The need for coordinated and strategic action to prevent and address malnutrition in all its forms is recognised internationally(1). This recognition is expressed in the range of government policies that have been developed across Europe(Reference Lachat, Van Camp and De Henauw2) and other regions of the world(3), largely in response to the surge in nutrition-related chronic disease over the past 20 years, that articulate the aspirations and strategic priorities of national governments to address nutrition challenges. While they provide a focus for public health nutrition (PHN) action at a national level, they do not necessarily identify what capacity exists to operationalise these strategies and they rarely commit to specific investments that make strategy implementation a reality. This has been identified as a major limitation of these policy instruments(Reference Thulin, Hughes and Bjarnholt4).
The health workforce, and the PHN workforce in particular, has previously been identified as a major determinant of the capacity of countries to implement national policy and action plans addressing nutrition(Reference Hughes5). The limited available data about the size, structure, composition, competence and ongoing development needs of the PHN workforce in developed countries suggest that there is considerable variability between countries in terms of workforce capacity, extent of professionalisation and workforce quality assurance(Reference Hughes5–Reference Haughton and George10). In developing countries, where the double burden of under- and overnutrition is becoming increasingly prevalent, requiring a broader range of interventions to address a broader profile of nutrition issues, the need for strategic workforce development is even greater. This suggests that PHN workforce development is likely to be an ongoing strategic need in most, if not all countries, irrespective of the degree of economic development or varying epidemiological profiles.
PHN workforce development at a global level is constrained by a number of systematic barriers summarised in Table 1(Reference Hughes5, Reference Lichtveld, Cioffi and Baker11–Reference Hughes14). While many of these reflect a lack of political commitment or appreciation of the utility of a specialist workforce, others reflect a lack of organisation and harmonisation of the workforce. This is an important role of professional associations and a desirable outcome of the professionalisation of PHN.
Systematic barriers to PHN workforce development internationally
PHN, public health nutrition.
Adapted from Hughes(Reference Hughes5), Lichtveld et al.(Reference Lichtveld, Cioffi and Baker11), CDC/ATSDR(12), Hutchins(Reference Hutchins13) and Hughes(Reference Hughes14).
Many of the challenges outlined in Table 1 reflect a degree of workforce and professional disorganisation that has been identified as limiting workforce capacity at national level(Reference Hughes5). Workforce regulation is a quality assurance and recognition strategy that has been widely used across the professions, including those in health and nutrition, to bring organisation and structure to workforce issues(Reference Hager and Otto15). Regulation can take a number of forms but has traditionally taken the form of national statutory regulation (such as mandatory registration systems like the registration systems used by the dietetics profession in Canada and the USA(Reference Fox, Chenhall and Traynor7, Reference Haughton and George10)) that is designed primarily to ensure patient safety and the practitioner's fitness to practise. In this form, registration is a pre-condition of legal right to practise. Voluntary regulation and recognition systems (using variable nomenclature such as registration, accreditation or certification) have also been developed, usually under the auspices of professional bodies and often in response to the need to promote professional integrity and credibility (such as the voluntary system for registering public health nutritionists developed by the Nutrition Society in the UK).
It has previously been argued that explicit delineation and promotion of a designated PHN workforce, distinct from the dietetics and/or the general public health workforce, is an important enabler of workforce capacity building to address PHN issues; the assumption being that specialisation, and recognition of specialisation, is a driver for more effective practice and organised workforce and community effort(Reference Hughes5, Reference Hughes14). A professional certification system, based on agreed competency standards, that defines a specialist PHN practitioner irrespective of practice setting, is suggested as a mechanism to serve this purpose.
The present paper reports on work undertaken as part of a multi-component project funded by the European Union (EU) to conduct formative research and consultation related to the development of the PHN workforce in Europe (the JobNut project). The objective of the work was to develop and test the feasibility of a Europe-wide system for professional recognition to ensure workforce quality, ongoing development and mobility.
Methods
A multistage iterative process was used to:
1. describe and explore existing, accessible and relevant professional recognition systems in the European Union;
2. propose a system to suit pan-European application; and
3. test the feasibility of the proposed system via a process of key stakeholder consultation.
The different stages and methods used in this process are summarised as follows.
