Using document analysis to revise competency frameworks: Perspectives from the revision of competency standards for dietitians

Introduction/Objective

In resource poor environments, low cost methods are needed to review competency standards to ensure they remain reflective of the current health workforce. This study aims to show how document analysis can be used to inform the revision of competency frameworks and standards.

Methods

Altheide and Schneider's document analysis was modified to revise the National Competency Standards for Dietitians in Australia. This involved an eight-step process: (i) define the goal, (ii) identify documents for analysis, (iii) choose the analysis approach, (iv) engage with the documents and perform the analysis, (v) draft revisions, (vi) stakeholder engagement, (vii) final revisions, (viii) dissemination. Documents were sought through a combination of literature searches, review of document databases, and targeted document sourcing for documents relevant to contemporary dietetic practice. Framework analysis was used to analyse the data, with the thematic framework including four categories: (i) Aboriginal and Torres Strait Islander peoples, (ii) Consumer perspectives, (iii) Contemporary and future dietetic roles, and (iv) Contemporary wording and structure of competency. All included documents were indexed and charted which informed revisions to the standards.

Results

Sixty-seven documents were reviewed. Four new competency standards were added to address the skills and attributes required of dietitians to work effectively with Aboriginal and Torres Strait Islander peoples. One competency standard was modified to include an individualized approach as this was deemed important by consumers but not previously included in the standards. The revised standards also place greater emphasis on dietitian's role in teaching and learning. In addition, there are now multiple standards that refer to advocacy, sustainability is referenced multiple times, a new standard specific to advanced care planning has been included, and their structure and wording was revised to ensure it was contemporary.

Conclusion

Using document analysis to revise competency standards offers an efficient and low-cost method to update competency standards in a resource poor environment. This addresses a key issue with competency standards where unless revised frequently they can become rapidly out of date. Further research is needed to learn if document analysis can be used as a method to create rather than revise competency standards.

A Six-Step Model for Developing Competency Frameworks in the Healthcare Professions

Competency frameworks are developed for a variety of purposes, including describing professional practice and informing education and assessment frameworks. Despite the volume of competency frameworks developed in the healthcare professions, guidance remains unclear and is inconsistently adhered to (perhaps in part due to a lack of organizing frameworks), there is variability in methodological choices, inconsistently reported outputs, and a lack of evaluation of frameworks. As such, we proposed the need for improved guidance. In this paper, we outline a six-step model for developing competency frameworks that is designed to address some of these shortcomings. The six-steps comprise [1] identifying purpose, intended uses, scope, and stakeholders; [2] theoretically informed ways of identifying the contexts of complex, "real-world" professional practice, which includes [3] aligned methods and means by which practice can be explored; [4] the identification and specification of competencies required for professional practice, [5] how to report the process and outputs of identifying such competencies, and [6] built-in strategies to continuously evaluate, update and maintain competency framework development processes and outputs. The model synthesizes and organizes existing guidance and literature, and furthers this existing guidance by highlighting the need for a theoretically-informed approach to describing and exploring practice that is appropriate, as well as offering guidance for developers on reporting the development process and outputs, and planning for the ongoing maintenance of frameworks.

Competency-Based Education: Developing an Advanced Competency Framework for Indonesian Pharmacists

Introduction: Pharmacists need to be adaptable, flexible, and capable of advancing their practice to adapt to rapidly changing population health needs. We describe an educational approach to pharmacy workforce transformation in Indonesia through an advanced practice competency framework development using an "adopt and adapt" methodology. Methods: The competency framework development process comprised a translation phase, an adopt and adapt phase, validation through a nationwide mapping survey, and a completion phase through leadership consensus panels. We conducted a forward-backwards translation of a previously validated Advanced to Consultancy Level Framework (ACLF) to yield the Indonesian Advanced Development Framework (IADF) draft. The subsequent adoption and adaptation process was conducted through a series of consensus panels. We validated the IADF through a nationwide workforce survey. The final phase included leadership consensus panels with the professional leadership body in Indonesia. We analyzed the qualitative data thematically and the quantitative data using a Multiple Correspondence Analysis (MCA) technique. Results: We identified conceptual challenges in adopting and adapting the existing ACLF, which were addressed by providing a national glossary and concrete examples. A total of 6,212 pharmacists participated in the national workforce survey, of which 43% had <2 years of post-license (post-registration) experience. The MCA results showed that practitioner self-assessment to the IADF could discriminate their career development stages. The results also indicated a four-stage career model (including early years career training). Embedding this model in a structured national training program will enhance the professional workforce development through a more structured career journey. Conclusions: We describe the first validation of an advanced competency development framework for the pharmacy workforce in a non-Anglophone country, showing the possibility of transnational applicability of this framework. We argue that this methodology can be used in Low and Middle-income countries (LMICs) for the more rapid advancement of pharmaceutical care practice.

