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Nutrition Counseling in Nursing Practice

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This is Part II in a series of articles that will address the professional, legal and ethical guidelines for nurses working in private practice outside of a medical environment. For an excellent article on APRN private practice please refer to Nursing America’s February 14, 2019 article on allnurses.com.

Nutrition Counseling in Nursing Practice

More and more nurses are leaving bedside care or physician-led practices to pursue their desire to practice less symptom driven medical care and have more disease prevention and health maintenance interaction with their patients.  It is projected that by 2030 seventy percent (70%) of nurses will be working outside of a hospital or medical facilities, in various venues and specialties with chronic disease prevention, health and wellness, and anti-aging being the more populated areas these nurses will be working in. In addition, a significant number will be conducting individual private practices or working with nurse practitioners.

The previous article in this series discusses at length the practical and legal guidelines surrounding nursing private practice outside of an APRN specialty. These are important things to be aware of if you are one of the less than half of all RNs in the U.S. who work outside of an acute care or hospital setting. Currently, there are so many nurses moving out of acute patient care that this past decade is being referred to as “the decade of the nurse entrepreneur”.

As the breadth of diversity in jobs for nurses is a relatively new occurrence, many nurses are not as familiar with the laws governing nurses in private settings and what the parameters are for specific areas of specialty. This can lead to both legal and financial problems for nurses who inadvertently violate laws pertaining to the practice and regulation of particular modalities or methods.

One significant example is the practice of nutrition counseling in a private nursing practice. While a nurse can offer nutrition education or guidance in a medical practice, once he/she goes outside of a professional position that is supervised by a medical physician, things change according to state laws and licensing. These state laws are continually changing in that more and more states are restricting individuals, including licensed nurses, from practicing nutrition counseling.

Currently, all states have regulations in place regarding nutrition counseling. And, not being aware of the law does not exempt anyone from being prosecuted for its violation. “Ignorantia juris non excusat or ignorantia legis neminem excusat” is a legal principle holding that a person who is unaware of a law may not escape liability for violating that law merely because one was unaware of its content. There are at present four different classifications of permissions utilized by all 50 states for nutrition counseling:

  • 16 states adhere to the following classification: “It is illegal to perform individualized nutrition counseling unless licensed or exempt. Effectively only RDs are eligible for licensure.”
  • The law in 5 states is: “It is illegal to perform individualized nutrition counseling unless licensed or exempt. There is a non-RD pathway for licensure. Check for exemptions.”
  • In 16 more states, “It is legal for all to perform individualized nutrition counseling. Effectively, only RDs are eligible for state recognition.”
  • In 13 additional states, the law states, “It is legal for all to perform individualized nutrition counseling; there may be restrictions on medical nutrition therapy.”

Apart from the state laws and regulations, there is a caveat here that needs to be paid close attention to. Outside of a license to practice nutrition, which allows for professional liability insurance to protect you from any legal form of claim or lawsuit, if you are not credentialed and choose to practice nutrition without defendable training and professional liability insurance, you may be placing your license and yourself in a vulnerable position, in the event a claim is taken against you.

Some might dismiss the idea of a nutritional lawsuit and the lack of any real danger to your livelihood or finances. I will share a real-life story with you that occurred in the state I live in, which allows for “all to perform nutrition counseling”. This happened to a caring and enthusiastic nurse who had a passion for all things nutrition.

She opened her own nutrition counseling practice and was well thought of. She had a friend of a friend’s husband consult with her regarding his desire to get off his hypertensive medication, which was interfering with his physical marital relations.

This nurse called herself a health coach and as such was coaching the man on how to reduce his blood pressure. She explained to him that the reason he had to take the medication was because he needed to lose 40 pounds, start eating less processed foods, try meditation or yoga to decrease work stress and get more sleep. She well-meaningly told him that if he did all of those things he wouldn’t have hypertension and that translated to he wouldn’t need to take the medication.

The client did follow her recommendations for losing weight through better eating.  After 3 months, he reported he felt better and that he would follow up with the health coach as needed. Nine months after she last heard from him he had a stroke. He has stopped taking his medications and his wife, on behalf of her husband, took a lawsuit against the health coach. The court favored the client’s claim and the nurse had disciplinary action taken against her license and wound up losing her home to pay damages.

It would appear from the exchange between her and the client that she did nothing wrong and was not responsible for this man’s stroke. The court did not see it that way. If someone takes an action against a practitioner who is not licensed in their practice area or does not have liability insurance in the specialty, they can be charged with practicing medicine without a license.

We know about this case because the organization I work for was asked to appear as an expert witness, which they declined to do. The unfortunate thing is these types of claims are not as isolated as one might think. In a recent discussion with the Executive Director of AHNA, she expressed her concern for the rising number of nurses who are getting into legal and financial trouble because of a lack of knowledge of the law in their state regarding their license scope of practice and the guidelines surrounding any specialty modality they may be offering to clients.

We are working cooperatively with nurse organizations to provide free seminars on this important subject of professional and legal guidelines and regulations.  If you would like more information about the free seminars, endorsed by AHNA, you can e-mail conor@niwh.org for information.

