Assessing patients' involvement in decision making during the nutritional consultation with a dietitian

Communication Skills: A Scoping Review of Experiences, Perceptions, and Use in Dietetics Practice

BACKGROUND

Communication skills are a cornerstone of practice for dietitians. The field of dietetics is evolving and there is a need to synthesize the available literature on communication skills to improve the effectiveness of patient consultations and inform practitioner development.

OBJECTIVE

This scoping review aimed to identify the research literature relating to communication skills used in dietetics practice and perceptions and experiences of dietetics students, dietitians, and patients regarding communication skills.

METHODS

This scoping review was conducted in accordance with the Joanna Briggs Institute methodology for scoping reviews and best practice guidance. Five databases (Medline, Embase, the Cumulative Index to Nursing and Allied Health Literature, Education Resources Information Center, and PsycInfo), two theses databases, and conference proceedings for 8 dietetics and health professions education associations were systematically searched for research on dietitians' communication skills. This included skills used in dietitian-patient communication, in communication interactions in different employment contexts, and diverse forms of communication (verbal, written, technological) and the views of dietetics students, dietitians, and patients, regarding communication skills. The search had no geographical or time limits. Studies were independently screened by two authors.

RESULTS

The 70 included studies spanned 45 years and were organized into four thematic categories: importance of communication skills in dietetics practice, development of communication skills, communication skills for dietitian-patient communication, and communication skills for wider dietetics practice. Sixty-five (92.9%) of the studies specifically explored the communication skills used for dietitian-patient consultations, including rapport building, questioning, listening, paraphrasing, and clarifying, whereas skills such as intercultural communication were less researched.

CONCLUSIONS

There is consensus between patients and dietitians regarding the skills that contribute to effective dietitian-patient communication. Areas less explored in the literature include the skills needed for intercultural communication and those needed for science communication. Greater understanding of the communication skills needed for contemporary nutrition and dietetics practice will guide education strategies for the development of dietitians.

Patient Characteristics and the Extent to Which Clinicians Involve Patients in Decision Making: Secondary Analyses of Pooled Data

BACKGROUND

The occurrence of shared decision making (SDM) in daily practice remains limited. Various patient characteristics have been suggested to potentially influence the extent to which clinicians involve patients in SDM.

OBJECTIVE

To assess associations between patient characteristics and the extent to which clinicians involve patients in SDM.

METHODS

We conducted a secondary analysis of data pooled from 10 studies comparing the care of adult patients with (intervention) or without (control) a within-encounter SDM conversation tool. We included studies with audio(-visual) recordings of clinical encounters in which decisions about starting or reconsidering treatment were discussed.

MAIN MEASURES

In the original studies, the Observing Patient Involvement in Decision Making 12-items (OPTION12 item) scale was used to code the extent to which clinicians involved patients in SDM in clinical encounters. We conducted multivariable analyses with patient characteristics (age, gender, race, education, marital status, number of daily medications, general health status, health literacy) as independent variables and OPTION12 as a dependent variable.

RESULTS

We included data from 1,614 patients. The between-arm difference in OPTION12 scores was 7.7 of 100 points (P < 0.001). We found no association between any patient characteristics and the OPTION12 score except for education level (p = 0.030), an association that was very small (2.8 points between the least and most educated), contributed mostly by, and only significant in, control arms (6.5 points). Subanalyses of a stroke prevention trial showed a positive association between age and OPTION12 score (P = 0.033).

CONCLUSIONS

Most characteristics showed no association with the extent to which clinicians involved patients in SDM. Without an SDM conversation tool, clinicians devoted more efforts to involve patients with higher education, a difference not observed when the tool was used.

HIGHLIGHTS

Most sociodemographic patient characteristics show no association with the extent to which clinicians involve patients in shared decision making.Clinicians devoted less effort to involve patients with lower education, a difference that was not observed when a shared decision-making conversation tool was used.SDM conversation tools can be useful for clinicians to better involve patients and ensure patients get involved equally regardless of educational background.

Descriptive and Content Analysis of Questionnaires Used to Assess Evidence-Based Practice Among Dietitians: A Systematic Review

BACKGROUND

Evidence-based practice (EBP) is described as the integration of the following 3 main dimensions in health professionals' decision making: best currently available research evidence, professional expertise, and patient's values and circumstances. Barriers to EBP at an individual level have been assessed using questionnaires. Knowing which EBP dimensions are actually explored in these questionnaires is essential to promote EBP and its adoption.

