Asserting professional value while navigating power relations in the acute care setting: A qualitative study of dietitian clinical decision making

Dietitian decision making in the acute setting focuses on identifying and addressing nutritional issues in patients. The aim of this doctoral research was to uncover the nature of clinical decision making of dietitians in the acute setting. A qualitative design within the interpretative paradigm was used, specifically philosophical hermeneutics. Philosophical hermeneutics is concerned with the human experience but more specifically, the interpreted meaning of this experience. This study involved two in-depth semi-structured interviews with ten experienced acute care dietitians that were recorded, transcribed and interpreted using the principles of hermeneutics. A reference group was then used to provide rigour and further interpretation of the findings. Findings revealed the nature of key relationships between dietitians and other health professionals within which the dietitians actively assert the value they believe they can offer to enhance patient care. Power relationships that exist between the dietitian and the medical practitioner, nurse and patient influence the decisions made as well as how dietitians choose to try and implement care plans. Power dominance of the medical practitioner leads to varying degrees of autonomy depending on the dietitians experience, reputation established with individual doctors and nature of the decision. Key responses to power differences in decision making included building and maintaining supportive relationships; advocating to medical practitioners on behalf of the patient; negotiating decisions using a timely, well reasoned and if needed compromising approach; consulting other members of the healthcare team for information or advice; giving instructions to nurses and patients to facilitate patient care with a focus on compliance; and enabling patients by empowering them to be part of clinical decision making about their own nutritional issues. A deeper understanding of this phenomenon provides insight into how decision making occurs and therefore potentially contribute to education, professional development and research activities which subsequently optimise patient care.