Stakeholder Engagement in Competency Framework Development in Health Professions: A Systematic Review

Competency framework development in health professions has downstream implications for all relevant stakeholders, from the professionals themselves, to organisations, and most importantly end users of services. However, there is little guidance related to what stakeholders might be involved in the competency development process, and when. This review aimed to systematically review literature related to competency framework development methodology in health, to identify the breadth and purpose of key stakeholders commonly involved in the process. Studies were identified using five electronic databases (MEDLINE, PubMed, CINAHL, EMBASE, and ERIC) and a search of websites of organisations involved in curriculum or regulation using keywords related to competency frameworks. The total yield from all databases was 10,625 results, with 73 articles included in the final review. Most articles were from Australia (30%) and were conducted in the nursing (34%) profession. Unsurprisingly, practitioners (86%) and academics (75%) were typically engaged as stakeholders in competency framework development. While many competency frameworks were described as patient-focused, only 14 (19%) studies elected to include service users as stakeholders. Similarly, despite the multi-disciplinary focus described in some frameworks, only nine (12%) studies involved practitioners from other professions. Limiting the conceptualisation of competence to that determined by members of the profession itself may not provide the depth of insight required to capture the complexity of healthcare and address the needs of important stakeholder groups. Future methodology should attempt to engage a variety of relevant stakeholders such as external health professions and the community to match professional education to health service demands. Systematic Review Registration: https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=128350.

Evaluation of the agreement, adoption, and adherence to the evidence-based guidelines for the nutritional management of adult patients with head and neck cancer among Australian dietitians

AIM

Evidence-based guideline translation to practice can improve outcomes but is often impaired by poor implementation. This project aimed to evaluate the implementation of the Evidence-based guidelines for the nutritional management of adult patients with head and neck cancer among Australian dietitians providing clinical care to this population.

METHODS

A questionnaire was developed, with face and content validity confirmed by an expert panel (n = 13), to gauge participant perceptions of the guidelines against an implementation evaluation framework. Dietitians were identified through Dietitians Australia and by contacting experts in the field. Eligibility was determined by questionnaire completion and prior guideline awareness. Responses were provided using a 5-point Likert scale. Results were analysed using descriptive statistics; with inferential analysis to determine if demographic information could reveal trends in guideline use and perception.

RESULTS

Of the 43 initial respondents, n = 28 completed the questionnaire, with n = 24/28 (86%) meeting full eligibility criteria for analysis. Median (range) scores for all four domains were high: awareness (4.0 [3.2-4.8]), agreement (4.4 [4.1-4.7]), adoption (3.5 [3.1-3.9]), and adherence (4.3 [4.1-4.9]). However, perception of guideline awareness and use among multidisciplinary team colleagues was low (mean 3.2/5.0 and 3.1/5.0, respectively). Dietitians with <10 years' experience had significantly higher perceptions of the guidelines' ability to positively influence practice; support evidence-based practice; and enhance dietitian credibility (P = 0.04) vs dietitians with ≥10 years' experience.

CONCLUSION

Dietitians demonstrated high rates of guideline implementation and positive perceptions for its use in clinical practice. Future implementation strategies and evaluation should expand to engage the wider multidisciplinary team and more experienced clinicians.

Implementing programmatic assessment transforms supervisor attitudes: An explanatory sequential mixed methods study

INTRODUCTION

Programmatic assessment (PA) is an increasingly popular approach to competency-based assessment (CBA), yet evaluation evidence is limited. This study aimed to identify and explore supervisor attitudes before and after implementing a novel PA using a sequential explanatory mixed methods design. In phase one, a survey was used to identify supervisor perspectives on work-based placements, PA and CBA. Survey results were then applied to develop focus group questions to further explore supervisor attitudes.