OBJECTIVE

The aim of this review was to identify and describe questionnaires that have been used among dietitians to evaluate knowledge, skills, attitudes, and/or behaviors related to EBP, and to perform a content analysis of these, drawn on the EBP dimensions explored.

METHODS

Questionnaires were identified through a systematic review in MEDLINE, Embase and the Cumulative Index to Nursing and Allied Health Literature (last search was November 2022). Eligibility criteria were studies using, evaluating, or developing questionnaires meant to evaluate knowledge, skills, attitudes, and/or behaviors related to EBP among dietitians. The content analysis was conducted to identify the EBP dimensions explored (ie, research evidence, professional expertise, and/or patient's values and circumstances). Questionnaire items were categorized as follows: 1 sole EBP dimension, a combination of dimensions, or no identifiable dimension.

RESULTS

Thirty reports (25 studies) were included. The analysis of the 847 items extracted from the 25 questionnaires used showed that the main EBP dimension explored was the integration of research evidence into decision making, found in 75% of items, solely or in combination with another dimension. Professional expertise was explored in 18% of the items, patient's values and circumstances were found in 3%, and the combination of these 3 dimensions was found in <1%.

CONCLUSIONS

The important imbalance of explored EBP dimensions in the questionnaires used may lead to a partial and misleading evaluation that prevents efficient strategies to foster EBP. There is an important need to develop more integrative and accurate evaluations of EBP targeting dietitians to promote and develop high-quality dietetics practice.

Blenderized tube feedings: Practice recommendations from the American Society for Parenteral and Enteral Nutrition

Prior to the 1970s, blending food and liquids and putting them through an enteral access device (EAD) was the most common form of enteral nutrition (EN). However, in the 1970s, blenderized tube feedings (BTFs) became less popular due to the emergence of modern commercial enteral formulas (CEFs). Recently, a cultural shift toward consuming a natural diet, consisting of whole foods, has led to a resurgence in the use of BTF. The increasing use of BTF in a variety of patient care settings identifies a need for practice recommendations that provide guidance for nutrition professionals and patients. Members of the American Society for Parental and Enteral Nutrition (ASPEN) Enteral Nutrition Committee identified salient clinical questions concerning BTF, conducted a comprehensive literature search, and subsequently developed practice recommendations pertaining to the use of BTF. This paper was approved by the ASPEN 2022-2023 Board of Directors.

Smuggled Doughnuts and Forbidden Fried Chicken: Addressing Tensions around Family and Food Restrictions in Hospitals

It is a common practice for family members to bring food to hospitalized loved ones. However, in some cases, this food contravenes a patient's dietary plan. Such situations can create significant tension and distrust between health care professionals and families and may lead the former to doubt a family's willingness or ability to support patient recovery. This case-study essay offers an ethical analysis of these situations. We draw on Hilde Lindemann's work to argue that providing food to family members is an important way that families discharge their moral functions of caring for their members and holding them in their identities. When family members are hospitalized, other means of performing these functions are limited. Acknowledging the ethical importance of feeding family members alongside the medical need for dietary restrictions, we offer strategies for creative problem-solving that center diet as a subject for shared decision-making and regular, ongoing communication among health care professionals, patients, and families.

Opportunities for Patient Participation in Perioperative Malnutrition Care: A Qualitative Study

Introduction

In the perioperative period of hospitalization, barriers to food intake are common due to special nutritional needs, compromised nutritional status, and metabolic stress. Good nutritional care call for an interdisciplinary approach. And patients themselves may also play an essential role in managing nutritional care.

Objective

This study aimed to explore how patients with malnutrition experience nutritional care, their perspectives on patient participation, and their own role in malnutrition care in the perioperative period of hospitalization.

Methods

A qualitative study was conducted using an interpretive phenomenological approach. To follow patients' experiences, in-depth longitudinal interviews were undertaken before, during, and after hospitalization. Interview transcripts were analyzed thematically using open, axial, and selective coding and interpreted in an iterative process.

Results

Fifty-six interviews were undertaken with 26 patients with malnutrition scheduled for surgery and during the perioperative period of hospitalization. Four themes were identified: (1) unawareness and stigmata about being malnourished, (2) feasibility of optimal nutritional care, (3) needs and expectations for self-management, and (4) barriers and facilitators of taking own responsibilities in nutritional care.

Conclusion

Awareness and responsiveness to patients' perspectives, motivation, and compliance are prerequisites for patient participation in malnutrition care. This requires good communication between healthcare professionals and patients in all phases of hospitalization.

