Clinical decision making of experienced dietitians in the acute care setting

The aim of this research was to deepen understanding of the nature of clinical decision making (CDM) of experienced dietitians in the acute care setting. Research around decision making in clinical dietetics is limited, and research in other areas of dietetics and health care professions offers limited insight into dietitian decision making in the acute care setting. The research reported in this thesis illuminated a nuanced understanding of experienced dietitians’ CDM. This nuanced understanding included how clinical dietitians in acute care make decisions, the place of professional judgement in such decision making, development of CDM expertise and relevance of professional artistry for dietetic practice.
A philosophical hermeneutics approach underpinned this research, utilising three key hermeneutic concepts: hermeneutic circle, a dialogue of question and answer, and fusion of horizons. Text construction involved a series of in-depth semi-structured interviews with ten dietitian participants with a range of 5-30 years of dietetic practice experience. An additional text set was constructed through a reference focus group with five of the ten participants. The reference focus group served as both a member checking strategy and a means for deeper exploration of emerging interpretations.
This research revealed experienced dietitian CDM to be a complex, multidimensional and fluid phenomenon embedded in particular contexts. Core CDM tasks were found to sit within a broad problem identification and solving approach to patient care included prioritising, assessing, care planning, implementing care plans and monitoring patients. These tasks were also revealed to be undertaken through multiple and frequent interactions with other health professionals, patients and carers.
Interprofessional relationships, particularly with medical practitioners, strongly characterised dietitian CDM. These relationships were framed by notions of power to which dietitians strategically responded. Key responses included building relationships, negotiating, advocating, instructing and enabling. Dietitian autonomy was highly contextually dependent on individual medical practitioners, the clinical specialty, nature of the decision, dietitian expertise and patient scenario.
Dietitian CDM involved multiple cognitive processes but was dominated by clinical judgement. Clinical judgement was revealed as a sophisticated meta reasoning process that was used to manage complexity, guide interactions, individualise patient care plans and synthesise information and knowledge. It enabled efficient and context relevant CDM and was underpinned by both evidence and highly tacit experience-based knowledge. The nature of a dietitian’s CDM was found to change over time and develop through experience. Type and amount of experience, reflection, confidence, supportive workplaces and intrinsic motivation were found to be core interdependent dimensions of developing expertise that shape CDM. The ideal expertise supporting CDM can be depicted by a dietitian with professional artistry with efficiency, adaptability and influence while striving for effective patient care.
The key products of this research are three new models that together offer a conceptual framework which could be used for clinical dietetics education, practice and research. The first, a model of developing dietitian CDM expertise; second, a model of professional artistry in clinical dietetics; and thirdly, a model of the multidimensional nature of dietitian CDM in the acute care setting conveying the core dimensions of tasks, interactions, reasoning, practitioner factors and context.