A qualitative examination of patients experiences of dietitians ' consultation engagement styles within nephrology

Background

Dietitians provide individuals with tailored, practical nutritional advice. For this reason, skills in effective interpersonal communication are essential. In the case of chronic kidney disease, the specifics of dietary advice may change according to renal function. The conveyance of accurate dietary advice and compliance is critical and requires full engagement with the service. The effect of communication styles on patients ' engagement experiences with renal dietetics is unknown. Accordingly, the present study aimed to explore patients ' engagement experiences with renal dietitians.

Methods

A qualitative phenomenology study using semi‐structured in‐depth interviews was undertaken with 20 adult renal service users who had engaged with renal dietitians to receive dietary advice. Interpretive phenomenological analysis was used to analyse data.

Results

Two main themes emerged from consultation experiences: helpful and unhelpful engagement styles. Individuals reporting helpful engagement styles experienced dietitians ' communication as empathetic, demonstrating positive regard for their lifestyles. However, individuals who reported experiences of unhelpful engagement styles found dietetic care indifferent and communication styles paternalistic. These individuals continued to engage reluctantly despite unhelpful engagement experiences, but felt disempowered. These diverse experiences of engagement can be interpreted by means of ‘ego states’ within the theoretical model of transactional analysis (TA). Adult ego states may underpin a helpful engagement style whilst a dietitians ' parental ego state was more likely to precipitate an unhelpful engagement style.

Conclusions

Ego states, in the context of TA theory, can help to explain the way in which patients engage with renal dietitians. Attention should be given to the employment of a humanistic approach within dietetic consultations. Dietitans need to ensure that they can demonstrate expertise and confidence in the specific communication skills required for patient‐centred care.     

Referrals to dietitians/nutritionists: A cross‐sectional analysis of Australian GP registrars’ clinical practice

Aim

The present study aimed to describe referral patterns of general practitioner (GP) registrars to dietitians/nutritionists. There is a paucity of research regarding GP referral patterns to dietitians/nutritionists. Limited data show increasing referrals from established GPs to dietitians/nutritionists. There are no data on GP registrar (trainee) referrals.

Methods

This was a cross‐sectional analysis of data from the Registrar Clinical Encounters in Training (ReCEnT) study. ReCEnT is an ongoing, multicentre, prospective cohort study of registrars, which documents 60 consecutive consultations of each registrar in each of the three six‐month GP training terms. The outcome factor in this analysis was a problem/diagnosis resulting in dietitian/nutritionist referral (2010–2015). Independent variables were related to registrar, patient, practice and consultation.

Results

A total of 1124 registrars contributed data from 145 708 consultations. Of 227 190 problems/diagnoses, 587 (0.26% (confidence interval: 0.23–0.29)) resulted in dietitian/nutritionist referral. The most common problems/diagnoses referred related to overweight/obesity (27.1%) and type 2 diabetes (21.1%). Of referrals to a dietitian/nutritionist, 60.8% were for a chronic disease, and 38.8% were related to a Chronic Disease Management plan. Dietitian/nutritionist referral was significantly associated with a number of independent variables reflecting continuity of care, patient complexity, chronic disease, health equity and registrar engagement.

Conclusions

Established patients with chronic disease and complex care needs are more likely than other patients to be referred by registrars to dietitians/nutritionists. Nutrition behaviours are a major risk factor in chronic disease, and we have found evidence for dietitian/nutritionist referrals representing one facet of engagement by registrars with patients’ complex care needs.     

Self-completed online dietary recalls as an alternative method of dietary assessment for dietetic outpatient appointments: A feasibility study

Background

Integrating digital dietary assessment within dietetic care could save time and reduce costs, at the same time as increasing patient engagement. The present study explores the feasibility of implementing a web-based dietary assessment tool, myfood24 ( https://www.myfood24.org ), into routine healthcare.

Methods

This mixed methods feasibility study recruited dietitians and patients from a National Health Service (NHS) hospital outpatient setting. Patients completed and shared three online 24-h dietary recalls in advance, which were used as a dietary assessment by dietitians. Recruitment data were collected and questionnaires on technology, usability, and acceptability were completed. Patient interviews and focus groups with dietitians were conducted.

