Being Heard’ Dietitians Involvement in Making Decisions about Artificial Nutrition and Hydration.

ABSTRACT

Background: Decisions about artificial nutrition and hydration (ANH) can be difficult to make. Team working, good communication and listening to other team views are recommended in non-emergency decisions relating to ANH (Royal College of Physicians and British Society of Gastroenterology [1]. The experience of dietitians’ involvement in these decisions has not been investigated. This research aims to explore the lived experience of dietitians’ involvement in decisions related to ANH. Methods: 16 registered dietitians were interviewed as part of a qualitative phenomenological study exploring their experiences of involvement in decision-making related to ANH. Convenience sampling via an email advert to the West Midlands Branch of the British Dietetic Association membership enabled participants’ with a range of clinical experience and from a range of clinical settings to be recruited. Interviews were fully transcribed and analysed within an interpretive phenomenological framework van Manen [2]. Ethical approval was obtained from Coventry and Warwickshire Research ethics committee. Results: ‘Wanting to be heard’ was a key theme which was made up from the subthemes of ‘being heard’, ‘trying to listen’ and ‘not being heard’. The sub-theme of ‘being heard’ is reported here. For my participants successful involvement in decision-making meant their voice ‘being heard’. This did not necessarily mean having their view accepted and adopted, but to them it meant being listened to and respected. Participants who were listened to and respected were known by the team and had positive working relationships with them. This was facilitated by have a physical presence in the clinical setting and being seen to make a difference to patient care. Many felt they needed to prove their worth to the team. For my participants, ‘being heard’ was also about speaking up for what they believed was right. For example if it was appropriate to initiate, continue with or withdraw a feed which may be related to end of life situations. Discussion: For these participants positive team relationships were needed to enable them to be heard. Attendance at team meetings where the clinical benefits of dietetic input on patient care could be discussed helped relationships to develop. Time was a barrier to this for some participants. Speaking up about appropriate use of ANH is interesting as implies that participants are not just thinking about ANH as fluid and fuel for the body, but ethical aspects as well. It might be expected that dietitians would promote the initiation and continuation of feeding as they are trained to detect, treat and prevent malnutrition. However, many participants took a more holistic view, showing courage to speak up and ethical sensitivity that it might not be right to feed some patients in certain situations. For some participants ‘being heard’ enabled them to demonstrate expert power. Mandel and Garey’s survey of New Jersey dietitians suggests this is important for dietitians, Mandel and Garey [3]. Conclusion: Dietitians want to have their opinions heard to inform the decision making process. However having opinions respected and listened to appeared to be more important than if their decision which was implemented. Developing relationships with the team and showing clinical benefits of dietetic input on patient care facilitated them ‘being heard’. Time may be a barrier to this. Many participants had the courage to speak up for what they believed was right.