Malnutrition
Conditions
Keywords
patient experience, disease-related malnutrition, nutritional care, dietetic consultation, older adults, oral nutritional support
Brief summary
This study aims to understand the experience of the dietetic consultation from the perspective of nutritionally vulnerable older patients receiving oral nutrition support and dietitians, as well as other key stakeholders involved in the process of such a consultation. Malnutrition is prevalent and increases the risk of health complications and socioeconomic burden. Patients with malnutrition are often older patients with complex needs and therefore may require specialist knowledge and skills to provide nutritional support. Dietitians are uniquely skilled to assess the multiple factors that underpin diet and to tailor nutritional support, which could help improve outcomes. Although the causes of malnutrition are complicated, its treatment typically involves oral nutritional supplements, dietary advice or food-based interventions, either separately or in combination. Effectiveness of the various oral nutritional support interventions has been studied, with the findings on food-based interventions suggesting more research is needed and the widespread research on ONS suggesting contradictory results and interpretations. Despite this, the factors responsible for these inconsistencies have not been identified. There are no studies so far that have examined the patient experience of the consultation with the dietitian in the context of nutritional support. Although the patient experience of consultations is increasingly being recognised as an important part of investigating their effectiveness in healthcare, to date, there are a number of limitations in this literature, leaving the role of the patient experience in dietetic consultations for the management of malnutrition, poorly understood. It's probable that this is one contributing factor to the variation observed in the literature. A review of the literature indicates a need for exploration of the patient experience and its possible impact on the success or failure of the dietetic encounter. This study aims to address some of the knowledge gaps. The use of qualitative interviews will allow an in-depth understanding of the experience of the dietetic consultation for the provision of nutrition support and will utilise an overall illuminative evaluation approach to broaden that understanding by considering data from various sources. Participants will include older patients who are considered nutritionally vulnerable, their consulting dietitians and patient-nominated key stakeholders. Four clinical settings within the Trust where dietitians would often see patients for nutritional support will be included.
Interventions
OTHERObservations, documents
Consultation observations, documentary analysis
OTHERInterviews, key stakeholders, documents
Qualitative interviews, key stakeholders, documentary analysis
Sponsors
King's College London
Study design
Observational model
OTHER
Time perspective
OTHER
Eligibility
Sex/Gender
ALL
Age
60 Years to No maximum
Healthy volunteers
No
Inclusion criteria
Patients: * Adults (aged \> 60 years) * National Health Service (NHS) number * Capable of giving informed consent * Able to communicate well in English * Nutritionally vulnerable according to the Nutrition Screening Tool in use at the NHS Trust prompting referral to a dietitian * Likely to receive a form of oral nutrition support in the management of malnutrition * A variety of the patient characteristics detailed earlier will be included where possible * Consents to having their qualitative interview audio-recorded (Group 2) Dietitians: * Consulting dietitian providing the nutritional advice to patient above * Employee of the NHS Trust and member of the Nutrition & Dietetic team * Minimum of three different dietitians across the healthcare settings to be included * Consents to having their qualitative interview audio-recorded Key Stakeholders: Up to 2 optional patient-nominated key stakeholders who are involved in the dietetic consultation and success of the dietetic intervention e.g. other HCP, family member, carer or friend. Their criteria for inclusion will include: * Nominated by the patient (from Group 2) participating in the study * Involved in some aspect of the implementation of goals agreed between the patient and dietitian during the consultation i.e. the nutritional intervention * Available for separate interview at a mutually agreed location * Capable of giving informed consent * Able to communicate well in English * Consents to having their qualitative interview audio-recorded
Exclusion criteria
Patients: * Participated or due to participate in another aspect of the study i.e. a patient will not be recruited to participate in consultation observations if they have already been or due to be recruited to take part in the qualitative interviews and vice versa. * Outside of stated age range for inclusion * Incapable of giving informed consent * No National Health Service (NHS) number * Unable to communicate well in English * Not considered nutritionally vulnerable according to Nutrition Screening Tool * Not referred to a dietitian for nutrition support * Patients receiving artificial nutrition support * Does not wish to have their qualitative interview audio-recorded (Group 2) Participants with visual or hearing impairment or other physical disabilities will NOT be excluded from the study.