Results

Eleven dietitians working in allergy, bariatrics, diabetes, oncology, general, renal, infectious diseases, and coeliac services took part with 39 patients. Recruitment rates were highest in bariatrics and lowest in renal and oncology. Compared to other studies, completion rates were good, with 29 (74.4%) completing three recalls despite lower technology readiness and software usability scores than in similar studies. Illness and difficulty with technology were reasons for non-completion. Opportunity to receive nutritional feedback from the tool and share this with a dietitian motivated patients to complete the record accurately. Consultation times were shortened in approximately one-third of appointments and a higher proportion of time was spent on nutritional education compared to usual practice. However, mean preparation time increased by 13 min per appointment because dietitians found nutritional analysis reports difficult to interpret.

Conclusions

It is feasible to introduce a digital dietary assessment tool into NHS dietetic practice. However, further development is needed to ensure that the tool is suitable for healthcare.     

Accuracy and confidence of allied health assistants administering the subjective global assessment on inpatients in a rural setting: a preliminary feasibility study

Aim

Malnutrition has a significant impact on patient outcomes and duration of inpatient stay. However, conducting timely nutrition assessments can be challenging for rural dietitians. A solution could be for allied health assistants (AHAs) to assist with these assessments. The present study aimed to assess the accuracy and confidence of AHAs trained to conduct the subjective global assessment (SGA) compared with dietitians.

Methods

A non‐inferiority study design was adopted. Forty‐five adult inpatients admitted to a rural and remote health service were assessed independently by both a trained AHA and dietitian within 24 hours. The order of assessment was randomised, with the second assessor blind to the outcome of the initial SGA. Levels of agreement were examined using kappa and percent exact agreement (PEA; set a priori at ≥80%). Rater confidence after each assessment was assessed using a 10‐point scale.

Results

Agreement for overall SGA ratings was high (kappa = 0.84; PEA 84.4%). PEA for individual sub‐components of the SGA ranged from 66.4 to 86.7%. Where discrepancies were identified in global SGA ratings, AHAs provided a more severe rating of malnutrition than dietitians. AHAs reported significantly lower confidence than dietitians (t = 4.49, P < 0.001), although mean confidence for both groups was quite high (AHA=7.5, dietitians = 9.0).

Conclusions

Trained AHAs completed the SGA with similar accuracy to dietitians. Using AHAs may help facilitate timely nutrition assessment in rural health services when a dietitian is not physically present. Further investigation is required to determine the benefits of incorporating this extended role into rural and remote health‐care services.     

‘We work in silos’: Exploring clinicians' perspectives on the dietary management of coronary heart disease and type 2 diabetes in an Australian public hospital and community health service

Aims

This study explored clinicians' perspectives on roles, practices and service delivery in the dietary management of coronary heart disease and type 2 diabetes in a public health service.

Methods

Semi-structured individual interviews were conducted with 57 clinicians (21 nurses, 19 doctors, 13 dietitians and 4 physiotherapists) involved in the care of relevant patients across hospital and post-acute community settings in a metropolitan health service in Australia. Interviews were audio-recorded, transcribed verbatim and analysed using inductive thematic analysis.

Results

A total of 3 themes with 10 subthemes were identified. (a) ‘Treatment prioritisation’: important role of nutrition in risk factor management; competing priorities with complex patients; weight loss as a priority; and dietitians individualise. (b) ‘Diverse roles in providing diet advice’: a tension between nutrients, restrictions and diet quality; patients seek and trust advice from non-dietitians; and providing nutrition information materials crosses professions. (c) ‘Dietitian access’: variable integration and resourcing; access governed by clinician discretion and perceived patient interest; and bespoke application of referral pathways.

Conclusions

Time and resource constraints, variable access and referral to dietitians, and inconsistent advice were key challenges in the dietary management of coronary heart disease and type 2 diabetes. Models of care may be improved with greater investment and integration of dietitians, including to provide professional support across disciplines and disease specialties.     