RESULTS

PA was found to improve supervisor-student relationships by removing high-stakes assessment decisions and creating greater capacity for feedback and teaching, leading to a productive learning environment. Assessment was perceived as an important role and supervisors wanted to feel valued and heard within PA. Trust was conceptualised as a triad between supervisor, student and university, and enabled supervisors to engage with PA which was important for success. Supervisor learning of PA was experiential and often supported by students, highlighting the need for hands-on training.

CONCLUSION

Participants reported a high level of agreement with PA and CBA principles which may have made them amenable to educational change. Further research is needed to explore the experience of all stakeholders and to understand how worldviews and culture influence assessment initiatives.

The revision of competency standards for occupational therapy driver assessors in Australia: A mixed methods approach

INTRODUCTION

Competency standards outline the knowledge, skills, and attributes that are required for competent practice. This study describes the process followed to revise and validate the competency standards for occupational therapy driver assessors in order to guide clinical practice in this area of advanced occupational therapy practice.

METHODS

A mixed methods research approach was used in this study. In phase 1, three focus groups with driver assessors reviewed and suggested revisions to the competency standards for occupational therapy driver assessors. Phase 2 involved content validation with key stakeholders through a focus group with consumers, written feedback from Australian state, and territory driver licensing authorities, and a two-round Delphi process with Australian occupational therapy driver assessors.

RESULTS

Forty-nine occupational therapy driver assessors participated in the phase 1 focus groups. Deductive content analysis of the transcripts provided data to revise the competency standards. Inductive analysis provided an in-depth understanding of the participants' views and was interpreted through six categories and their underlying subcategories: purposes and benefits; jurisdictional variations and practice diversity; language use; defining competent practice; challenging systems and processes; and competency standards content. Forty-eight occupational therapy driver assessors participated in the Delphi process. In Round 1, only 1 of the 164 competency standards and practice behaviours rated did not achieve the pre-determined 70% consensus rate. In Round 2, all statements achieved consensus, with the overall average consensus level obtained across the Round 2 statements at 96.8%.

CONCLUSION

The revised Australian Competency Standards for Occupational Therapy Driver Assessors have been endorsed by Occupational Therapy Australia and released for clinical use. The methods described in this research provide a framework suitable for revision or development of competency standards in both other areas of occupational therapy practice and other health-care professions.

Key concepts for dietetic curriculum: An observational study of Australian dietitians' perceptions

AIM

A concept-based approach to dietetic curriculum design has been proposed to prevent content overload and promote critical thinking. Fifty-six concepts were identified in a previous study. The aim of the present study was to investigate whether the dietetic profession views these concepts as representative of current practice and key for nutrition and dietetics education, and identify any new or emerging concepts.

METHODS

Accredited Practising Dietitians (APDs) were invited to participate in a self-administered online survey that included scale responses on the relevance of the 56 concepts and open-ended suggestions of additional concepts. Respondent characteristics were also collected.

RESULTS

Ninety-eight APDs completed the survey. Greater than 65% of respondents agreed/strongly agreed that all 56 concepts were relevant. There was less agreement on the concepts of acid-base balance; leadership; management; physical activity, exercise and health; quality assurance and improvement; risk; safety; stakeholder; standards; sustainability; systems and technology and health informatics. Respondents working in regional, rural and remote areas were less likely to agree that leadership was a key concept (χ²  = 4.45, P = .035). Respondents working in teaching and education were more likely to agree that sustainability was a key concept (χ²  = 7.02, P = .008). No new concepts were identified.

CONCLUSIONS

The existing 56 concepts were considered key for nutrition and dietetics education. Although the respondents to this survey view these concepts as relevant to current practice, this may not represent the entire profession. It is yet to be determined if the concepts will meet future priorities for the dietetic workforce.

