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

Becoming an expert: highly-experienced allied health professionals' relationships with their work

Purpose

Highly-experienced allied health professionals have the opportunity to perform at the expert-level by sharing knowledge and skills with more junior staff, with the aim of upskilling the workforce. The study explored the current motivators, aspirations and the role of work in the life of highly-experienced practitioners, revealing factors that hinder or support them to further develop their own expertise and be inspiring role-models and mentors for less experienced staff.

Design/methodology/approach

Taking a grounded theoretical research design, we report on interviews with 45 allied health practitioners with at least seven years of professional experience from different professions and across organisational sectors. Transcripts were coded iteratively in conjunction with reviewing the literature, and cases were categorised to form a conceptual typology of work orientation.

Findings

Four work orientations are characterised capturing the diversity of the allied health workforce, particularly in relation to two dimensions of personal fulfilment and future ambition. The relationship between the types and expert-level performance is discussed, leading to recommendations for support that can be implemented to develop and sustain expert-level performance within a community.

Originality/value

A new view of work orientation is introduced that relates expert-level performance with meaningful work. The findings highlight a diversity of work orientation for highly-experienced allied health professionals, that all require managerial awareness. Once recognised, the four types would benefit from different supports that could develop and maintain expert-level performance in those that seek it. Alternatives are also available for those that do not. Implications for workforce policy are discussed.

The patient-centered dental home: A standardized definition for quality assessment, improvement, and integration

OBJECTIVE

To develop the first standardized definition of the patient-centered dental home (PCDH).

DATA SOURCES/STUDY SETTING

Primary data from a 55-member national expert panel and public comments.

STUDY DESIGN

We used a modified Delphi process with three rounds of surveys to collect panelists' ratings of PCDH characteristics and open-ended comments. The process was supplemented with a 1-month public comment period.

DATA COLLECTION/EXTRACTION METHODS

We calculated median ratings, analyzed consensus using the interpercentile range adjusted for symmetry, and qualitatively evaluated comments.

PRINCIPAL FINDINGS

Forty-nine experts (89%) completed three rounds and identified eight essential PCDH characteristics, resulting in the following definition: "The patient-centered dental home is a model of care that is accessible, comprehensive, continuous, coordinated, patient- and family-centered, and focused on quality and safety as an integrated part of a health home for people throughout the life span."

CONCLUSIONS

This PCDH definition provides the foundation for developing measures for research, care improvement, and accreditation and is aligned with the patient-centered medical home. Consensus among a broad national expert panel-including provider, payer, and accreditation stakeholder organizations and experts in medicine, dentistry, and quality measurement-supports the definition's usability and its potential to facilitate medical-dental primary care integration.

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.

A mixed-methods research approach to the review of competency standards for orthotist/prosthetists in Australia

AIM

The requirement for an allied health workforce is expanding as the global burden of disease increases internationally. To safely meet the demand for an expanded workforce of orthotist/prosthetists in Australia, competency based standards, which are up-to-date and evidence-based, are required. The aims of this study were to determine the minimum level for entry into the orthotic/prosthetic profession; to develop entry level competency standards for the profession; and to validate the developed entry-level competency standards within the profession nationally, using an evidence-based approach.

METHODS

A mixed-methods research design was applied, using a three-step sequential exploratory design, where step 1 involved collecting and analyzing qualitative data from two focus groups; step 2 involved exploratory instrument development and testing, developing the draft competency standards; and step 3 involved quantitative data collection and analysis - a Delphi survey. In stage 1 (steps 1 and 2), the two focus groups - an expert and a recent graduate group of Australian orthotist/prosthetists - were led by an experienced facilitator, to identify gaps in the current competency standards and then to outline a key purpose, and work roles and tasks for the profession. The resulting domains and activities of the first draft of the competency standards were synthesized using thematic analysis. In stage 2 (step 3), the draft-competency standards were circulated to a purposive sample of the membership of the Australian Orthotic Prosthetic Association, using three rounds of Delphi survey. A project reference group of orthotist/prosthetists reviewed the results of both stages.

RESULTS

In stage 1, the expert (n = 10) and the new graduate (n = 8) groups separately identified work roles and tasks, which formed the initial draft of the competency standards. Further drafts were refined and performance criteria added by the project reference group, resulting in the final draft-competency standards. In stage 2, the final draft-competency standards were circulated to 56 members (n = 44 final round) of the Association, who agreed on the key purpose, 6 domains, 18 activities, and 68 performance criteria of the final competency standards.

CONCLUSION

This study outlines a rigorous and evidence-based mixed-methods approach for developing and endorsing professional competency standards, which is representative of the views of the profession of orthotist/prosthetists.

Gadamerian philosophical hermeneutics as a useful methodological framework for the Delphi technique

In this article we aim to demonstrate how Gadamerian philosophical hermeneutics may provide a sound methodological framework for researchers using the Delphi Technique (Delphi) in studies exploring health and well-being. Reporting of the use of Delphi in health and well-being research is increasing, but less attention has been given to covering its methodological underpinnings. In Delphi, a structured anonymous conversation between participants is facilitated, via an iterative survey process. Participants are specifically selected for their knowledge and experience with the topic of interest. The purpose of structuring conversation in this manner is to cultivate collective opinion and highlight areas of disagreement, using a process that minimizes the influence of group dynamics. The underlying premise is that the opinion of a collective is more useful than that of an individual. In designing our study into health literacy, Delphi aligned well with our research focus and would enable us to capture collective views. However, we were interested in the methodology that would inform our study. As researchers, we believe that methodology provides the framework and principles for a study and is integral to research integrity. In assessing the suitability of Delphi for our research purpose, we found little information about underpinning methodology. The absence of a universally recognized or consistent methodology associated with Delphi was highlighted through a scoping review we undertook to assist us in our methodological thinking. This led us to consider alternative methodologies, which might be congruent with the key principles of Delphi. We identified Gadamerian philosophical hermeneutics as a methodology that could provide a supportive framework and principles. We suggest that this methodology may be useful in health and well-being studies utilizing the Delphi method.

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.

Development and validation of a questionnaire to measure research involvement among registered dietitians

Research involvement among registered dietitians (RDs) is important in advancing dietetics practice and ensuring high-quality and cost-effective health care. There are no standardized approaches to measuring levels of research involvement. The aim of the study was to develop a standardized measure of research involvement and test its validity and reliability among RDs. The Research Involvement Questionnaire (RIQ) was developed and underwent content validation, resulting in a content validity index of 0.92. A postal questionnaire survey of RDs was undertaken at two time points. RDs were purposively selected and, based on their number of publications and grants, were assigned by the authors to one of four levels of research involvement: evidence-based practice, collaborating on research, leading research, and leadership in research. Of 192 questionnaires mailed, 111 RDs (58%) returned the first RIQ, of whom 82 (74%) also returned the second RIQ. Total scores and scores for each level were higher for RDs with higher levels of research involvement (P<0.001). RDs assigned by the RIQ to higher levels of research involvement had higher qualifications; were qualified for longer; and had greater evidence of research output, including journal publications and grants (P<0.001). There was excellent internal consistency as measured using Cronbach's coefficient (α=.98). The level of research involvement assigned by the RIQ and by the purposive selection process agreed on 76% of occasions, indicating substantial agreement beyond chance (κ=0.67; P<0.001). The level of research involvement assigned by the RIQ at two time points agreed on 86% of occasions, indicating almost perfect agreement beyond chance (κ=0.81; P<0.001). A valid and reliable questionnaire has been developed to measure research involvement among RDs, providing a useful tool for evaluating and supporting members of the profession to become more involved in research.