Discrepancies Between Australian Eating Disorder Clinicians and Consumers Regarding Essential Components of Dietetic Treatment

BackgroundA recent Delphi study indicated that, compared with eating disorder (ED) consumers and carers, ED specialists were less likely to endorse involvement of a dietitian as a standard component of treatment. In addition, there was disagreement between these groups regarding the inclusion of a number of components of dietetic treatment.ObjectiveThis study aimed to further investigate these data to identify areas of disagreement among ED specialist dietitians, ED specialist non–dietetic clinicians, consumers, and carers with regard to outpatient dietetic treatment.Design and participants/settingThe ED specialists panel from a previous Delphi study was recoded into 2 panels: ED specialist dietitians (n = 31) and ED specialist non–dietetic clinicians (n = 48) to compare responses of these panels with responses from consumers (n = 32) and carers (n = 23).Main outcome measuresStatements in 7 categories relating to referral to dietitian, essential components of outpatient dietetic treatment regarding 4 ED patient populations, strategies to promote multidisciplinary collaboration, and skills dietitians should possess if treating patients with an ED were rated on a 5-point Likert scale.Statistical analysis performedOne-way analysis of variance was conducted with post-hoc multiple comparisons to compare mean statement ratings.ResultsThirty-seven statements (30%) showed statistically significant differences (P < .05) in responses between panels. Discrepancies were primarily observed for statements regarding how and when dietetics is included in treatment and essential components of dietetic treatment, particularly the use of behavioral tasks, such meal plans and self-monitoring. Results also highlighted deficits in participants’ understanding of core responsibilities of dietitians in ED treatment and dietitians “drifting” from delivering evidence-based components of dietetic treatment.ConclusionsResults of this study show discrepancies among ED dietitians, clinicians, consumers, and carers regarding what dietetic treatment for people with EDs should encompass. It also indicates the need for further research into optimizing dietetic treatment for EDs that is conducted in collaboration with individuals with lived experience.     

Patient‐reported dietetic care post hospital for free‐living patients: a Canadian Malnutrition Task Force Study

Background

Transitions out of hospital can influence recovery. Ideally, malnourished patients should be followed by someone with nutrition expertise, specifically a dietitian, post discharge from hospital. Predictors of dietetic care post discharge are currently unknown. The present study aimed to determine the patient factors independently associated with 30‐days post hospital discharge dietetic care for free‐living patients who transitioned to the community.

Methodology

Nine hundred and twenty‐two medical or surgical adult patients were recruited in 16 acute care hospitals in eight Canadian provinces on admission. Eligible patients could speak English or French, provide their written consent, were anticipated to have a hospital stay of ≥2 days and were not considered palliative. Telephone interviews were completed with 747 (81%) participants using a standardised questionnaire to determine whether dietetic care occurred post discharge; 544 patients discharged to the community were included in the multivariate analyses, excluding those who were admitted to nursing homes or rehabilitation facilities. Covariates during and post hospitalisation were collected prospectively and used in logistic regression analyses to determine independent patient‐level predictors.

Results

Dietetic care post discharge was reported by 61/544 (11%) of participants and was associated with severe malnutrition [Subjective Global Assessment category C: odd's ratio (OR) 2.43 (1.23–4.83)], weight loss post discharge [(OR 2.86 (1.45–5.62)], comorbidity [(OR 1.09 (1.02–1.17)] and a dietitian consultation on admission [(OR 3.41 (1.95–5.97)].

Conclusions

Dietetic care post discharge occurs in few patients, despite the known high prevalence of malnutrition on admission and discharge. Dietetic care in hospital was the most influential predictor of post‐hospital care.     

Exploring stakeholder experiences of dietetic service and care delivery: A systematic qualitative review

Background

There is limited understanding of patients' and healthcare professionals' perceptions and experiences of receiving and delivering dietetic care, respectively. This systematic review of the literature used qualitative synthesis to explore the perceptions and experiences of multiple stakeholders involved in the delivery of nutrition care and dietetic service.

Methods

MEDLINE, Embase, CINAHL, Cochrane Library, Scopus, ISI Web of Science, PsycINFO and ProQuest were systematically searched. Study characteristics and perceptions of stakeholders regarding nutrition care services were extracted. Qualitative synthesis was employed and thematic analysis conducted.