The development of competency frameworks in healthcare professions: a scoping review

Competency frameworks serve various roles including outlining characteristics of a competent workforce, facilitating mobility, and analysing or assessing expertise. Given these roles and their relevance in the health professions, we sought to understand the methods and strategies used in the development of existing competency frameworks. We applied the Arksey and O'Malley framework to undertake this scoping review. We searched six electronic databases (MEDLINE, CINAHL, PsycINFO, EMBASE, Scopus, and ERIC) and three grey literature sources (greylit.org, Trove and Google Scholar) using keywords related to competency frameworks. We screened studies for inclusion by title and abstract, and we included studies of any type that described the development of a competency framework in a healthcare profession. Two reviewers independently extracted data including study characteristics. Data synthesis was both quantitative and qualitative. Among 5710 citations, we selected 190 for analysis. The majority of studies were conducted in medicine and nursing professions. Literature reviews and group techniques were conducted in 116 studies each (61%), and 85 (45%) outlined some form of stakeholder deliberation. We observed a significant degree of diversity in methodological strategies, inconsistent adherence to existing guidance on the selection of methods, who was involved, and based on the variation we observed in timeframes, combination, function, application and reporting of methods and strategies, there is no apparent gold standard or standardised approach to competency framework development. We observed significant variation within the conduct and reporting of the competency framework development process. While some variation can be expected given the differences across and within professions, our results suggest there is some difficulty in determining whether methods were fit-for-purpose, and therefore in making determinations regarding the appropriateness of the development process. This uncertainty may unwillingly create and legitimise uncertain or artificial outcomes. There is a need for improved guidance in the process for developing and reporting competency frameworks.

E-portfolios and Entrustable Professional Activities to support competency-based education in dietetics

The concept of Entrustable Professional Activities, recently pioneered in medical education, has emerged to support the implementation of competency-based education. Although competency-based frameworks are widely used in healthcare professional education to develop outcomes-based curricula, assessment of student competency in professional placement settings remains challenging. The novel concept of Entrustable Professional Activities together with established methods of competency assessment, namely e-portfolios and self-assessment, was implemented in the "[La Trobe University Dietetic program in 2015-2016. This study aimed to appraise the e-portfolio and evaluate the use of Entrustable Professional Activities to assess competence. A mixed-methods evaluation, using qualitative and quantitative surveys with follow-up structured consultations, was conducted with final year dietetics students and their supervisors. Dietetics students were comfortable with Entrustable Professional Activities and competency-based assessment, whereas supervisors preferred Entrustable Professional Activity based assessment. All stakeholders valued student self-assessment and the ongoing use of structured e-portfolios to develop and document competency. The use of structured e-portfolios, student self-assessment, and the emerging concept of Entrustable Professional Activities are useful tools to support dietetics student education in professional placement settings.

A model of the multidimensional nature of experienced dietitian clinical decision-making in the acute care setting

BACKGROUND

Clinical decision-making (CDM) is an essential component of dietetic practice that can significantly affect the quality of patient care. Research around CDM in clinical dietetics is scarce, with research in other healthcare professions offering limited insight into dietitian CDM in the specific setting of the acute care hospitals. The aim of this qualitative research was to deepen our understanding of the nature of the CDM of experienced dietitians in the acute care setting.

METHODS

The present study employed philosophical hermeneutics to guide methods situated within the interpretative paradigm. This study invited dietitians currently practising in adult acute care hospitals with at least 3 years of experience to be involved two in-depth semi-structured interviews using the principles of hermeneutics. A reference focus group session was then used to provide rigour and further interpretation of the findings.

RESULTS

Ten dietitians participated in the interviews and five of these same participants in the reference focus group. The findings have informed the development of A Model of the Multidimensional Nature of Dietitian CDM in the Acute Care Setting, which reflects the nature of making decisions for patient care through the synergistic relationship between five key dimensions: (i) tasks; (ii) interactions; (iii) reasoning; (iv) practitioner factors; and (v) context, all of which are managed and monitored by the higher- order reasoning process of the dietitian's clinical judgement.

CONCLUSIONS

Because there is scarcity of research on the CDM of dietitians in acute care settings, the present study can provide training and professional development insights to managers, educators and supervisors.

Hidden Jedi: A critical qualitative exploration of the Fellow credential and advanced expertise

AIM

The present study aimed to describe the characteristics of a Fellow and critically review factors relevant to recognition and promotion of excellence within the profession of dietetics in Australia.

METHODS

Through the development of revised Competency Standards for the Fellow credential, a critical qualitative approach drawing on action research was used whereby members of the profession were given a voice in the research process. Six focus groups with a total of 30 participants explored descriptions of expertise and perceptions of Fellow by the profession and determinants of uptake. Focus groups were conducted during February and March 2018. Data were examined using a thematic analysis approach, with additional meaning explored through cultural historical activity theory. Participants/setting - A purposive sample of Australian dietitians.

