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.

The role of dietitian clinical judgement in the nutrition care process within the acute care setting: a qualitative study

BACKGROUND

Dietitian clinical decision making in the acute care setting likely incorporates a practitioner's clinical judgement to effectively support patient care. The term 'dietitian clinical judgement' is well used in clinical practice, yet is poorly defined and often used interchangeably with other concepts. The aim of this research was to describe the nature of dietitians' clinical judgement in the acute care setting.

METHODS

A qualitative design within the interpretative paradigm was used guided by principles of philosophical hermeneutics. Dietitians with at least 3 years experience were invited to participate in two 60-min in-depth semi-structured interviews which were recorded, transcribed and interpreted using hermeneutic principles. A reference group was used to increase rigour and further interpretation of the findings.

RESULTS

Ten dietitians participated in the interviews and five of these same participants in the reference focus group. The findings revealed clinical judgement to be a sophisticated practitioner dependent meta-reasoning process that helps the dietitian manage complexity, guide interpersonal interactions and individualise patient care. It is characterised by tacit and efficient use of various reasoning strategies reliant on the dietitian's clinical experience, used to synthesise and weigh up various types of information and knowledge with respect to delivering context-relevant care.

CONCLUSIONS

Dietitian clinical judgement is a necessary part of clinical decision making that extends beyond logical or critical thinking. It facilitates a person-centredness to patient care and professional relationships that are key dimensions to dietitian clinical decision making. These findings provide training and professional development insights to managers, educators and supervisors.

A model of the multidimensional nature of experienced dietitian clinical decision-making in the acute care setting

BACKGROUND

Clinical decision-making (CDM) is an essential component of dietetic practice that can significantly affect the quality of patient care. Research around CDM in clinical dietetics is scarce, with research in other healthcare professions offering limited insight into dietitian CDM in the specific setting of the acute care hospitals. The aim of this qualitative research was to deepen our understanding of the nature of the CDM of experienced dietitians in the acute care setting.

METHODS

The present study employed philosophical hermeneutics to guide methods situated within the interpretative paradigm. This study invited dietitians currently practising in adult acute care hospitals with at least 3 years of experience to be involved two in-depth semi-structured interviews using the principles of hermeneutics. A reference focus group session was then used to provide rigour and further interpretation of the findings.

RESULTS

Ten dietitians participated in the interviews and five of these same participants in the reference focus group. The findings have informed the development of A Model of the Multidimensional Nature of Dietitian CDM in the Acute Care Setting, which reflects the nature of making decisions for patient care through the synergistic relationship between five key dimensions: (i) tasks; (ii) interactions; (iii) reasoning; (iv) practitioner factors; and (v) context, all of which are managed and monitored by the higher- order reasoning process of the dietitian's clinical judgement.

CONCLUSIONS

Because there is scarcity of research on the CDM of dietitians in acute care settings, the present study can provide training and professional development insights to managers, educators and supervisors.

Summary and recommendations from the Australasian guidelines for the management of pancreatic exocrine insufficiency

AIM

Because of increasing awareness of variations in the use of pancreatic exocrine replacement therapy, the Australasian Pancreatic Club decided it was timely to re-review the literature and create new Australasian guidelines for the management of pancreatic exocrine insufficiency (PEI).

METHODS

A working party of expert clinicians was convened and initially determined that by dividing the types of presentation into three categories for the likelihood of PEI (definite, possible and unlikely) they were able to consider the difficulties of diagnosing PEI and relate these to the value of treatment for each diagnostic category.

RESULTS AND CONCLUSIONS

Recent studies confirm that patients with chronic pancreatitis receive similar benefit from pancreatic exocrine replacement therapy (PERT) to that established in children with cystic fibrosis. Severe acute pancreatitis is frequently followed by PEI and PERT should be considered for these patients because of their nutritional requirements. Evidence is also becoming stronger for the benefits of PERT in patients with unresectable pancreatic cancer. However there is as yet no clear guide to help identify those patients in the 'unlikely' PEI group who would benefit from PERT. For example, patients with coeliac disease, diabetes mellitus, irritable bowel syndrome and weight loss in the elderly may occasionally be given a trial of PERT, but determining its effectiveness will be difficult. The starting dose of PERT should be from 25,000-40,000 IU lipase taken with food. This may need to be titrated up and there may be a need for proton pump inhibitors in some patients to improve efficacy.