of commencement in post.
The majority of the work for the Adult Dietetic Technicians is generated by the use of the Malnutrition Universal Screening Tool (MUST) criteria and are time critical on the response. These patients have little or no other complicated nutritional issues and there is a clear exclusion criteria to follow, indicating that any referral received should be passed on to a Registered Dietitian.
Figure 1. Flow chart with step-by-step decision process
Inclusion criteria are:
- Any inpatients referred to the dietetic department with a MUST of 2 or above (malnourished or at risk of malnutrition);
- MUST of 0 or 1 and a background of Chronic Obstructive Pulmonary Disease (COPD) and/or where food first approach intervention has failed.
Relative exclusion criteria – discussion with Registered Dietitian:
- Refeeding syndrome risk
- Abnormal biochemistry (such as low Sodium)
- Fluid restriction (< 1.5L/day)
- Calorie deficit >600kcal/day
- Allergy/special diet
- Overweight/living with obesity
- Other issues which could impact nutrition (inflammatory bowel disease, advanced kidney disease)
Absolute exclusion criteria:
- Patient nil by mouth (NBM)
- Enteral and parenteral nutrition
- Patients on Insulin
- Patient with decompensated liver disease
- Stage 3/4/ unstageable pressure ulcers
The Dietetic Technicians can advise on five selected Advisory Committee of Borderline Substances (ACBS) nutritional products on inpatient drug charts. A service level agreement (SLA) was developed by working closely with our pharmacy department and guidance from our governance division.
Typical day in the role
There is no typical day for a Dietetic Technician – but we hope to give you an insight into what our team may encounter at any one time.
The day for a Dietetic Technician will start with a meeting with other technicians, rotation Registered Dietitians where patient referrals are checked, and the case load will be disseminated within the team. We aim for all of the team to be present on the wards as soon as possible in the day and the technicians will work as a member of the multi-professional team (MPT). The Dietetic Technicians follow a standard procedure, working within a service level agreement (SLA) and within a specific level of practice, that provides elements of autonomy.
On some days, the technicians will be responsible for co-ordinating orders of nutritional products required by wards and this is time critical, needing to be completed at 11.30am.
The budget and ordering of nutritional products at NUH are held by the dietetic department (not Pharmacy) and the Dietetic Technicians are key players. We have close links with our nutritional product suppliers and this enables us to control the spending and use of product. The team take stock, order and coordinate the use of all nutritional products within the Trust. Undertaking the stock control in this way means we have excellent vision of nutritional products within NUH and can identify where products are required and move them to other areas if needed which in turn helps to eliminate wastage.
New graduate dietitians work closely with the Dietetic Technicians, this allows them to gain valuable experience with more complex cases, and there is a strong emphasis on teamwork.
The Dietetic Technicians carry out meal time observations, together with a representative from the catering and a member of the nursing team. The observations may be on their own ward or any other within the Trust, helps develop good relationships with both catering, and the ward based MPT.
Afternoons may see the Dietetic Technician delivering patient education such as cardiac rehabilitation or other health promotion events. Teaching to our colleagues at ward level is extremely important and the Dietetic Technicians will help with delivering sessions such as malnutrition awareness, how to complete food record charts and the efficient use of nutritional support items.
Our Dietetic Technicians play a valuable part in student dietitian training as most have taken on the role of mentor, having attended the Mentor & Facilitation of Learning Courses at the University of Nottingham.
We are currently introducing a medical devices package to enable the Dietetic teams to fulfil all of their competencies and we plan for the Dietetic Technicians to be able to offer training on Enteral Feeding Pumps, Weighing Scales, Stadiometers, Hand Grip Dynamometer, and Baby Measuring Mats.
Once the package is established, we will include Cardiopulmonary Resuscitation (CPR) and offer the complete competency package in one session. This will enable us to have clear visibility of our compliance as a profession.
Other Dietetic Technicians are key members of the Health & Safety at Work team, while some have taken on First Aid Training and will offer this alongside their day-to-day roles. We also have a Dietetic Technician as a representative on the British Dietetic Association Union.
Paediatric Dietetic Technicians
The Dietetic Technicians on our Paediatric department work in the areas of Renal, Metabolic and Oncology. On a typical day, they would work with the Registered Dietitian to contact patients with blood results.
Support and motivation to the children and their families is a vital role of the paediatric Dietetic Technicians and they attend multi professional clinics, organise and support events such as cookery sessions, education days, and any other patient and parent events. This will also include teaching families new skills such as baking specialist items for Phenylketonuria (PKU), learning to read labels on a visit to the supermarket and encouraging them to try new products.
We encourage regular meetings with the rotational dietitians to discuss any worries or challenges that the Dietetic Technicians may have, and a preceptor is allocated on commencement in post.
All of our Dietetic Technicians take a huge part in promoting the profession as whole and play a huge part in events such as Dietitians Week and Nutrition and Hydration Week.
Benefits of the role
We continue to increase our numbers of Dietetic Technicians and look at deploying them into new areas of our department.
Our Dietetic Technicians provide a vital role within the team. The service they deliver for in-patient oral nutritional support allows the Registered Dietitians to spend more time on complex cases.
A number of our Dietetic Technicians have gone on back to university to become Registered Dietitians and subsequently returned to our dietetic department at NUH.
Our entry requirements
We ask our new recruits to have:
- National Vocational Qualification (NVQ) level 3 or equivalent in a relevant area such as nutrition, health care or catering.
- Good level of literacy and numeracy.
- Experience of working with people who are ill.
- Experience with the NHS or healthcare is desirable.
- Having experience as a Dietetic Assistant is a distinct advantage, and many of our Dietetic Technicians have progressed from this role.
Summary
The role of the Dietetic Technician has been a huge benefit to our department providing strong support to all of the teams. The range of skills acquired mean that registered staff can spend more time on the complex cases and our training to ward based MPT is timely and efficient. We plan to expand our Dietetic Technician numbers and we hope to offer dietetic apprenticeship in the near future.
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