RESULTS

Fellows embodied leadership, impact, influence, innovation and inspiration, internal and external to the profession and this was reflected in the revised Competency Standards. Potential Fellows perceived they were not capable of achieving the standard required. A lack of recognition of the credential both from within the community of dietetics, and externally, was identified. The role of the social system in which these credentials operate including the role of the professional association in awarding the credential are relevant.

CONCLUSIONS

Changes to the standards, and the system, may improve perceptions and uptake of the credential. This example provides highly relevant insights for the profession internationally.

Toward a Global Definition of Professionalism for Nutrition and Dietetics Education: A Systematic Review of the Literature

BACKGROUND

Professionalism of health care practitioners is central to safe and ethical health care, and forms part of the trust that the public places in health care practitioners. Lapses in professionalism in health care present considerable challenges and can have serious consequences and outcomes. Teaching, learning, and assessing professionalism is an important component of nutrition and dietetics education. There is scant peer-reviewed published research related to professionalism in nutrition and dietetics. Providing a definition of professionalism will support progress in curriculum planning and design, teaching, learning and assessment of students, and ongoing professional development of educators and practitioners.

OBJECTIVE

The aim of this study was to conceptualize and define professionalism for the purpose of teaching nutrition and dietetics.

DESIGN

This study included a critical systematic literature review of original research and a targeted and systematic search of national and international dietetics competency standards, exploring the concept and definitions of professionalism in nutrition and dietetics. Competency standards were chosen as an additional focus in the systematic literature search, as they are the key framework documents that guide curriculum development and education standards internationally. Thematic analysis was used to synthesize extracted data and an inductive, interpretivist approach was then applied in conceptualizing a definition of professionalism.

RESULTS

Seven studies and six national and international sets of competency standards were included in the literature review. Four major themes conceptualizing a definition of professionalism for nutrition and dietetics were identified from the integration of the original research and targeted gray literature reviews: 1) personal attributes; 2) interpersonal communication; 3) approach to practice; and 4) commitment to lifelong learning.

CONCLUSIONS

Defining professionalism for nutrition and dietetics supports progress toward shared understandings, building trust, and assisting in dietetics education and practice. It can be used to support and extend teaching, learning, and assessment of professionalism.

The contested space: The impact of competency-based education and accreditation on dietetic practice in Australia

AIM

Competency-based Education (CBE) has underpinned the education of dietitians in Australia since the first Competency Standards (CS) were published; however, little is known about how CBE has influenced dietetic practice. The aim of this paper is to explore how a CBE framework and the CS have influenced dietetic practice in Australia since 1990.

METHODS

A qualitative investigation explored concepts of dietetic practice. Data analysed were original interviews previously undertaken with recent graduate dietitians during 1991 (n = 26), 1998 (n = 23) and 2007 (n = 19) and seven guided discussions with dietitians and employers (n = 28) conducted in 2014 to identify themes. The DAA Competency Standards and Accreditation Manuals/Standards since 1990 were also analysed to triangulate the interview data and to investigate how the CS were interpreted.

RESULTS AND CONCLUSIONS

Themes identified from interviews included: (i) communicating for better care, (ii) scientific enquiry for effective practice, (iii) critical thinking and evidence-based practice and (iv) professionalism, which remained core to dietetic practice over time, but leadership, advocacy, business management and entrepreneurial skills have emerged more strongly as the scope of practice has diversified. The landscape in which dietitians' practice showed increasing complexity and clear boundaries separating professional roles were disappearing. The 2015 CS and the 2017 Accreditation Standards highlighted that competency remains a shifting construct and that professional behaviours change depending on economic and political reasons in the play of power. Accreditation policy and current standards have successfully maintained a standard of dietetic practice across a diverse country but have the potential to constrain innovation.

The use of advanced web-based survey design in Delphi research

AIM

A discussion of the application of metadata, paradata and embedded data in web-based survey research, using two completed Delphi surveys as examples.

BACKGROUND

Metadata, paradata and embedded data use in web-based Delphi surveys has not been described in the literature. The rapid evolution and widespread use of online survey methods imply that paper-based Delphi methods will likely become obsolete. Commercially available web-based survey tools offer a convenient and affordable means of conducting Delphi research. Researchers and ethics committees may be unaware of the benefits and risks of using metadata in web-based surveys.

DESIGN

Discussion paper.

