The State of the Clinical Dietetics Industry

By Sara Griffin, MS, RDN, CNSC

For the first time in decades, clinical dietitians have powerful bargaining power. What changed?

Clinical dietetics used to be the job everyone wanted. It was once very normal for dietitians to work in hospitals and long term care facilities for the first few years of their career. But, it’s no secret that dietitians have been leaving clinical jobs for decades. I haven’t talked to a single intern or new dietitian in the past four years whose goal is to land a clinical job. These positions are seen as fallbacks–temporary gigs that can pay the bills until something better comes along. Private practice is the new “it” thing. What happened to cause this drastic shift in the industry?

To some extent, this is a fairly normal economic phenomenon. When an industry is saturated with employees, jobs fill up quickly and people have to compete for jobs. This drives down wages. As wages decrease, incoming graduates seek other positions that pay better, and employees begin to leave low paying positions. 

The same thing is happening in the inpatient clinical dietetics world*. These are hands-on, in-person, intense jobs that require you to be “on the ground” working all day. Inpatient jobs in hospitals and long term care facilities often don’t offer remote work, flexible hours, or unlimited PTO. Millennials and Gen Z (anyone who is 18-43 years old) are interested in flexibility, work-life balance, and four day work weeks¹¹–all things that most inpatient dietitian jobs don’t provide. Many of us are burnt out, tired of being overworked and underpaid. Who wants to be placing feeding tubes and charting stool output when you can be sipping a nitro cold brew in a local coffee shop, or working from your living room? 

Dietitians are leaving hospitals in droves, in favor of remote work and online private practices. 48% of clinical nutrition managers surveyed recently said 2022-2023 saw higher turnover than the previous five years⁴. New dietitians are the first to go–those with less than three years’ experience are leaving at record rates to pursue another career, or another job within the field. The US is not alone; dietitians are leaving hospitals at historic rates in Canada and abroad⁹. The CEO of Dietitians on Demand, a well-known dietitian staffing company, reported a 500% increase in job openings in 2021⁶. CDR registry data shows dietitians working inpatient jobs dropped from 38% in 2021 to 28% in 2024. This represents a drastic 10% decrease (or approximately 11,000 employees) of inpatient clinical dietitians in just three years

Of course, leaving low-paying positions that run employees into the ground is a healthy move. The 2021 Great Resignation hit every industry in the US, with employees citing disrespect, low pay, and no opportunity for advancement as their top three reasons for leaving¹⁰. Companies now know they need to offer flexibility and better benefits in order to remain competitive. But, something else is going on in the dietetic industry. An estimated 23% of US employees quit jobs in 2021–so this only partially explains the drastic spike in dietitian job openings. 

It’s no secret that wages for inpatient clinical dietitians have been low for far too long. Many don’t make a livable wage, especially as inflation and cost of living have far outpaced raises in the past four years. It’s hard to know exactly why this has happened, but I believe lack of licensure protecting the scope of dietitians, failure of insurance companies to recognize and bill for dietitian services, failure to advocate for ourselves and the profession, and failure on our part to negotiate are largely to blame for the wage “valley” we have been trapped in. 

In many states, anyone can call themself a nutritionist and provide nutrition counseling (and, many do). Staffing agencies, managers, and even hospital administrators don’t know what clinical dietitians really do all day. We often get lumped in with the foodservice department, and it is assumed that we mostly write meal plans and recipes. In fact, clinical dietitians are at the forefront of evidenced-based medicine. We maintain a high level of competency, with higher standards for ethical practice than required anywhere else in the industry. Credentials such as CNSC and CBDCE require maintenance and re-examination. Clinical dietitians practice at the top of their scope, performing nutrition-focused physical exams, diagnosing protein calorie malnutrition, writing enteral and parenteral orders from scratch, being a critical part of the interdisciplinary team, rounding with doctors, and even placing feeding tubes. The pandemic elevated us to the status of “healthcare heroes”, illuminating the previously invisible work of the dietitian. We showed up, and we saved lives. 

Not only are we a huge value added for the hospital, laws require us to assess and care for at-risk patients. In fact, ASPEN and ESPEN now recommend a dietitian be part of a PN order-writing team. An international summit for parenteral nutrition safety recommends that experienced, trained dietitians be part of every parenteral nutrition team, with 100% expert consensus³. Drs. Sriram and Cresci, in a Letter to the Editor in 2022, lamented the Society for Critical Care Medicine’s failure to name dietitians as vital members of the interdisciplinary team: “The dietitian is the most knowledgeable member of the interprofessional healthcare team with respect to identification of malnutrition, macro- and micronutrient requirements, and the type of the nutrition support therapy indicated…it is impossible to provide optimal care to critically ill patients without the participation of dietitians.” 

Healthcare professionals on all sides recognize our worth–why can’t we? A whopping 76% of dietitians still struggle with imposter syndrome⁸. 

