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.

Practice and perspectives of Australian dietitians in management of patients on pancreatic enzyme replacement therapy.

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.

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.