Results

Five themes were identified from 44 studies related to stakeholders' perceptions of dietetic services. Studies included quantitative, qualitative and mixed methods involving patients, families, dietitians and other healthcare professionals. The themes were (1) patients desiring a personalised approach to nutrition care; (2) accessing dietetic service; (3) perceived impact of nutrition care on the patient; (4) relationships between stakeholders; and (5) beliefs about nutrition expertise. Two themes were specific to patients; these were the desire for individualised care and the impact of nutrition care. Within each theme perceptions varied with patients' views often contrasting with those of dietetic service providers.

Conclusions

Experiences of dietetic service do not always meet stakeholder expectations which impacts on patient engagement. Seeking stakeholder input is imperative to design dietetic services that engage patients in positive and supportive clinical partnerships.     

A survey of provision of dietetic services for coeliac disease in the UK

BACKGROUND: Management guidelines for care of coeliac patients published by the British Society of Gastroenterology (BSG), 2002 recommend that patients should see a dietitian at diagnosis and at least at annual review. In the absence of information on dietetic provision in coeliac disease management in the UK and with surveys in other countries suggesting that patients with coeliac disease gain most information from coeliac support groups (Green et al., 2001), Coeliac UK set out to investigate dietetic services for coeliac patients in the UK. METHODS: Questionnaires were sent to dietetic departments in the UK via the Regional Managers Group of the British Dietetic Association (BDA) by email. The questionnaires were in two parts, the first was completed by the dietetic manager and the second by the dietitian with the main responsibility for the management of coeliac patients within the department. RESULTS: Over one-quarter of departments reported allocating a maximum of 1 h of dietitians' time per month per 100,000 population to seeing coeliac patients. More hours were allocated to coeliac patients in departments where dietitians had attended coeliac disease training, where dietitians were professional members of Coeliac UK or where coeliac patient care was undertaken by a multi-disciplinary team. CONCLUSION: There is wide variation in dietetic provision for diagnosed coeliac patients in the UK. The Coeliac UK survey suggests that the current level of dietetic provision is in the region of one-third of what is required according to the BSG management guidelines (British Society of Gastroenterology (BSG), 2002) to provide diagnosed coeliacs with only basic support and annual review.     

Nutritional problems of patients with COVID-19 receiving dietetic treatment in primary care

Background

The nutritional problems of patients who are hospitalised for COVID-19 are becoming increasingly clear. However, a large group of patients have never been hospitalised and also appear to experience persistent nutritional problems. The present study describes the nutritional status, risk of sarcopaenia and nutrition-related complaints of patients recovering from COVID-19 receiving dietetic treatment in primary care.

Methods

In this retrospective observational study, data were collected during dietetic treatment by a primary care dietitian between April and December 2020. Both patients who had and had not been admitted to the hospital were included at their first visit to a primary care dietitian. Data on nutritional status, risk of sarcopaenia and nutrition-related complaints were collected longitudinally.

Results

Data from 246 patients with COVID-19 were collected. Mean ± SD age was 57 ± 16 years and 61% of the patient population was female. At first consultation, two thirds of patients were classified as overweight or obese (body mass index >25 kg m^–2). The majority had experienced unintentional weight loss because of COVID-19. Additionally, 55% of hospitalised and 34% of non-hospitalised patients had a high risk of sarcopaenia. Most commonly reported nutrition-related complaints were decreased appetite, shortness of breath, changed or loss of taste and feeling of being full. Nutrition-related complaints decreased after the first consultation, but remained present over time.

Conclusions

In conclusion, weight changes, risk of sarcopaenia and nutrition-related complaints were prevalent in patients with COVID-19, treated by a primary care dietitian. Nutrition-related complaints improved over time, but remained prevalent until several months after infection.     

Structured advice provided by a dietitian increases adherence of consumers to diet and lifestyle changes and lowers blood low‐density lipoprotein (LDL)‐cholesterol: the Increasing Adherence of Consumers to Diet & Lifestyle Changes to Lower (LDL) Cholesterol (ACT) randomised controlled trial

Background

Evidence from healthcare professionals suggest that consumer compliance to healthy diet and lifestyle changes is often poor. The present study investigated the effect of advice provided by a physician or dietitian on consumer adherence to these measures combined with consuming foods with added plant sterols (PS) with the aim of lowering low‐density lipoprotein cholesterol (LDL‐C).

