Using Initiative to Achieve Autonomy: A Model for Advanced Practice in Medical Nutrition Therapy

Does the Transformation of Dietitians from Counseling to Therapy Also Apply to the Physical and Therapeutic Environment? A Case Study of Israeli Practice

BACKGROUND

Lifestyle change can be influenced through effective interaction between care receiver and care provider. The physical environment where the interaction occurs can affect the dynamics of long-term therapeutic treatment. There have been no studies on the perception of the physical environment in nutritional treatment.

OBJECTIVE

Our aim was to ascertain the impact of the physical environment on the dynamics and communication between dietitian and patient based on perceptions of dietitians.

DESIGN

We conducted qualitative constructivist phenomenological research.

PARTICIPANTS

In-depth interviews (n=10) and eight focus groups (n=62) were held with dietitians who offer treatment in a physical environment designed according to the medical model and/or in a physical dynamic environmental design according to the dynamic model.

RESULTS

Most dietitians in Israel treat their patients in a physical environment arranged according to the medical model. The participants reported that the physical environment affects the interaction. However, the idea of transforming the physical environment according to the dynamic model raised reservations. Barriers include upsetting therapeutic boundaries, challenging professional authority, and lack of therapeutic tools suitable for the change.

CONCLUSIONS

Changes in the spatial design in which the therapeutic interaction occurs might support the dietitians' transformation from counseling into therapy. The barriers toward such change suggest that professional training is needed to enable dietitians to overcome them. We recommend conducting further research to evaluate the current physical environment, as well as raising dietitians' awareness and training them to work in the new environment, reflecting a counseling/therapeutic mindset. These changes should be followed by additional research among practitioners to report on their effects.

What clinical activities do advanced-practice registered dietitian nutritionists perform? Results of a Delphi study

Activities performed by advanced-practice registered dietitian nutritionists (RDNs) have yet to be clearly elucidated. The study aimed to gain consensus on the practice activities of advanced-practice RDNs who provide direct clinical nutrition care. A three-round Delphi study was conducted. Purposive sampling identified 117 RDN experts working as clinicians and/or managers in direct care settings that met inclusion criteria for advanced-level practice. In Round 1, 85 experts provided open-ended advanced-level practice activities linked to the Nutrition Care Process sections. Using content analysis, the responses were coded into activity statements. In Round 2, experts rated the essentiality of these activities. In Round 3, experts re-rated statements not reaching consensus while viewing their previous rating, the group median, and comments. Median ratings of 1.0 to 3.0 were defined as essential, 4.0 were neither essential nor nonessential, and 5.0 to 7.0 were nonessential. Consensus was reached when the interquartile range of responses to each question was <2.0. Seventy-six (89.4%) experts completed all rounds. From 770 comments, 129 activity statements were generated. All statements reached consensus: 97.7% as essential; 0.8% as nonessential; and 1.5% as neither. Of essential activities, 67.5% were highly essential with limited variability (median=1.0; interquartile range≤2.0). Advanced-practice RDNs' tasks are patient-centered and reflect complex care; involve a comprehensive and discriminating approach; are grounded in advanced knowledge and expertise in clinical nutrition; include use of advanced interviewing, education, and counseling strategies; and require communication with patient, families, and the health care team. The high-level of consensus from experts suggest advanced-level clinical nutrition practice exists and can be defined.

Charismatic authority in modern healthcare: the case of the 'diabetes specialist podiatrist'

Professional specialisation is broadly considered to result from increased complexity in professional knowledge and to be linked to specialist education, formalised credentials and registration. However, the degree of formal organisation may vary across professions. In healthcare, although medical specialisation is linked to rigorous selection criteria, formal training programmes and specialist registration, some forms of specialisation in the allied health professions are much less formal. Drawing on Weber's concept of charismatic authority, the establishment of a specialist role in podiatry, the 'diabetes specialist podiatrist', in the absence of codified or credentialed authority, is explored. 'Charismatic' leaders in podiatry, having attracted a following of practitioners, were able to constitute a speciality area of practice in the absence of established career pathways and acquire a degree of legitimacy in the medical field of diabetology.

Identifying components of advanced-level clinical nutrition practice: a Delphi study