Bringing personal perspective elicitation to the heart of shared decision-making: A scoping review

OBJECTIVES

Proponents of shared decision-making (SDM) advocate the elicitation of the patient's perspective. This scoping review explores if, and to what extent, the personal perspectives of patients are elicited during a clinical encounter, as part of a SDM process. We define personal perspective elicitation (PPE) as: the disclosure (either elicited by the clinician or spontaneously expressed by the patient) of information related to the patient's personal preferences, values and/or context.

METHODS

A search was conducted in five literature databases from inception dates up to July 2020, to identify empirical studies about SDM (with/without SDM instrument).

RESULTS

The search identified 4562 abstracts; 263 articles were read in full text, resulting in 99 included studies. Studies reported low levels of PPE. Integration of personal perspectives into the conversation or a future care plan was largely absent. The majority of the discussed content related to physical health, while social and psychological topics were mostly unaddressed.

CONCLUSIONS

PPE occurs on a very low level in efforts to achieve SDM according to evaluation studies.

PRACTICE IMPLICATIONS

PPE is advocated but rarely achieved in SDM evaluation studies. Causes should be identified, followed by designing interventions to improve this aspect of SDM.

How are patient-related characteristics associated with shared decision-making about treatment? A scoping review of quantitative studies

OBJECTIVES

To identify what patient-related characteristics have been reported to be associated with the occurrence of shared decision-making (SDM) about treatment.

DESIGN

Scoping review.

ELIGIBILITY CRITERIA

Peer-reviewed articles in English or Dutch reporting on associations between patient-related characteristics and the occurrence of SDM for actual treatment decisions.

INFORMATION SOURCES

COCHRANE Library, Embase, MEDLINE, PsycInfo, PubMed and Web of Science were systematically searched for articles published until 25 March 2019.

RESULTS

The search yielded 5289 hits of which 53 were retained. Multiple categories of patient characteristics were identified: (1) sociodemographic characteristics (eg, gender), (2) general health and clinical characteristics (eg, symptom severity), (3) psychological characteristics and coping with illness (eg, self-efficacy) and (4) SDM style or preference. Many characteristics showed no association or unclear relationships with SDM occurrence. For example, for female gender positive, negative and, most frequently, non-significant associations were seen.

CONCLUSIONS

A large variety of patient-related characteristics have been studied, but for many the association with SDM occurrence remains unclear. The results will caution often-made assumptions about associations and provide an important step to target effective interventions to foster SDM with all patients.

Immune-mediated inflammatory diseases and nutrition: results from an online survey on patients' practices and perceptions

Background

The central role of microbiota and the contribution of diet in immune-mediated inflammatory diseases (IMID) are increasingly examined. However, patients’ perspectives on nutrition and its impact on their disease has not received a lot of attention. We aimed to directly collect information from patients with IMID about their dietary behaviors and their perceptions of the influence of nutrition on their disease.

Methods

Adult patients with rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis, Crohn’s disease, ulcerative colitis or psoriasis registered in an online patient community were invited to participate in the study and complete an online self-administered questionnaire. We assessed patients’ dietary knowledge and choices by collecting information on the diet regimens they were following or recommended and their perceptions of the diet and its consequences on their disease.

Results

Fifty patients per target disease were included with a mean age of 48.1 years (95%CI 46.7–49.6). Other sociodemographic and clinical characteristics varied across the diseases. Since diagnosis, 44% of the patients changed their eating habits, mainly patients with inflammatory bowel disease with 69% of these making the change on their own initiative. Patients who did not change their diet habits reported not having received nutritional advice from their healthcare professionals (HCP) in 69% of the cases. The perceived impact of nutrition on their symptoms was mixed (overall 74% of the patients reported positive consequences and 60% negative ones) and varied across the diseases. Patients with psoriasis only experienced positive consequences from changing their diet, such as reduction of stress and improved mental health, while patients with Crohn’s disease reported more negative effects such as increased fatigue and disturbed sleep. Patients with rheumatic diseases and ulcerative colitis reported weight loss and better physical fitness, but also increased fatigue.

Conclusions

Even if differences exist across diseases, the importance of nutrition and its potential positive role in symptom management is acknowledged by the majority of the patients. However, there is a need and a demand from patients to receive more dietary advice. Developing therapeutic education tools on nutrition for people with IMID and involving patients’ organizations would provide useful information and encourage communication between HCP and patients.