Methods

One hundred mildly‐to‐moderately hypercholesterolaemic individuals were enrolled into a parallel, randomised, placebo‐controlled study. Dietitians (dietitian group; DG) advised 50 individuals in six weekly face‐to‐face behavioural therapy sessions, whereas the other 50 received standard advice from physicians (physician group, PG). Both groups consumed foods with added PS (three servings a day) for 6 weeks. Subsequently, all individuals were followed‐up for another 6 weeks under real‐life conditions. Blood lipids were measured at baseline and weeks 6 and 12 and 3‐day diet diaries were taken at weeks 1, 6 and 12.

Results

Individuals in the DG significantly improved their dietary habits, physical activity and increased PS intake compared to the PG. After 6 weeks, LDL‐C decreased in both groups compared to baseline without any significant differences between groups. At week 12, LDL‐C was further significantly improved only in the DG (P = 0.006) compared to week 6. Total cholesterol, LDL‐C and triglycerides were significantly lower in the DG compared to the PG at week 12 after adjusting for levels at week 6 (P < 0.001, P < 0.001 and P = 0.009, respectively).

Conclusions

Although structured counselling by dietitians and common standard advice by physicians were equally effective with respect to improving blood cholesterol after 6 weeks, dietitians were more effective in the longer‐term (i.e. 6 weeks after the end of the intervention period).

     

Cost evaluation of providing evidence‐based dietetic services for weight management in adults: In‐person versus eHealth delivery

Aim

To compare the theoretical costs of best‐practice weight management delivered by dietitians in a traditional, in‐person setting compared to remote consultations delivered using eHealth technologies.

Methods

Using national guidelines, a framework was developed outlining dietitian‐delivered weight management for in‐person and eHealth delivery modes. This framework mapped one‐on‐one patient–dietitian consultations for an adult requiring active management (BMI ≥ 30 kg/m²) over a one‐year period using both delivery modes. Resources required for both the dietitian and patient to implement each treatment mode were identified, with costs attributed for material, fixed, travel and personnel components. The resource costs were categorised as either establishment or recurring costs associated with the treatment of one patient.

Results

Establishment costs were higher for eHealth compared to in‐person costs ($1394.21 vs $90.05). Excluding establishment costs, the total (combined dietitian and patient) cost for one patient receiving best‐practice weight management for 12 months was $560.59 for in‐person delivery, compared to $389.78 for eHealth delivery. Compared to the eHealth mode, a higher proportion of the overall recurring delivery costs was attributed to the patient for the in‐person mode (46.4% and 33.9%, respectively).

Conclusions

Although it is initially more expensive to establish an eHealth service mode, the overall reoccurring costs per patient for delivery of best‐practice weight management were lower compared to the in‐person mode. This theoretical cost evaluation establishes preliminary evidence to support alternative obesity management service models using eHealth technologies. Further research is required to determine the feasibility, efficacy and cost‐effectiveness of these models within dietetic practice.     

Managing Malnutrition in Older Persons Residing in Care Homes: Nutritional and Clinical Outcomes Following a Screening and Intervention Program

This study aimed to establish prevalence of malnutrition in older adult care home residents and investigate whether a nutritional screening and intervention program could improve nutritional and clinical outcomes. A community-based cohort study was conducted in five Newcastle care homes. 205 participants entered; 175 were followed up. Residents already taking oral nutritional supplements (ONS) were excluded from interventions. Those with Malnutrition Universal Screening Tool (MUST) score of 1 received dietetic advice and ≥2 received dietetic advice and were prescribed ONS (220 ml, 1.5 kcal/ml) twice daily for 12 weeks. Body mass index (BMI), MUST, mini nutritional assessment score (MNA)®, mid upper arm muscle circumference (MAMC), and Geriatric Depression Scale (GDS) were recorded at baseline and 12 weeks. Malnutrition prevalence was 36.6% ± 6.6 (95% CI). A higher MUST was associated with greater mortality (p = 0.004). Type of intervention received was significantly associated with change in MUST score (p < 0.001); dietetic advice resulting in the greatest improvement. There were no significant changes in BMI (p = 0.445), MAMC (p = 0.256), or GDS (p = 0.385) following the interventions. Dietitian advice may slow the progression of nutritional decline. In this study oral nutritional supplements over a 3-month period did not significantly improve nutritional status in malnourished care home residents.     