A dietetic internship is the pipeline to becoming a Registered Dietitian Nutritionist. But, the internship is in bad shape. Dietetic interns from 2022-2023 decreased by 35% (DPD match and pre-select)¹. There were 2405 unfilled positions after last year’s DICAS match, the first time ever where we saw more unfilled internship positions than filled positions¹. In just 10 years, unfilled internship positions have increased by a factor of seven¹. At the same time, match rates have been steadily increasing since 2017 (55% → 85%)¹. This means, not only is the industry upside-down (significantly fewer interns year over year), but competition for these previously very competitive internship spots have almost entirely disappeared. 

The Bureau of Labor Statistics predicts demand for dietitians to increase 7% in the next decade (2022-2032)⁷. The Academy of Nutrition and Dietetics predicts need for dietitians to increase substantially in the next 10 years, as rates of chronic diseases continue to trend upwards². But, with our internship programs hemorrhaging, what will this mean for the future? 

In 2020, ACEND decreased the internship from 1200 to 1000 hours. Many programs have trimmed down their clinical rotations, and many new dietitians are no longer prepared to practice at a high competency level after graduation. First time testers used to pass the RD exam at high rates (87% in 2016); now they are down to 60%⁵. Pass rates for the RD exam are so low that CDR is offering a bundle voucher, assuming the average intern won’t pass on their first attempt. 

It will take many years to see the true impact the Master’s requirement has on our industry. The Future Education Model is so new, it will take a while for universities and internships to sort things out (and they are working very hard to do so). Technological advancements such as partnering with nursing skills labs and using dummies and AI to practice clinical skills may be the new rising star of the dietetic education system. High-quality virtual education such as digital course content may be a key component of future dietetics education, allowing interns to complete coursework from anywhere (perhaps even while working a job to afford the program). Undergraduate, graduate and internship programs will have to be creative to remain competitive. 

The Academy of Nutrition and Dietetics recognizes that times are changing. A 2023 FNCE presentation addressed this head-on, citing the Great Resignation and the “extended timeline” to becoming a dietitian causing a “delay” in dietitians sitting for the credentialing exam (and, as we know, pass rates for the exam have dwindled, creating an even longer delay until new dietitians are ready to enter the workforce). Staffing shortages among dietitians have just begun

I believe this situation is ripe with opportunity for existing clinical dietitians. There has never been a better time to advocate for higher wages for yourself and your colleagues. In this post-pandemic world where cost of living and inflation have risen at record rates, where the value of the healthcare worker has been proven, where hospital systems have withstood the test of time and are now desperate to maintain loyal, experienced employees–now is the time. Benefits are increasing across the board. 

For the first time ever, I’m hearing stories of dietitians asking for more money and getting it. Hospitals are offering retention and sign-on bonuses, and better benefits. A quick look at Indeed will prove that wages for inpatient clinical dietitians are at all-time highs, and continuing to increase. Experienced dietitians who have been at a company for 10+ years and/or are highly specialized (nutrition support, renal, bariatrics) are the most sought-after practitioners of all. 

In 2021, Dietitians on Demand CEO Ryan Davis was already suggesting wages for dietitians need to jump another $10-$20 an hour. Inpatient clinical dietitians who remain in the industry, particularly those who have experience and a specialty, are rapidly becoming the unicorns of the dietetics world. Dr. Paul Wischmeyer, an internationally-recognized nutrition expert and staunch advocate for the dietetics profession, posted on LinkedIn recently, “We must pay dietitians more! RDs change lives & save lives everyday…When are we going to start compensating them fairly for all they do for our patients?” 

Now is the time to do your research, advocate, and negotiate. Celebrate any dietitian who makes more than you (and ask them how they did it). For a few years now, hospitals have been hiring new dietitians in at higher wages than existing dietitians. It’s tempting to be threatened by this, but I see this as a huge step in the right direction. If hospital administrators and hiring managers recognize the value of an RDN without any experience, wages for experienced dietitians will only continue to increase. As Stacey from Nutrition Jobs, a dietitian who empowers other dietitians to live their best work lives reminds us, “A rising tide lifts all ships.” 

The best (and often only) time to negotiate is before you sign a job contract. It is substantially more difficult to increase your wage once you are in a job. You can expect a 3% increase per year to account for inflation, and sometimes a few percent for exemplary performance. If you are promoted, you will have the opportunity to negotiate again (but, promotions in this world are hard to come by, as most facilities don’t offer a career ladder). 

I did not negotiate when I was offered my first clinical position. Had I negotiated and gotten just another $2/hour (and invested that money), I would have 1.5 million dollars stashed away by the time I retire. Of course, it’s hard to imagine negotiating at your first job. I was filled with imposter syndrome, really needed a job, and naively assumed my boss would offer me a fair wage. The truth is that most managers expect you to negotiate, and so many dietitians leave money on the table when we don’t**. 

Stephanie Schwartz, an experienced clinical dietitian, shared that her first inpatient job felt like “gold” after slogging through an internship in pricey New York. This experience is very common in the industry–desperate to start making money and painfully aware of the competitive job market, many of us failed to negotiate. The good news is, this is now a thing of the past.