Power, autonomy and interprofessional practice in dietitian clinical decision making: An interpretive study in acute hospitals

Dietitians learn clinical decision making (CDM) predominantly as an autonomous cognitive process that considers the needs and preferences of the patient. Although interprofessional education is increasing in tertiary dietetic programmes, a paucity of research exists that explores the nature of how practising dietitians make decisions, independent or otherwise. This qualitative interpretative study explored the nature of experienced dietitian CDM in the acute care setting. Philosophical hermeneutic principles guided text construction and interpretation via in-depth, semi-structured interviews with practising dietitians with at least 3 years of experience. A reference focus group commented on the emerging findings, increasing the rigour of the research. Ten dietitians participated in the interviews and there were five dietitians in the reference focus group. CDM was found to be a highly social phenomenon with varying degrees of autonomy involving complex power relations with various other health professionals, in particular, medical practitioners. Dietitians respond to existing power relations in key ways, including building and maintaining relationships, advocating on behalf of the patient and negotiating decisions with other healthcare staff when in pursuit of improved health and nutrition related outcomes for patients. Strategic interprofessional communication skills are foundational to effective patient care and advancing the role of the dietitian. Power and autonomy in dietitian CDM are important concepts that could inform interprofessional education when seeking to promote both effective dietetic and interprofessional practice.

UK Dietitians' views on communication skills for behaviour change: A 10 year follow-up survey

BACKGROUND

In 2007, a survey of UK dietitians identified that dietitians were positive about the use of Communication Skills for Behaviour Change (CSBC) in practice, although barriers to the implementation of skills were acknowledged. This follow-up survey aimed to explore current perceptions of CSBC and compare them with the previous survey.

METHODS

A cross-sectional online survey of British Dietetic Association (BDA) members' views of CSBC was undertaken. The results for full members are presented. Quantitative data were analysed descriptively. Qualitative data were subject to either content, or inductive thematic analysis.

RESULTS

A response rate of 9.4% (n = 729) was achieved. Respondents were predominately female (n = 684; 95.1%) and worked in the National Health Service (n = 634; 87.4%). They were positive about the importance of CSBC in practice (n = 714; 99.5%). Pre-registration training had been completed by 346 respondents (48.7%). Post-registration training had been undertaken by 520 (74.7%) respondents and 514 of these (99.6%) had implemented training into practice, with few barriers identified. Perception of ability to use skills had increased, with 513 (83.6%) respondents rating their skills as excellent/very good compared to 62% previously. The majority (n = 594; 93.7%) reported that post-registration training was necessary, with the need for skills to be regularly reviewed (n = 456; 74.5%), and 235 (51.9%) respondents suggested this be mandatory. By contrast, some suggested that a skill review was not a priority, and would be difficult to administer and stressful.

CONCLUSIONS

Perception of the importance of CSBC remains high. Although the perceived ability to apply CSBC has increased, the perceived need for post-registration training is high, with respondents' favouring mandatory training.

A qualitative exploration of dietitians' experiences of prescribing oral nutritional supplements to patients with malnutrition: A focus on shared tailoring and behaviour change support

BACKGROUND

Oral nutritional supplements (ONS) are commonly prescribed to patients with malnutrition. Dietitians have been suggested as preferred prescribers but generally lack ONS prescribing rights. How dietitians with prescribing rights experience their professional practice of prescribing ONS remains understudied. Thus, by exploring dietitians' experiences of prescribing ONS, the present study aimed to obtain a deeper understanding of specific aspects that are of importance for dietitians when providing a nutrition therapy including ONS.

METHODS

Qualitative individual interviews were conducted with 13 dietitians prescribing ONS to free-living adult outpatients with malnutrition or at nutritional risk in the hospital or primary care setting. Systematic text condensation was used for data analysis.

RESULTS

Two main categories signifying important aspects were identified and labelled: 'Shared tailoring of the ONS prescription' and 'Supporting and facilitating ONS use'. First, the dietitians described tailoring the ONS prescription together with the patient, having their acceptance as a prerequisite, and being flexible regarding products and amounts prescribed. Second, they described performing different communication strategies and organising of practical issues (e.g., ONS delivery and support from others) to support and facilitate patients' ONS usage.

CONCLUSIONS

The present study identifies patient involvement and the role of dietitians as behaviour change facilitators as two important aspects when dietitians prescribe ONS. These findings allow for dietitians' ideals and strategies on how to prescribe ONS to be made more visible, which can inform both clinical practice and clinical trials for future improvements in nutrition therapy to address malnutrition.