Examining dietitians' knowledge,skills and attitudes regarding working with older adults in residential aged care facilities and home care services: An integrative review

Background

The Australian 2021 Royal Commission identified that the dietetic workforce needs to grow in size and capacity to support nutrition care in older adults. However, little is known about dietitians' knowledge, skills and attitudes (KSA) regarding working with older adults in residential aged care facilities (RACFs) or their homes. This review describes dietitians' KSA regarding older adults in RACFs and home care services.

Methods

A systematic literature search was conducted in August 2021 to identify studies examining any aspect of dietitians or student dietitians' KSA working in RACFs and home care services. No restrictions were applied to methodological design, language, location or publication year. Studies were assessed for quality using the Johanna Briggs Institute Quality Appraisal Tools. Study findings were analysed thematically using meta-synthesis.

Results

All 17 studies that met the inclusion criteria explored dietitians' attitudes towards their role, three studies examined perceived knowledge, although no studies objectively explored dietitians' skill levels. Five themes were developed inductively: (1) recognising their contribution as dietitians; (2) lacking clarity about the boundaries of their role; (3) all team members have a role to play in nutrition care; (4) assumptions and biases about working with older people; and (5) needing to build capacity in the workforce.

Discussion

Dietitians have mixed attitudes about working in RACFs and home care services. Future directions include evaluating dietitians' role in RACFs, reviewing education and training and practical opportunities for student dietitians, and assessing the impact of more dietitian support on an older person's dietary intake and nutrition.     

Patients' perceptions and experiences of patient‐centred care in dietetic consultations

Background

Patient‐centred care (PCC ) is essential to quality healthcare. However, there is a paucity of research on PCC in dietetics, particularly regarding patients' experiences and perspectives of PCC . We aimed to enhance our understanding of PCC in dietetics by exploring patients' perceptions and experiences of PCC in individual dietetic consultations.

Methods

The present study used qualitative methods, situated in a constructivist–interpretivist paradigm. Maximum variation purposive sampling was used to recruit English speaking adult participants who had participated in ≥1 dietetic consultations for nutrition care. Individual semi‐structured interviews explored participants' perceptions and experiences of PCC in dietetic consultations. Data were analysed thematically.

Results

Eleven patients were interviewed between September and November 2016. Four overarching themes emerged: (i) fostering and maintaining caring relationships; (ii) delivering individualised care; (iii) enabling patient involvement; and (iv) taking control of one's own health.

Conclusions

PCC is important to patients. Thus, there is opportunity for dietitians to enhance the care they provide by adopting patient‐centred practices. As the first study of its kind, these findings can inform future dietetic practice, education and research by contributing patients' perspectives of PCC . By understanding patients' unique needs and preferences, dietitians can better align their practice with a patient‐centred approach. Furthermore, these findings are useful for informing future dietetic research and education.

     

The role of the clinical dietitian: II. Staffing patterns and job functions

On the basis of responses to a telephone questionnaire, this study evaluated--from the viewpoint of nutrition support dietitians, general clinical dietitians (dietitians who are not members of a nutrition support team and who provide general clinical dietetic services), and other health professionals--the current job functions that nutrition support and general clinical dietitians perform in hospitals. Anticipated staffing needs and desired job functions were also assessed. For the nutrition support and general clinical dietitians, as viewed by themselves and other health professionals, there was considerable overlap in many job activities. However, a significantly larger proportion of directors of nursing thought that nutrition support dietitians were more involved than general clinical dietitians in the evaluation of nutritional status (42% vs. 14%) and in contributing expertise to medical team discussions (48% vs. 12%). A significantly larger proportion of physicians viewed the nutrition support dietitian as more involved than the general clinical dietitian in in-service programs for medical and nursing staffs (32% vs. 6%). A large proportion of directors of nursing (62%), hospital administrators (34%), and physicians (56%) believed that dietetic involvement in the supervision of food preparation, especially by general clinical dietitians, was much greater than did the dietetic staff. The outlook for the future suggests a greater participation by both the nutrition support and the general clinical dietitian in direct patient care functions and less involvement in food preparation and clerical tasks.