Stage 1: Review of existing systems and literature
The initial review stage involved a step-wise process of information identification, review and verification. A non-exhaustive literature review was conducted of published reports and reviews of different approaches to certification, registration, regulation and professional quality assurance in discipline areas including PHN, nutrition, public health, dietetics, other allied health professions and medicine. This was complemented by a web-based search to identify organisations, professional bodies and governmental agencies involved in the regulation and registration of different health-care professionals and professional bodies or societies across Europe. Key stakeholders (academics, practitioners) in PHN in each country/member state (sourced from an earlier study's key stakeholder contact list(Reference Jonsdottir, Hughes and Thorsdottir16)) were contacted for more information and contact details regarding agencies, organisations or bodies related to the regulation of the professions of interest in each country, where they existed. Stakeholder follow-up was limited to two email contacts over a 2-month period. Once information had been gathered, a summary was prepared and reported back to individual contacts for further clarification and verification of information gathered. Following collation and clarification of the information from all the countries that had engaged with the process, a situational analysis was undertaken.
Stage 2: Model development and description
Following the first stage of reviewing the literature and existing models it became clear that a statutory regulatory model for the profession of PHN that has a primary function of consumer protection was not warranted in our disciplinary context. It was also considered not feasible in the pan-European context because of the absence of an international legal framework with relevant jurisdiction. This pointed to a professional self-regulatory model with primarily workforce and professional development functions. Informed by the review of existing systems, literature and considerations of the practicalities of a pan-European system, the authors developed an individual practitioner-based certification model for professional recognition (described in detail in Fig. 1 and Table 2).
Schematic illustration of the proposed certification system for public health nutritionists
Attributes of and feedback on the PHN certification model
PHN, public health nutrition; IT, information technology.
The proposed system
In order to avoid the complexity and cost of establishing international legislative and regulatory structures, the system proposed was based on a voluntary, self-regulatory certification process. Certification in this context was defined(Reference Rooney and van Ostenberg17) as:
a process by which an authorised body/agency, such as a professional body or governmental agency, grants recognition to those individuals as having met certain pre-determined requirements or criteria.
The system proposed is best described as a voluntary individual practitioner certification system based on a process of peer review and feedback, similar to well-established journal review processes. Figure 1 presents a schematic of the certification system, while the process and principles for each step are detailed in Table 2.
The primary functions of this certification system were a combination of workforce development and professionalisation, including:
1. setting a standard for peer review and continuing professional development guidance;
2. setting benchmarks for competency attainment that explicitly inform workforce preparation and continuing education self-assessment;
3. helping define the work of public health nutritionists;
4. helping inform workforce recruitment (certification can be viewed as a credential/proxy measure of specialisation/advanced competence); and
5. facilitating workforce mobility in Europe.
The secondary functions of this certification system addressed consumer protection, including:
1. assuring the public that certified practitioners meet defined quality standards, maintain practice standards and are accountable professionally; and
2. providing a mechanism for individual practitioner accountability via complaints and re-certification processes.
Stage 3: Consultation and feasibility testing
A consultation document that described the certification system was developed to inform the stakeholder consultation and feasibility testing process. This document included sixteen embedded questions (Table 3) that focused stakeholder feedback and discussion about different stages and attributes of the proposed system. The consultation document was circulated electronically to 145 individuals representing twenty-nine countries and organisations operating within Europe. These persons were encouraged to circulate the consultation document as widely as possible to relevant stakeholders (snowball sampling). Stakeholders returned feedback against embedded questions by email return.
Certification system stakeholder consultation questions
Consultation workshops
Two consultation workshops were facilitated in Slovenia by the authors to engage stakeholders from new EU member states where there had been limited previous contact or where engagement had been difficult using an electronic approach. Participants in these workshops involved academics and practitioners from Bulgaria, Croatia, Greece, Hungary, Norway, Poland, Serbia/Central and Eastern European Network and Slovenia. The workshop events involved a facilitated discussion of each aspect of the model drawing on the sixteen questions asked in the consultation paper. This was done in order to ensure the methodology and information collected was comparable to that carried out/gathered through the email consultation process. Two authors (R.H. and B.M.) recorded key discussion notes from the workshop discussion against questions posed in Table 3.
Qualitative analysis of feedback
The qualitative data gathered through the workshops and email consultation were thematically analysed by two authors (J.D. and R.H.) independently before scrutinising response themes collectively as a research team. This process was designed to maximise the trustworthiness of analysis and response interpretation.
Results
Existing professional recognition systems
Country-specific information was gathered from twenty-eight countries, including feedback and information from academics, employers, policy makers, professional bodies/associations and practising public health nutritionists. The variability of accessibility and quantity of information available between countries was noteworthy and made detailed descriptions and comparisons of existing systems difficult. Across Europe (up to August 2008), there appeared to be only one formal registration system explicitly for PHN in existence (i.e. the voluntary register of the Nutrition Society, UK). There were, however, other registration-type systems in place for nutritionists, nutrition scientists, dietetics, medicine and other allied health professionals, run on a voluntary or mandatory basis in at least twenty EU countries. Mandatory registration was the most common form in these related professions, with many EU member countries (more than twenty) having no identifiable professional recognition system specifically for PHN.