Effects of nursing nutrition interventions on outcomes in malnourished hospital inpatients and nursing home residents: A systematic review

CONTEXT

Malnutrition in institutionalized patients is associated with adverse outcomes and increased costs. Nurses have a crucial role in the recognition and treatment of malnutrition and empowering patients in nutritional care.

OBJECTIVE

This systematic review provides an overview of the effectiveness of nursing nutritional interventions to counteract malnutrition.

DATA SOURCES

Data were obtained through a systematic search in MEDLINE/PubMed, Cochrane, CINAHL, EMBASE and ISI Web of Science databases from inception to February 15^th 2018.

DATA EXTRACTION

Studies were eligible for inclusion when published in English, Spanish or German. Primary outcome parameters were nutritional status and dietary intake.

DATA ANALYSIS

The Evidence analysis checklist from the American Dietetic Association and GRADE were used to evaluate the methodological quality of the studies.

RESULTS

Out of 8162 studies, fifteen studies were included in the study, representing nine hospitals and six long-term care facilities. Two main categories of nursing nutrition interventions were identified; the implementation of 1) a nursing nutrition plan focusing on nursing actions in nutritional care or 2) nursing assistance in feeding support, mostly during mealtimes. Studies were heterogeneous and of most of them of low quality. This hampered drawing conclusions on effectiveness of nursing nutrition interventions on malnutrition related outcomes in clinical care. Nevertheless, six out of 15 studies reported a slightly improved nutritional status and/or clinical outcomes as a result of the interventions.

CONCLUSION

This review identified two categories of nursing nutrition interventions to counteract malnutrition. Their effectiveness needs to be further evaluated in future studies. Tweetable abstract: Systematic review of effective Nursing Nutrition Interventions in the management of malnutrition in hospital and nursing home care.

Effectiveness of dietetic intervention for people with type 2 diabetes: A meta-analysis

BACKGROUND

Diet is central to treatment of type 2 diabetes. This review aimed to compare the effectiveness of nutrition therapy delivered by dietitians to nutrition advice delivered by other healthcare professionals in adults with type 2 diabetes on metabolic parameters.

METHODS

Cochrane CENTRAL, CINAHL, EMBASE, MEDLINE and PsychINFO were searched for randomised controlled trials of three months duration or longer, published from 1st January 2008 to 18th June 2019. Relevant data were extracted from studies with additional author information. Random-effects meta-analysis assessed mean changes in HbA1c and other clinical parameters. PROSPERO registration number: CRD42019130528.

RESULTS

Of 2477 records identified, fourteen studies, involving 3338 participants, were eligible for qualitative synthesis and meta-analysis. The mean changes [95% CI] at follow-up in HbA1c, BMI, weight, LDL cholesterol, systolic and diastolic blood pressure were -0·47 [-0·92, -0·02] %, -0·38 [-0·63, -0·13] kg/m², -1·49 [-2·14, -0·84] kg, -0·15 [-0·33, 0·04] mmol/L, -0·75 [-2·45, 0·96] mm Hg and -1·17 [-4·52, 2·17] mm Hg respectively in favour of the intervention group. The quality of evidence was limited due to heterogeneity, risk of bias, publication bias and indirectness.

CONCLUSIONS

Nutrition therapy provided by dietitians was associated with better clinical parameters of type 2 diabetes, including clinically significant improved glycaemic control, across diverse multiethnic patient groups from all six inhabited continents. This conclusion should be reflected in clinical guidelines.

People With Type 2 Diabetes Report Dietitians, Social Support, and Health Literacy Facilitate Their Dietary Change

OBJECTIVE

To describe the experiences and perspectives of people with type 2 diabetes mellitus (T2DM) regarding dietetic services and to suggest improvements for their access and delivery.

DESIGN

Semistructured telephone interviews.

SETTING

Urban and rural Australia.

PARTICIPANTS

A total of 30 English-speaking adults with T2DM recruited by means of electronic advertisements and posters.

PHENOMENON OF INTEREST

Engagement with services, adherence to diet, and perspectives regarding dietetic services.

ANALYSIS

Capability, opportunity, and motivation model of behavior and theoretical domains framework informed the analysis.

