title: Advancing Patient-Centred Care in Dietetics
Creators: name: Sladdin, Ishtar K.
Publisher: name: Griffith University
Year: 2019
Subjects: subject: Patient-centred care
subject: Dietetics
subject: Dietitians
subject: Patient–dietitian relationships

description: Patient-centred care (PCC) is an integral component of high-quality care and has been associated with significant benefits for patients. Despite the increasing emphasis on ensuring healthcare systems are patient-centred, limited research has been conducted on this topic in dietetics. Dietitians play an important role in the management of chronic, lifestyle-related diseases, particularly in the primary care setting. There is potential for patient-centred practices to lead to enhanced care by dietitians and ultimately better outcomes for patients. To enhance understandings of PCC in dietetics, the aims of this research were to synthesise literature relating to PCC in dietetics and identify any gaps requiring further exploration; explore patients’ perceptions and experiences of PCC in dietetics; develop and psychometrically test a patient and dietitian-reported inventory to measure PCC in dietetics; and compare patients’ and dietitians’ experiences of PCC. These aims were addressed in three phases of research. In Phase I, a systematic literature search was conducted to identify studies that involved dietitians and/or patients who had participated in an individual dietetic consultation and related to one or more dimensions of PCC. Twenty-seven studies met the inclusion criteria and were analysed using meta-synthesis. Six themes arose: establishing a positive dietitian–patient relationship; displaying humanistic behaviours; using effective communication skills; individualising and adapting care; redistributing power to the patient; and lacking time for PCC practices. Findings suggested that research relating to PCC in dietetics was sparse, with only a small number of studies directly referring to PCC in their aims. The application of PCC in dietetics had not been widely investigated and no study specifically aimed to examine patients’ understandings of PCC. In Phase II, qualitative semi-structured interviews were conducted with a purposive sample of 11 adult patients who had participated in at least one dietetic consultation, had received nutrition care for the management one or more medical conditions and were English speaking. Participants were sought from dietitian-specific primary healthcare clinics using the patient database of a large primary healthcare service in Queensland, Australia. Participants’ perceptions and experiences of PCC were explored, and data were analysed thematically. The results highlighted that patients valued PCC highly. Patients wanted dietitians to develop a holistic understanding of their background and the underlying factors influencing their health; tailor advice and strategies to patients’ unique circumstances; be invested in their wellbeing; and be involved in decision-making. Some participants perceived care as generic and non-individualised and thought that dietitians controlled the encounter, limiting patient involvement. These findings contributed to the development of a conceptual model of PCC in dietetics. In Phase III, a patient and dietitian-reported inventory of five valid scales was compiled to reflect the conceptual model. The scales were the Communication Assessment Tool; 9-item Shared Decision-Making Questionnaire; Patient-Doctor Depth of Relationship Scale; SPNCS Seeing the Individual Patient sub-scale; and the PCPI-s Providing Holistic Care sub-scale. Between November 2017 and May 2018, the inventory was distributed as a survey to adult patients who had attended at least one individual dietetic consultation with an accredited practising dietitian (APD) working in primary care, and APDs with experience working in primary care. Six dietetic practices across Queensland (n = 3), New South Wales (n = 2) and Victoria (n = 1) participated in the recruitment of patients. Dietitians completed an e-survey that was initially distributed by the Dietitians Association of Australia. Subsequent strategies employed to enhance the response rate included an invitation via the Dietitian Connection weekly e-newsletter and dietitian specific social media sites. Exploratory factor analysis was performed using principal component analysis. Cronbach’s alpha, inter-item correlations and corrected item-total correlations were computed to evaluate the internal consistency of each scale. Data from the cross-sectional survey were analysed using the Mann-Whitney U test to compare patients’ and dietitians’ median scale scores to identify any differences between participants’ perspectives of PCC. One hundred and eighty dietitians and 133 patients completed the survey. Five factors were extracted, and Cronbach’s alpha values ranged from 0.73 to 0.91 and 0.87 to 0.97 across factors for the dietitian and patient versions respectively. Most items had strong loadings on only one factor. Factors were labelled shared decision-making; holistic and individualised care; patient–dietitian communication; knowing the patient/dietitian; and caring patient–dietitian relationships. Results suggested good preliminary validity and internal consistency for both inventories. Patients’ scores were significantly higher than dietitians’ for ‘shared decision-making’ (p=.004), but significantly lower for ‘providing holistic and individualised care’ (p=.005), ‘knowing the patient/dietitian’ (p=.001) and ‘caring patient–dietitian relationships’ (p=.009) suggesting small but important divergences between patients’ and dietitians’ experiences. This research contributes novel and important findings relevant to PCC in dietetics. Patients clearly value PCC, but do not always perceive that dietitians adopt this approach in practice. Strategies to enhance dietitians’ PCC should particularly focus on ensuring care is holistic and individualised, and good patient–dietitian relationships are established. Finally, the conceptually grounded inventory has promising preliminary validity and reliability. This research provides a solid foundation for future work in advancing PCC in dietetics.