Abstract
Background: Malnutrition is prevalent among older people. Dietitians are uniquely skilled in supporting nutritionally vulnerable older adults through dietetic consultations for nutritional support. The relative efficacy of oral nutritional support interventions has been investigated, with discordant results and interpretations. Examination of the literature in this area indicated heterogeneous effects of conventional nutritional support approaches, overlooking the influence of how dietetic consultations are experienced and whether this is a contributing factor to their effectiveness. A feasible explanation for these inconsistencies has not yet been offered as no previous studies have examined the experience of the dietetic consultation in the context of nutritional support. Dietetic consultations are complex interventions which aim to facilitate dietary behaviour change in the patient through information exchange, negotiation and goal-setting. The success or failure of the dietetic consultation might be influenced by how well relationship-building between the patient and dietitian occurred, the dietitian’s skillset and contextual factors. An understanding of what contextual conditions helped or hindered consultation success or why some dietetic consultations ‘worked’ for some and produced positive outcomes but others had little or no impact, was not previously explored. Although the human experience of clinical consultations has been increasingly liked to their effectiveness in healthcare, there were several limitations in this literature, leaving its role in the management of malnutrition, unknown. Therefore, a deeper understanding of how malnourished older adults receiving oral nutrition support, their carers (key stakeholders) and dietitians experienced nutrition support consultations was indicated.Research Design & Methodology: A convergent parallel mixed method approach was used. Realist methodology was used to synthesise a broad dietetic consultation literature, understand the programme architecture of the dietetic encounter and uncover causal mechanisms (Pawson et al, 2005). Illuminative evaluation was used (Parlett & Hamilton, 1972) to understand how the dietetic consultation was experienced by various stakeholders (patients, dietitians and carers), in different settings, under different circumstances and using multiple data sources.
Methods: I adopted a realist approach for synthesis of the literature. A review team of clinical and academic dietitians was consulted to brainstorm an initial programme theory of the dietetic consultation before identification and selection of studies, appraisal, data extraction and synthesis. Studies of any research design, in which a dietitian provided nutritional advice to an adult patient with any clinical condition, in any healthcare setting, and where the study authors provided some causal insights about the dietetic encounter, were included. Realist methods were used to map and refine the programme theory and generate context-mechanism-outcome (CMO) configurations. Further paper inclusion in the synthesis ceased when saturation occurred. For the illuminative evaluation arm of this research, purposive maximum variation sampling was used to recruit participants. Participants included nutritionally vulnerable older patients >60 years, their consulting dietitians, and patient-nominated key stakeholders. Data were collected from three clinical settings including hospital wards, outpatient clinics, and the community (home visits). Some participants were interviewed separately about their recent dietetic encounter and other participants had their live dietetic consultations observed. Dietetic records pertaining to the consultation were also examined and triangulated with interview and observation data. The data were analysed inductively with identification of codes, categories and themes until saturation was reached. NVivo software was used to organise the data.
Findings: For the realist synthesis, a series of iterative searches yielded 6516 records from electronic databases and other sources. Following removal of duplicates, and title and abstract screening, 92 full-text publications were shortlisted for inclusion by two reviewers working independently. 37 papers were included in the synthesis. The synthesis revealed multiple layers of influence on consultation outcomes in the programme theory. The programme theory suggested that a supportive therapeutic relationship lies at the heart of the dietetic encounter but its establishment is partially dependent on effective application of dietitian skill, which in turn requires a facilitative dietetic service structure in order to generate positive consultation outcomes. At each level, specific contextual conditions impacted the firing of generative mechanisms which affected subsequent levels and ultimately consultation outcomes. The illuminative evaluation involved analysis and triangulation of observation, interview and documentary data gathered from 39 participants, including patients, dietitians and carers (key stakeholders). Participants were recruited from three clinical settings within a South London NHS Trust, including hospital wards, outpatient clinics and the community. Four main themes were concurrently constructed: 1. Building a therapeutic alliance 2. Navigating changes beyond the consultation 3. Dynamics of expectations, power and satisfaction 4. Influences and realities of professional practice.
Under the theme ‘Building a therapeutic alliance’, findings suggested that participants valued the relationship with their dietitian and an empathic, individualised, patient-centred approach, although this was not always their experience. Good communication was also a key component of an effective therapeutic relationship between the dietitian, the patient and their family, although this too was highly inconsistent. The theme ‘Navigating changes beyond the consultation’ suggested that patients and key stakeholders found it challenging at times to accept their nutritional diagnosis and implement the dietary advice given by the dietitian.
Malnutrition impacted their daily lives and personal relationships in unanticipated ways and subsequently, their ability to bring about dietary behaviour change. There were several barriers and facilitators to change, but their acknowledgement was lacking at times. The ‘Dynamics of expectations, power and satisfaction’ theme included concepts of power, control, satisfaction and expectations. Paternalistic behaviour from the dietitian was mostly unwelcome, although some patients perceived the dietitian as an expert, non-threatening authority in the consultation dynamic. Preconceived views about power and positionality also extended into wider perceptions about the dietetic service and healthcare system. Some participants held strong views about how consultations should work in an ideal world but this rarely matched reality on reflection, affecting how satisfied participants felt about their consultation experience. The final theme, ‘Influences and realities of professional practice’, highlighted variable inter-professional practice between dietitians and other healthcare professionals. Findings suggested the need for stronger multidisciplinary collaboration, recognition of dietetic expertise and dietitian role clarity. Furthermore, experiences of navigating and delivering dietetic services were also complex and varied with many local pressures affecting the quality of care dietitians felt able to provide.
Conclusions: This study is the first to use a convergent parallel mixed method approach to understand the mechanisms and experiences of the dietetic consultation, a complex intervention. It provides integrative insights into the generative mechanisms underlying the dietetic consultation and the influence of contextual factors, as well as an in-depth understanding of the experience of the dietetic consultation from multiple perspectives and data sources. Use of a realist approach enabled synthesis of a methodologically diverse literature and offered a theory-driven explanation of the hidden consultation mechanisms at play. Understanding what it is about dietetic encounters that work, for whom, under what circumstances, provides a launch pad for innovation in this aspect of dietetic practice.
Furthermore, a holistic understanding of how the consultation is experienced, provided new insights into where dietetic practice can be improved for older, nutritionally vulnerable adults to optimise care, outcomes and satisfaction. The dietetic consultation is a complex intervention that seeks to facilitate behaviour change to improve health status. However, with human and institutional factors also contributing to its success or failure, dietetic practitioners should pay attention to those areas which are amenable to future innovation and outcome maximisation. Based on the findings of this portfolio of studies, this thesis concludes with recommendations for a more patient-centred model for dietetic care as well as better role clarity and visibility for dietitians. In addition, implications for dietetic education and future research are considered.
| Date of Award | 1 Oct 2023 |
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| Original language | English |
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| Supervisor | Alastair Duncan (Supervisor), Sharon Markless (Supervisor) & Christine Baldwin (Supervisor) |