RESULTS

Participants were predominantly middle-aged, White, university-educated, and full-time professionals. Most had been diagnosed with T2DM for 2 years or more, were overweight or obese, were on glucose-lowering medication, and had visited the dietitian at least once. Two inter-related behaviors were identified: eating a healthy diet for T2DM and participating with dietetic services. Health literacy, as well as support by family, friends, and professionals, were reported as enablers for both these behaviors. Barriers stated included misconceptions about diets and the role of dietitians, unpleasant previous experiences with services, and lack of social support.

CONCLUSIONS AND IMPLICATIONS

These data support that improving health literacy of people with T2DM, in conjunction with social support by family and friends and professional support by dietitians, is likely to facilitate dietary behavior change.

Doctors identify regulatory barriers for their patients with type 2 diabetes to access the nutritional expertise of dietitians

Diet is central to the management of type 2 diabetes (T2D) and better outcomes are achieved when the dietary intervention is delivered by a dietitian. Yet, many people with T2D never see a dietitian. It has been proposed that doctors prefer to provide the dietary advice themselves or rely on medication to treat their patients instead of referring them to a dietitian. This study aimed to collect the opinions and perspectives of doctors with regard to the dietary management of people with T2D in Australia. GPs and physicians treating people with T2D were recruited to participate in semistructured interviews conducted over the telephone. Inductive thematic analysis of content was conducted. Five GPs and seven physicians participated in the study. The qualitative analysis identified four main themes: the importance and role of diet in the management of T2D; the perceived value of dietetic care; access to dietetic services; and patients' motivation to consult a dietitian. All participants acknowledged the importance of diet in the treatment of T2D and all but one preferred to refer patients to a dietitian for nutritional management. Among the reported barriers to accessing dietetic services were: specialist physicians' lack of access to the national referral scheme for chronic conditions; patients' financial circumstances; and inadequacy of the number of subsidised sessions. It is important to facilitate and subsidise access to dietetic services through existing mechanisms by increasing the number of visits on the chronic disease management scheme and providing referral rights to specialist physicians.

A comparison of patients' and dietitians' perceptions of patient-centred care: A cross-sectional survey

AIM

The aim of this study was to compare patients' and dietitians' perceptions of patient-centred care (PCC) in dietetic practice.

METHODS

Participants were as follows: (a) adult patients who had attended ≥1 individual dietetic consultation with an Accredited Practicing Dietitian (APD) working in primary care; and (b) APDs with experience working in primary care. A cross-sectional survey was undertaken using a patient- and dietitian-reported inventory to measure PCC in dietetic practice. The inventory comprised of five previously validated scales: The Communication Assessment Tool; the 9-item Shared Decision-Making Questionnaire; the Patient-Doctor Depth of Relationship Scale; the Schmidt Perception of Nursing Care Scale-Seeing the Individual Patient sub-scale; and the Person-Centred Practice Inventory-Staff -Providing Holistic Care sub-scale. Descriptive statistics were used to analyse participant characteristics and to compute total scores for the five scales. The Mann-Whitney U test was used to compare median scores between patients and dietitians.

RESULTS

One-hundred and thirty-three patients and 180 dietitians completed the survey. Patients reported significantly higher scores compared to dietitians for "shared decision-making" (P = 0.004), but significantly lower scores for "providing holistic and individualized care" (P = 0.005), "knowing the patient/dietitian" (P = 0.001) and "caring patient-dietitian relationships" (P =0.009).

CONCLUSION

This study highlighted potentially important differences between patients' and dietitians' perceptions of PCC and identified key aspects of dietetic care requiring practice improvements. Strategies are needed to bridge gaps between dietitians' and patients' perceptions and enhance PCC in dietetic practice. These findings suggest that dietitians should focus on individualizing nutrition care, gaining a holistic understanding of their patients and knowing/understanding each patient.

Shared decision making and antibiotic benefit-harm conversations: an observational study of consultations between general practitioners and patients with acute respiratory infections

Background

Little research has examined whether shared decision making (SDM) occurs in consultations for acute respiratory infections (ARIs), including what, and how, antibiotic benefits and harms are discussed. We aimed to analyse the extent and nature of SDM in consultations between GPs and patients with ARIs, and explore communication with and without the use of patient decision aids.

Methods

This was an observational study in Australian general practices, nested within a cluster randomised trial of decision aids (for acute otitis media [AOM], sore throat, acute bronchitis) designed for general practitioners (GPs) to use with patients, compared with usual care (no decision aids). Audio-recordings of consultations of a convenience sample of consenting patients seeing a GP for an ARI were independently analysed by two raters using the OPTION-12 (observing patient involvement in decision making) scale (maximum score of 100) and 5 items (about communicating evidence) from the Assessing Communication about Evidence and Patient Preferences (ACEPP) tool (maximum score of 5). Patients also self-completed a questionnaire post-consultation that contained items from CollaboRATE-5 (perceptions of involvement in the decision-making process), a decisional conflict scale, and a decision self-efficacy scale. Descriptive statistics were calculated for each measure.

