Delegation Opportunities for Malnutrition Care Activities to Dietitian Assistants—Findings of a Multi-Site Survey

Abstract

Approximately one-third of adult inpatients are malnourished with substantial associated healthcare burden. Delegation frameworks facilitate improved nutrition care delivery and high-value healthcare. This study aimed to explore knowledge, attitudes, and practices of dietitians and dietitian assistants regarding delegation of malnutrition care activities. This multi-site study was nested within a nutrition care implementation program, conducted across Queensland (Australia) hospitals. A quantitative questionnaire was conducted across eight sites; 87 dietitians and 37 dietitian assistants responded and descriptive analyses completed. Dietitians felt guidelines to support delegation were inadequate (agreement: <50% for assessment/diagnosis, care coordination, education, and monitoring and evaluation); dietitian assistants perceived knowledge and guidelines to undertake delegated tasks were adequate (agreement: >50% food and nutrient delivery, education, and monitoring and evaluation). Dietitians and dietitian assistants reported confidence to delegate/receive delegation (dietitian agreement: >50% across all care components; dietitian assistant agreement: >50% for assessment/diagnosis, food and nutrient delivery, education, monitoring and evaluation). Practice of select nutrition care activities were routinely performed by dietitians, rather than assistants (p < 0.001 across all nutrition care components). The process for care delegation needs to be improved. Clarity around barriers and enablers to delegation of care prior to implementing reforms to the current models of care is key.

Barriers and Enablers to Delegating Malnutrition Care Activities to Dietitian Assistants

“…The views, perceptions, and opinions of staff members regarding delegation to dietitian assistants influenced why ‘below-scope’ tasks are still being retained by dietitians rather than being delegated to dietitian assistants where possible and safe to do so [ 8 , 19 ]. Commonly perceived humanistic traits of clinical dietitians were to fear harm, be risk-averse, resist change, and distrust the delegation process and capacity of dietitian assistants.…”

“…Additionally, the dietetic workforce has identified and prioritised delegation of malnutrition care as an opportunity to facilitate high-value healthcare [ 20 ]. However, malnutrition care appears to still predominately be undertaken by dietitians [ 8 , 14 , 19 ]. This introduces another novel insight: the cognitive dissonance observed in relation to delegation to dietitian assistants.…”

“…Knowledge and attitudes surrounding delegation appear positive, with dietitians and dietitian assistants reporting high confidence in delegation of malnutrition care activities [ 19 ]. However, a recent report of nutrition care practice, within Queensland hospitals in Australia, suggests poor uptake of delegated nutrition care processes, with 75% or more of dietitians continuing to individually undertake malnutrition care activities [ 19 ].…”

“…Knowledge and attitudes surrounding delegation appear positive, with dietitians and dietitian assistants reporting high confidence in delegation of malnutrition care activities [ 19 ]. However, a recent report of nutrition care practice, within Queensland hospitals in Australia, suggests poor uptake of delegated nutrition care processes, with 75% or more of dietitians continuing to individually undertake malnutrition care activities [ 19 ]. The dietetic profession has identified and prioritised delegation of elements of malnutrition care as opportunities to facilitate systematised interdisciplinary malnutrition care; however, it was suggested that further investigation into the complexities surrounding implementation of delegation to dietitian assistants is required [ 20 ].…”

“…The dietetic profession has identified and prioritised delegation of elements of malnutrition care as opportunities to facilitate systematised interdisciplinary malnutrition care; however, it was suggested that further investigation into the complexities surrounding implementation of delegation to dietitian assistants is required [ 20 ]. Identifying barriers and enablers to delegation has been highlighted as a crucial step for translation and change in practice [ 19 , 20 ]. Consequently, the aim of this study is to use a qualitative approach to identify barriers and enablers to delegating malnutrition care activities to dietitian assistants from the perspectives of dietitian assistants, dietitians, and management.…”