Consultation feedback
A total of thirty-four completed consultation documents were received from key stakeholders across the EU, with more than one person contributing to the response from some countries. Approximately one-third (n 14) of the responses received were from non-academics and the rest (n 20) were from academics. An additional twenty-one stakeholders participated in the consultation workshops, representing a total of thirteen countries. Those who took part in the consultation had a wealth of experience in PHN practice averaging 18 years (range 1 to >40 years). Table 2 summarises the key attributes of the certification system at each stage and the key response themes from consultations about the system. All respondents, bar one, agreed that there was a need for a pan-European body to govern the certification system. There was less agreement over who and how a representative should be selected from each member state on to a pan-European body. There was agreement that there needed to be individuals from a range of backgrounds.
Discussion
A common feature of models that already exist in EU member states involves an individual gaining a specific qualification from an accredited course, at either bachelor or postgraduate level, as a basis for recognition. Hence, the quality assessment centres on the educational institution rather than the specific competency of the graduate to practise. This is arguably limited as a system for practitioner quality assurance in that it assumes that all those gaining such a qualification have achieved a common minimum level of competency required to effectively practise as a public health nutritionist. Given the important role of experiential learning in PHN competency development(Reference Hughes18) and the limited work-integrated learning (placement) requirements of many nutrition training programmes observed in the EU(Reference Margetts9), reliance on a qualification alone is probably inadequate. The fundamental principle of the certification system model developed is that it involves a one-step peer assessment using well-established and well-used information technology platforms for peer review, focused on demonstrable evidence of competency and performance in practice contexts. It removes the need to accredit higher education institutions and reduces the burden of resources required for assessment.
We recognise that in some countries in the broader international context (e.g. Canada, USA) public health nutritionists are required by law to be registered with national or state registration bodies, and that in other countries systems of professional self-regulation exist at a national level (e.g. UK, Australia). The proposed system is not intended to either replace or diminish the value of these systems. Instead, the system is intended to internationalise professional recognition and workforce quality improvement so as to complement existing systems or create a system in countries where there is none. The absence of any system for professional recognition in most of the countries reviewed in the EU and the variable levels of development of PHN as a professional workforce group in EU countries(Reference Margetts9) support the development of a international system to fill these gaps and assist international exchange and workforce mobility. This reflects a majority view among PHN academics and employers involved in an earlier consensus study from this project, namely that developing a system that ensures quality of practice and maintains professional standards is a high priority(Reference Jonsdottir19).
The present key stakeholder consultation in Europe demonstrated that there is a broad level of qualified support for a pan-European (international) system for professional recognition to support the development of the PHN workforce and profession in Europe. The feasibility of the system was dependent on a range of logistical parameters, including:
1. the establishment of international consensus standards for certification (competency standards);
2. the establishment of an international certification agency with the appropriate credibility, capability and capacity to govern the system;
3. the establishment of a pool of peer reviewers with suitable training in certification review, appeals and complaints processes to ensure a robust and objective system;
4. the development or adoption of an appropriate information technology system to enable document management and distribution; and
5. resources to ensure the sustainability and credibility of the system.
Conclusions
There is considerable stakeholder enthusiasm for a voluntary pan-European professional certification model to assist PHN workforce development across Europe. This enthusiasm is however tempered with considerations of the resources and processes required to ensure the system has integrity and credibility, without which a certification system has limited utility to individual practitioners or the progression of the profession as a whole. Nevertheless, it was well recognised that the added value to such a system is not limited only to workforce development and quality assurance, but also in raising the professional profile of PHN on the international stage.
Acknowledgements
Source of funding: This work was supported by funding from the European Commission Leonardo DaVinci Community Vocational Training Programme (agreement number 2003320). Conflicts of interest: None to declare. Authorship responsibilities: J.D. had the principal role in data collection, analysis and drafting of the study. R.H. and B.M. contributed to study conceptualisation and methods design, and assisted with data collection and analysis. All authors contributed to the drafting and final editing of the manuscript. Acknowledgments: The study is a component of a broader project (the JobNut project) conducted by a consortium of partners across Europe. The collaborative contributions and support of the JobNut project team, including Agneta Yngve, Inga Thosrdottir, Nick Kennedy, Carmen Perez-Rodrigo, Susannah Kugelberg, Christel Lynch, Svandis Jonsdottir and Christina Black, is appreciated. The authors also acknowledge the sharing of expertise, experience and insights of the many stakeholders across the EU who engaged throughout the consultation process.