Results

Thirty-six consultations, involving 13 GPs, were recorded (20 for bronchitis, 10 sore throat, 6 AOM). The mean (SD) total OPTION-12 score was 29.4 (12.5; range 4–54), with item 12 (need to review decision) the highest (mean = 3) and item 10 (eliciting patients’ preferred level of decision-making involvement) the lowest (mean = 0.1). The mean (SD) total ACEPP score was 2 (1.6), with the item about discussing benefits scoring highest. In consultations where a decision aid was used (15, 42%), compared to the 21 usual care consultations, mean observer-assessed SDM scores (OPTION-12, ACEPP scores) were higher and antibiotic harms mentioned in all (compared to only 1) consultations. Patients generally reported high decision involvement and self-efficacy, and low decisional conflict.

Conclusions

The extent of observer-assessed SDM between GPs and patients with ARIs was generally low. Balanced discussion of antibiotic benefits and harms occurred more often when decision aids were used.

Electronic supplementary material

The online version of this article (10.1186/s12875-018-0854-y) contains supplementary material, which is available to authorized users.

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.

Patient-centred care to improve dietetic practice: an integrative review

BACKGROUND

Patient-centred care (PCC) is associated with significant improvements in patients' health outcomes and healthcare systems. There is an opportunity to better understand PCC in dietetics. Thus, the present integrative review aims to critically synthesise literature relating to PCC in dietetics.

METHODS

A systematic literature search was conducted between February and March 2016. Studies were included if they (i) involved dietitians and/or patients who had participated in an individual dietetic consultation; (ii) related to one or more components of PCC; and (iii) were empirical full-text studies in English, involving adult participants, published between 1997 and 2016. Following title and abstract screening, full texts were retrieved and independently assessed for inclusion by two of the investigators. Two independent investigators conducted data extraction and quality assessment using the Mixed Methods Appraisal Tool. Study findings were analysed thematically using meta-synthesis. Twenty-seven studies met the inclusion criteria.

RESULTS

Six themes were discovered inductively: (i) establishing a positive dietitian-patient relationship; (ii) displaying humanistic behaviours; (iii) using effective communication skills; (iv) individualising and adapting care; (v) redistributing power to the patient; and (vi) lacking time for PCC practices. The first three themes were closely related. Studies used a broad range of methodological designs. Limitations of the studies included a lack of reflexivity and a lack of representativeness of the study population.

CONCLUSIONS

It is apparent that dietitians require good communication skills and humanistic qualities to build positive relationships with patients. Patients strongly desire individualised nutrition care and greater involvement in care. Ensuring dietitians are able to incorporate patient-centred practises during care requires further research.

Shared decision making within goal setting in rehabilitation settings: A systematic review

OBJECTIVE

To map out and synthesise literature that considers the extent of shared decision-making (SDM) within goal-setting in rehabilitation settings and explore participants' views of this approach within goal-setting.

METHODS

Four databases were systematically searched between January 2005-September 2015. All articles addressing SDM within goal-setting involving adult rehabilitation patients were included. The literature was critically appraised followed by a thematic synthesis.

RESULTS

The search output identified 3129 studies and 15 articles met the inclusion criteria. Themes that emerged related to methods of SDM within goal-setting, participants' views on SDM, perceived benefits of SDM, barriers and facilitators to using SDM and suggestions to improve involvement of patients resulting in a better process of goal-setting.

CONCLUSIONS

The literature showed various levels of patient involvement existing within goal-setting however few teams adopted an entirely patient-centred approach. However, since the review has identified clear value to consider SDM within goal-setting for rehabilitation, further research is required and practice should consider educating both clinicians and patients about this approach.

PRACTICE IMPLICATIONS

To enhance the use of SDM within goal-setting in rehabilitation it is likely clinicians and patients will require further education on this approach. For clinicians this could commence during their training at undergraduate level.

Exploration of shared decision-making processes among dieticians and patients during a consultation for the nutritional treatment of dyslipidaemia

BACKGROUND

Shared decision making (SDM) holds great potential for improving the therapeutic efficiency and quality of nutritional treatment of dyslipidaemia by promoting patient involvement in decision making. Adoption of specific behaviours fostering SDM during consultations has yet to be studied in routine dietetic practice.