DATA SOURCES

Two web-based, three-round Delphi surveys were conducted sequentially between August 2014 - January 2015 and April - May 2016. Their aims were to validate the Australian nurse practitioner metaspecialties and their respective clinical practice standards. Our discussion paper is supported by researcher experience and data obtained from conducting both web-based Delphi surveys.

IMPLICATIONS FOR NURSING

Researchers and ethics committees should consider the benefits and risks of metadata use in web-based survey methods. Web-based Delphi research using paradata and embedded data may introduce efficiencies that improve individual participant survey experiences and reduce attrition across iterations. Use of embedded data allows the efficient conduct of multiple simultaneous Delphi surveys across a shorter timeframe than traditional survey methods.

CONCLUSION

The use of metadata, paradata and embedded data appears to improve response rates, identify bias and give possible explanation for apparent outlier responses, providing an efficient method of conducting web-based Delphi surveys.

Development of advanced practice competency standards for dietetics in Australia

AIM

This study aimed to explore the work roles, major tasks and core activities of advanced practice dietitians in Australia to define the Competency Standards for advanced practice.

METHODS

A qualitative approach was used to review advanced dietetic practice in Australia involving experienced professionals, mostly dietitians. Four focus groups were conducted with a total of 17 participants and an average of 20 years experience: 15 dietitian practitioners plus 2 employers (1 dietitian and 1 non-dietitian). The focus groups explored the key purpose, roles and outcomes of these practitioners. Data from the focus groups were confirmed with in-depth interviews about their core activities with a purposive sample of 10 individuals recently recognised as Advanced Accredited Practising Dietitians. Data from both focus groups and interviews were analysed adductively to identify key themes.

RESULTS

The key theme that emerged to define advanced dietetics practice was leadership, with four subthemes that described in more detail the major work roles and outcomes of advanced practice. These subthemes identified that advanced practitioners were (i) outcome-focused, having impact; (ii) influence others and advocate; (iii) innovate and embrace change; and (iv) inspire others and are recognised for their practice. These outcomes were conceptualised within a broad generalist framework to generate revised Competency Standards.

CONCLUSIONS

This study confirmed that leadership rather than specialist practice skills is the key determinant of advanced practice.

Dietetics students' construction of competence through assessment and placement experiences

AIM

Competency standards are widely adopted as a framework to describe standards of performance required in the workplace. Little is known, however, about how students construct competence. This qualitative study aimed to explore how dietetics students ready to graduate construct the concept of competence and the role of assessment in developing professional competence.

METHODS

A qualitative description was used to gather data from a convenience sample of students ready to graduate from universities with accredited dietetics programs across Australia (10 out of 15 at the time of the study). A total of 11 focus groups were conducted to explore perspectives of competence and experiences of 'competency-based' assessment. Data were audio-recorded, transcribed and analysed using a thematic analysis approach.

RESULTS

A total of 81 (n = 81) participants across 10 universities representing 22% of total students participated in the focus groups. Themes revealed that: (i) there is no shared understanding of competence; (ii) current work placement experiences may not reflect current standards or workforce needs; (iii) assessment approaches may not fully support the development of competence; and (iv) the competent performance of supervising dietitians/clinical educators in the workplace influences the construction of competence.

CONCLUSIONS

There is a need to work towards a shared understanding of dietetic entry-level competence in the profession. 'Work-based' learning experiences may need to be modified to ensure students meet current competency standards. Practitioners involved in student supervision need to acknowledge the influential role they have in the development of the future workforce.

Attributes of the complete dental record: a Delphi approach to standards

BACKGROUND

Adherence to the Dental Board of Australia Guidelines on dental records is not universal and remediation of deficient practise requires clarity in the practical application of standards. The aim of this research is to clarify practical requirements of dental record keeping in New South Wales.

METHODS

Seventeen experts were invited to participate in an electronically administered series of Delphi questionnaires. Concepts were refined until consensus was reached.

RESULTS

Two rounds were required to achieve a satisfactory level of consensus (>80%). A high level of consensus was obtained across the two rounds, with 72% and 86% agreement on propositions in the first and second rounds, respectively. Consensus criteria were established in 14 domains to establish attributes of the complete dental record (ACDR).

CONCLUSIONS

The ACDR may supplement existing national guidelines and are likely to be useful in a remediation context in which clear, unambiguous expectations for conduct are paramount.