The dietetics profession lacks a comprehensive definition of advanced-level practice. Using a three-round Delphi study with mailed surveys, expert consensus on four dimensions of advanced-level practice that define advanced practice registered dietitians (RDs) in clinical nutrition was explored. Purposive sampling identified 117 RDs who met advanced-level practice criteria. In round 1, experts rated the essentiality of statements on a 7-point ordinal scale and generated open-ended practice activity statements regarding the following four dimensions of advanced-level practice: professional knowledge, abilities and skills, approaches to practice, roles and relationships, and practice behaviors. Median ratings of 1.0 to 3.0 were defined as essential, 4.0 was neutral, and 5.0 to 7.0 were nonessential. In rounds 2 and 3, experts re-rated statements not reaching consensus by evaluating their previous responses, group median rating, and comments. Consensus was reached when the interquartile range of responses to a statement was ≤2.0. Eighty-five experts enrolled (72.6%); 76 (89.4%) completed all rounds. In total, 233 statements were rated, with 100% achieving consensus; 211 (90.6%) were essential to advanced practice RD clinical practice. Having a master's degree; completing an advanced practice residency; research coursework; and advanced continuing education were essential, as were having 8 years of experience; clinical nutrition knowledge/expertise; specialization; participation in research activities; and skills in technology and communication. Highly essential approaches to practice were systematic yet adaptable and used critical thinking and intuition and highly essential values encompassed professional growth and service to patients. Roles emphasized patient care and leadership. Essential practice activities within the nutrition care process included provision of complex patient-centered nutrition care using application of advanced knowledge/expertise and interviewing and counseling strategies approached in a comprehensive yet discriminating manner. Communication with patients and the health care team is a priority. An advanced-level practice model in clinical nutrition was proposed depicting the requisite attributes and activities within four dimensions of professional practice.

A Definition, Description, and Framework For Advanced Practice in Dietetics

Purpose: We explored advanced practice (AP) across the diversity of dietetics to develop a definition, description, and framework for guiding future education, research agendas, and policy development.

Methods: The process began with a literature review and discussion with dietitians exploring AP in other countries. Various concepts were identified, and these informed the phase 1 survey questions. Phase 1 was a 36-item survey created in SurveyMonkey, engaging a purposeful sample of key stakeholders (n=136). A modified Delphi approach, involving seven dietitians from different geographical locations and practice areas, finalized the phase 2 survey. An e-mail link to this 50-item survey was sent to a random sample of dietitians (n=885). The proposed AP framework entailed an iterative approach, integrating survey results with AP literature.

Results: Response rates were 40% for phase 1 and 35% for phase 2. In phase 1, 83% of respondents agreed that a depth and breadth definition captured all dietetic job roles, and 95% agreed that it differentiated AP from entry-level practice. Descriptive statistics are presented to provide demographic information and level of agreement with themes relevant to AP.

Conclusions: A framework is presented, and discrepancies with phase 2 results indicate areas for professional development, such as leadership, mentorship, and outcome measurement.

Nursing's role in nutrition

There are not enough dietitians and nutritionists available to serve the entire healthcare industry. That means that nurses often fill the role of nutrition counselors. Nurses do not receive extensive education about nutrition, but there are great opportunities for nurses in nutrition, both as educators and researchers. One way this can happen is through the use of nutrition assessment tools. This article introduces a freeware nutritional assessment tool for use on Windows-based computers (available at http://nursing.jmu.edu). Unlike currently available tools, the Nutrition Analyzer is a stand-alone, Web-independent product, which builds a database of client data that can be manipulated for analysis and research.

The bits and bytes to advanced graduate degree programs

Lifelong learning may afford the dietetics professional more opportunities for career advancement, a richer self-satisfaction, and a revived confidence regarding career choices. The avenue to lifelong learning is a process unique to every health professional because of individual differences in interest and work arenas. Learning activities may take the form of continuing education conferences or certificate programs, advanced or specialty training, or academic degree programs. These programs may be in one's local community or may be accessed via distance learning. This paper will focus on advanced-degree academic programs using the distance education route. Characteristics of technologically savvy programs and learners will be addressed.

Clinical Registered Dietitians, Employers, and Educators Are Interested in Advanced Practice Education and Professional Doctorate Degrees in Clinical Nutrition

A subset of registered dietitians (RDs) is known to practice at an advanced level, but a clear educational pathway supporting advanced medical nutrition therapy practice has not been identified. Thus, an electronic survey was designed to investigate interest of clinical RDs, employers, and educators in advanced practice competencies and professional doctorate degree programs in clinical nutrition. Usable responses were obtained from 440 of 978 (45%) RDs, 61 of 107 (57%) employers, and 76 of 114 (67%) educators. Mean interest (5 = very interested, 1 = very uninterested) in obtaining advanced practice education was highest among RDs (3.93+/-1.01) and was significantly different (P < 0.01) from employers (3.74 +/-1.28) and educators (2.76+/-1.33). Interest in completing a professional doctorate in clinical nutrition was significantly (P < 0.01) different among RDs (3.05+/-1.28), employers (3.18+/-1.30), and educators (2.3+/-1.34). Employers' mean interest score for hiring RDs with a professional doctorate in clinical nutrition was 4.02+/-0.93. A subset of clinical RDs appears to be interested in obtaining advanced practice competency and enrolling in professional doctorate degrees in clinical nutrition. Clinical nutrition managers in academic medical centers may be interested in hiring advanced practice clinical RDs with professional doctorate degrees. Opportunities exist for educators to develop advanced practice educational experiences and professional doctorate degree programs.