Georgianna Donadio, MSc, DC, PhD, is the Director of the National Institute of Whole Health, and a health care visionary who pioneered the integration of Whole Health and Whole Person Healthcare within medical and holistic health organizations. Georgianna is one of only six Florence Nightingale Scholars in the U.S., an MNA award-winning Nurse Advocate and widely published Integrative Health expert and healthcare provider. Named “Best Integrative Healthcare Practitioner” in Boston, for 20 years she hosted the nationally syndicated, regionally Emmy nominated women’s TV programming, Woman-to-Woman®. She is currently the host of iHeart radio’s Living above the Drama which is heard globally, and an Amazon #1 Bestselling award winning author. She has been a regular contributor/writer for the Huffington Post, Dr Oz’s Share Care, Daily Strength and other national blogs.

2 Followers; 5 Articles; 1,975 Visitors; 26 Posts

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887 Visitors; 315 Posts

Thank you very much.  This is really a cautionary tale for RNs to know our scope of practice.  There was a recent discussion on Allnurses about giving nutritional advice re: vegan/vegetarian diet, so this is timely.

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2 Followers; 5 Articles; 1,975 Visitors; 26 Posts

Hello Golden RN MSN
Yes, unfortunately, there is so much misinformation about nursing private practice that it is becoming, in the words of my colleagues on the national nursing boards "an epidemic" - that nurses are now starting to run afoul of the law. NIWH, as stated at the end of the article, provides free seminars for any nurse would like more information about how to avoid any legal or professional issues if they choose to start a private nurse practice.

Many thanks for your comment. 
Kind regards,Georgianna

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1,502 Visitors; 58 Posts

Hi,

There's some key missing information here. Nurses should know that not all hypertension is directly weight or diet related. And not all strokes are hypertension-related. What were the BP meds? Did the patient or client discontinue them all of a sudden? What was the tapering schedule? What were results of his blood pressure throughout his time with this nurse, including after discontinuing the medications? Are we meant to infer that his stroke was BP related?

Thinking of myself in that nurse's position, I would certainly have referred the man to his primary care physician in terms of advice of getting off any medications. Getting a person off any medication is not a nurse's call. Assuming his hypertension did not go away after lifestyle changes and did indeed cause his stroke, staying within the scope of practice would have protected her and presumably the patient.

HCT

Edited by Hematocrit13

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2 Followers; 5 Articles; 1,975 Visitors; 26 Posts

Hello HCT and thank you for your comment.
ou are COMPLETELY spot on regarding nutrition counseling.

As a nurse educator, the intent of the article was to caution nurses that the practice of nutrition is a separate credentialed scope of practice. 

While some states allow an individual to do nutrition counseling without a license as an RD or licensed nutritionists (usually masters degree level)
that does not imply that an individual can "practice" nutrition which involves professional, legal and ethical considerations.

The allowance of nutrition counseling is often available for weight loss in a variety of settings, which given our runaway obesity rates, can be helpful for those struggling with to get their weight under control. Almost all weight loss programs now have individuals who can answer questions about the diet plan and losing weight being offered.

Unfortunately, there are many nurses who take courses in various kinds of nutrition and are conducting private practices where they function in the capacity of nutritionists. 
This has become commonplace today and many nurses find themselves with legal or professional issues as a result.

EDUCATING a patient about nutrition is very different than practicing nutrition. Providing holistic, evidence-based health information that allows the patient to understand why they may chose to make lifestyle changes is not the same as directing the patient on nutrition issues and also avoids the pitfalls you so appropriately pointed out.

Many thanks for taking the time to comment.
Kind regards
Georgianna 

 

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1,502 Visitors; 58 Posts

1 hour ago, Dr Georgianna Donadio said:

 

But this man died due to poor medical (mal)practice not poor nutritional advice, no? The advice he got regarding nutrition, from the little we have been presented with, seemed pretty good.

Added up, I have probably spent months if not years, total, learning about food and its impact on our bodies. I do consider myself quite up to date on the latest research, and yes, the latest trends. I have implemented a lot of what I've learned on myself and have developed flyers and learning tools to inspire others. I would probably self-eject from a classroom setting if I had to listen to traditional nutritionists talk and lecture, as I think I know a fair amount and have learned a lot on my own. In other words, I'm not someone who is impressed with certificates and licenses regarding nutrition. But I allow that that opinion may be misguided.

I would never recommend anyone to come off any medication.

HCT

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2 Followers; 5 Articles; 1,975 Visitors; 26 Posts

Hello HCT,
Fortunately, the man did not die but was impaired, which is bad enough. I agree with and understand everything you are saying. Today, boundaries are blurred, especially with nutrition. Many lay people, as well professionals, cross the line with "recommendations" and prescriptions and as you can see there is "no one size fits all" approach to anything in medical or healthcare, let alone something as individual as nutrition.

Our organization does its best to educate nurses about appropriate boundaries and the legalities surrounding
many issues that can come up in private practice. There needs to be a balance between our passion for self-directed care and rejection of established standards and regulations for various medical specialty practices.

Thanks again for your comment. 
Kind regards,
Georgianna

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