No abstract

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 higherorder 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.

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.

Prescribing pathways for Australian dietitians are limited in comparison to dietitians practising in New Zealand and the United Kingdom. Therefore where medication dose may be titrated relative to dietary intake, such as in pancreatic exocrine insufficiency, dietitians in Australia are unable to initiate therapy or adjust dosage. Aim To explore current practice roles of Australian dietitians working with patients requiring pancreatic enzyme replacement therapy (PERT), and opinions and influences on these practices. Methods An online survey and telephone interviews with self‐nominated dietitians who identified with extended scope of practice with patients on PERT. Thematic analysis was undertaken through an inductive approach to better understand the contexts and reasoning around a dietitian's extended scope of practice. Results The majority of participants in the online survey (74/81) described roles beyond traditional scope of practice with patients requiring PERT, especially in a multidisciplinary team environment. Most respondents (97%) believed PERT prescribing for dietitians would be beneficial. Nine semi‐structured telephone interviews with experienced dietitians revealed perceived benefits of current advanced and informal extended scope of practice for dietitians including greater efficiency; improved patient care; increased job satisfaction and enhanced inter‐professional communication. Dietitians believe they are adequately equipped to prescribe medication where dose is largely dependent upon diet. Conclusions In Australia, it is common for dietitians in care of patients prescribed PERT to engage in informal, extended scope of practice. Further research is required to determine the framework to achieve formal extended scope of practice related to PERT and potentially other medications.

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.