Dietitian managers can advocate for the profession from within, by offering fair wages and a clear promotion pathway to their employees. This is already happening, particularly at large companies who staff clinical dietitians, and it’s setting the stage for wages to continue climbing upwards.

If you are stuck in a low-paying clinical job with bad office culture that isn’t changing, it might be time to jump ship. Know when it’s time to move on, learn negotiation tactics, networking tips (beyond the obvious), how to practice at top of scope, how to advocate for the profession, and more in my new course, launching Fall 2024

It’s an exciting time to be a clinical inpatient dietitian. Not only are we at the forefront of evidence-based medicine, but we are being recognized for our achievements and beginning to be compensated more fairly. I expect this trend to continue–clinical dietitians in hospital settings will continue to see improved wages and more competitive benefits. Dietitian managers and RDNs who work at large companies will continue to advocate for higher wages for their staff. And, particularly as these jobs become less competitive, we will all be more prone to negotiate. 

In a 1999 Journal of the Academy of Nutrition and Dietetics Editor’s Letter, industry experts predicted dietitians would be “in a better position than the rest of the workforce.” Citing increased demand for dietitians, improved physician relationships, and healthcare changes, the authors energetically asserted that “the future looks bright for dietetics.” Though no one at that time could have predicted a worldwide pandemic and the extreme changes our profession has undergone in the years following, I am tempted to agree that our future, however erratic it may seem at this moment, remains bright.

 

*This by no means excludes other dietitians who are experiencing similar trends. Because my career has always been in the clinical inpatient world and these trends affect that particular area of dietetics the most, this article is focused there.

**Unionized dietitians may be exempt from negotiation due to collective bargaining. 

Works Cited

  1. Academy of Nutrition and Dietetics. ACEND Data. Eatrightpro.org. Accessed March 18, 2024. https://www.eatrightpro.org/acend/about-acend/acend-data.

  2. Academy of Nutrition and Dietetics. Dietitian Job Outlook. Eatrightpro.org. Accessed March 18, 2024. https://www.eatrightpro.org/acend/students-and-advancing-education/career-information/dietitian-job-outlook#:~:text=The%20U.S.%20Bureau%20of%20Labor,on%2Dgoing%20U.S.%20health%20crisis.

  3. Ayers P, Berger MM, Berlana D. et al. International safety and quality of parenteral nutrition summit: summary of proceedings and expert consensus statements. Submitted for publication. American Journal of Health-System Pharmacy. 

  4. Brady L. Fewer future Dietitians: Top 5 remarkable reasons. Sage Nutrition Associates. November 1, 2023. Accessed March 18, 2024. https://sagerdn.com/fewer-future-dietitians/#:~:text=People%20are%20leaving%20areas%20like,to%20the%20previous%205%20years

  5. Commission on Dietetic Registration. DTR Exam Pass/Fail Statistics. https://www.cdrnet.org/dtr-exam-stats. Accessed March 18, 2024.

  6. Davis R. Competing for dietitian talent in unprecedented times. LinkedIn. November 30, 2021. Accessed March 18, 2024. https://www.linkedin.com/pulse/competing-dietitian-talent-unprecedented-times-ryan-davis/

  7. Dietitians and nutritionists : Occupational outlook handbook. U.S. Bureau of Labor Statistics. March 1, 2024. Accessed March 18, 2024. https://www.bls.gov/ooh/healthcare/dietitians-and-nutritionists.htm#:~:text=in%20May%202022.-,Job%20Outlook,on%20average%2C%20over%20the%20decade.

  8. Hernandez JL, Lopez NV. Impostor phenomenon in registered dietitians: An exploratory survey. BMC Nutrition. 2023;9(1). doi:10.1186/s40795-023-00720-1. 

  9. Hewko S, Oyesegun A, Clow S, VanLeeuwen C. High turnover in clinical dietetics: a qualitative analysis. BMC Health Serv Res. 2021 Jan 6;21(1):25. doi: 10.1186/s12913-020-06008-5. PMID: 33407423; PMCID: PMC7789381.

  10. Parker K. Majority of workers who quit a job in 2021 cite low pay, no opportunities for advancement, feeling disrespected. Pew Research Center. March 9, 2022. Accessed March 18, 2024. https://www.pewresearch.org/short-reads/2022/03/09/majority-of-workers-who-quit-a-job-in-2021-cite-low-pay-no-opportunities-for-advancement-feeling-disrespected/.

  11. Wade S. For generation Z, flexibility is more than a policy. LinkedIn. October 12, 2023. Accessed March 18, 2024. https://www.linkedin.com/pulse/generation-z-flexibility-more-than-policy-sophie-wade/.

About the Author

Sara Griffin, MS, RDN, CNSC is a currently practicing clinical dietitian specializing in critical care nutrition & nutrition support. She has precepted dozens of interns, and has received accolades for her precepting work. Sara was selected as Colorado Dietitian of the Year, and was recently nominated for an Academy of Nutrition and Dietetics Excellence in Practice award. She is a Duke Clinical Nutrition Fellowship student. To share questions or comments about the article, email sara@edge-clinical.com.