OBJECTIVE

Using a cross-sectional study design, we aimed to explore both dieticians' and patients' adoption of SDM behaviours in dietetic consultations regarding the nutritional treatment of dyslipidaemia.

METHODS

Twenty-six dieticians working in local health clinics in the Quebec City metropolitan area were each asked to identify one dyslipidaemic patient they would see in an upcoming consultation. Based on the Theory of Planned Behaviour (TPB), questionnaires were designed to study two targeted SDM behaviours: 'to discuss nutritional treatment options for dyslipidaemia' and 'to discuss patients' values and preferences about nutritional treatment options for dyslipidaemia'. These questionnaires were administered to the dietician-patient dyad individually before the consultation. Associations between TPB constructs (attitude, subjective norm and perceived behavioural control) towards behavioural intentions were analysed using Spearman's partial correlations.

RESULTS

Thirteen unique patient-dietician dyads completed the study. Perceived behavioural control was the only TPB construct significantly associated with both dieticians' and patients' intentions to adopt the targeted SDM behaviours (P < 0.05).

CONCLUSIONS

As perceived behavioural control seems to determine dieticians' and patients' adoption of SDM behaviours, interventions addressing barriers and reinforcing enablers of these behaviours are indicated. This exploratory study highlights issues that could be addressed in future research endeavours to expand the knowledge base relating to SDM adoption in dietetic practice.

Clinicians' involvement of patients in decision making. A video based comparison of their behavior in public vs. private practice

BACKGROUND

Little is known about the extent to which Peruvian physicians seek to involve patients in shared decision making, or about the variation in these efforts across different settings.

OBJECTIVE

To measure the extent to which Peruvian clinicians involve their patients in decision making and to explore the differences between clinicians' behavior in private vs. public practice.

DESIGN

Videographic analysis.

PARTICIPANTS AND SETTING

Seven academic physicians who provided care to patients in a public and a private setting participate in this study. All the encounters in both settings were filmed on one random day of February 2012.

APPROACH

Two raters, working independently and in duplicate used the 12-item OPTION scale to quantify the extent of physician effort to involve patients in shared decision making (with 0 indicating no effort and 100 maximum possible effort) in 58 video recordings of usual clinical encounters in private and public practice.

RESULTS

The mean OPTION score was 14.3 (SD 7.0). Although the OPTION score in the private setting (mean 16.5, SD 7.3) was higher than in the public setting (mean 12.3 SD 6.1) this difference was not statistically significant (p = .09).

CONCLUSION

Peruvian academic physicians in this convenience sample barely sought to involve their patients in shared decision making. Additional studies are required to confirm these results which suggest that patient-centered care remains an unfulfilled promise and a source of inequity within and across the private and the public sectors in Peru.

Assessments of the extent to which health-care providers involve patients in decision making: a systematic review of studies using the OPTION instrument

BACKGROUND

We have no clear overview of the extent to which health-care providers involve patients in the decision-making process during consultations. The Observing Patient Involvement in Decision Making instrument (OPTION) was designed to assess this.

OBJECTIVE

To systematically review studies that used the OPTION instrument to observe the extent to which health-care providers involve patients in decision making across a range of clinical contexts, including different health professions and lengths of consultation.

SEARCH STRATEGY

We conducted online literature searches in multiple databases (2001-12) and gathered further data through networking.

INCLUSION CRITERIA

(i) OPTION scores as reported outcomes and (ii) health-care providers and patients as study participants. For analysis, we only included studies using the revised scale.

DATA EXTRACTION

Extracted data included: (i) study and participant characteristics and (ii) OPTION outcomes (scores, statistical associations and reported psychometric results). We also assessed the quality of OPTION outcomes reporting.

MAIN RESULTS

We found 33 eligible studies, 29 of which used the revised scale. Overall, we found low levels of patient-involving behaviours: in cases where no intervention was used to implement shared decision making (SDM), the mean OPTION score was 23 ± 14 (0-100 scale). When assessed, the variables most consistently associated with higher OPTION scores were interventions to implement SDM (n = 8/9) and duration of consultations (n = 8/15).

CONCLUSIONS

Whatever the clinical context, few health-care providers consistently attempt to facilitate patient involvement, and even fewer adjust care to patient preferences. However, both SDM interventions and longer consultations could improve this.