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Experience of the Dietetic Consultation (Number of Participants With Dietetic Consultation Experience That Relate to Each Theme) | Through study completion, an average of 2 months | Themes and sub-themes related to the patient experience, dietitian experience and key stakeholder experience of the consultation. These were derived from qualitative thematic analysis of triangulated data from interviews, consultation observations and consultation documents derived from ALL study participants (n=39). Final themes included: 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. Please note that ALL study participants (n=39) from all 4 groups (Patient Group 1, Patient Group 2, Dietitians, and Key Stakeholders) contributed to all 4 final constructed themes noted above as all data were qualitatively triangulated. These 4 themes represent how the dietetic consultation was experienced from multiple perspectives, in different contexts and highlighted key areas of the dietetic encounter that mattered to participants. |
Other
| Measure | Time frame | Description |
|---|---|---|
| Dietitian AfC Banding | At enrollment. | The NHS AfC Banding for consulting dietitians included. NHS Band 5 = entry level dietitian, NHS Band 6 = more experienced and specialised dietitian, NHS Band 7 = more advanced level dietitian. Data were collected on the NHS Banding (determined by their employer) for each dietitian included to understand how their experiences differed by seniority. Data collected for dietitians only. |
| Dietitian Speciality | At enrollment | Clinical speciality of consulting dietitians included. Data collected for dietitians only. |
| Relationship to Patient | At enrollment. | Relationship of key stakeholder to patient. Data collected for key stakeholders only. |
| Consultation Type | At enrollment. | New (i.e. new episode of dietetic care) or review/follow-up (had previous consultation in current episode of care) re the dietetic consultation. Data collected for patients only. |
| Family Support | At enrollment. | Whether the patient had family support or not at the time of study enrollment. Data collected for patients only. |
| Type of Intervention | At enrollment. | Type of nutritional support intervention the patient received during dietetic consultation. Data collected for patients only. |
Countries
United Kingdom
Participant flow
Pre-assignment details
Please note that 45 participants were enrolled but only 39 took part in research activities. 4 dietitians gave consent but did not complete the study activities due to changes in their clinical speciality, change in employment, maternity leave and lack of eligible patients within the study time frame. Also, 2 patients gave consent but didn't complete the study activities, 1 patient died before this was possible and 1 withdrew their consent to participate so no research activities were commenced.
Participants by arm
| Arm | Count |
|---|---|
| Patient Group 1 Consultation observation, documentary analysis
Observations, documents: Consultation observations, documentary analysis | 10 |
| Patient Group 2 Qualitative interview, key stakeholders, documentary analysis
Interviews, key stakeholders, documents: Qualitative interviews, key stakeholders, documentary analysis | 11 |
| Dietitians Consulting dietitians | 13 |
| Key Stakeholders Key stakeholders (relatives/carers of the patient. | 5 |
| Total | 39 |
Baseline characteristics
| Characteristic | Patient Group 1 | Patient Group 2 | Dietitians | Key Stakeholders | Total |
|---|---|---|---|---|---|
| Age, Categorical <=18 years | 0 Participants | 0 Participants | 0 Participants | 0 Participants | 0 Participants |
| Age, Categorical >=65 years | 10 Participants | 11 Participants | 0 Participants | 3 Participants | 24 Participants |
| Age, Categorical Between 18 and 65 years | 0 Participants | 0 Participants | 13 Participants | 2 Participants | 15 Participants |
| Clinical setting Community | 2 Participants | 3 Participants | 4 Participants | 1 Participants | 10 Participants |
| Clinical setting Hospital | 6 Participants | 3 Participants | 6 Participants | 1 Participants | 16 Participants |
| Clinical setting Outpatient clinic | 2 Participants | 5 Participants | 3 Participants | 3 Participants | 13 Participants |
| Race (NIH/OMB) American Indian or Alaska Native | 0 Participants | 0 Participants | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) Asian | 0 Participants | 1 Participants | 0 Participants | 0 Participants | 1 Participants |
| Race (NIH/OMB) Black or African American | 0 Participants | 3 Participants | 0 Participants | 0 Participants | 3 Participants |
| Race (NIH/OMB) More than one race | 0 Participants | 0 Participants | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) Native Hawaiian or Other Pacific Islander | 0 Participants | 0 Participants | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) Unknown or Not Reported | 0 Participants | 0 Participants | 13 Participants | 5 Participants | 18 Participants |
| Race (NIH/OMB) White | 10 Participants | 7 Participants | 0 Participants | 0 Participants | 17 Participants |
| Region of Enrollment United Kingdom | 10 participants | 11 participants | 13 participants | 5 participants | 39 participants |
| Sex: Female, Male Female | 3 Participants | 7 Participants | 11 Participants | 5 Participants | 26 Participants |
| Sex: Female, Male Male | 7 Participants | 4 Participants | 2 Participants | 0 Participants | 13 Participants |
Adverse events
| Event type | EG000 affected / at risk | EG001 affected / at risk | EG002 affected / at risk | EG003 affected / at risk |
|---|---|---|---|---|
| deaths Total, all-cause mortality | 0 / 10 | 1 / 11 | 0 / 13 | 0 / 5 |
| other Total, other adverse events | 0 / 10 | 0 / 11 | 0 / 13 | 0 / 5 |
| serious Total, serious adverse events | 0 / 10 | 0 / 11 | 0 / 13 | 0 / 5 |
Outcome results
Primary
Experience of the Dietetic Consultation (Number of Participants With Dietetic Consultation Experience That Relate to Each Theme)
Themes and sub-themes related to the patient experience, dietitian experience and key stakeholder experience of the consultation. These were derived from qualitative thematic analysis of triangulated data from interviews, consultation observations and consultation documents derived from ALL study participants (n=39). Final themes included: 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. Please note that ALL study participants (n=39) from all 4 groups (Patient Group 1, Patient Group 2, Dietitians, and Key Stakeholders) contributed to all 4 final constructed themes noted above as all data were qualitatively triangulated. These 4 themes represent how the dietetic consultation was experienced from multiple perspectives, in different contexts and highlighted key areas of the dietetic encounter that mattered to participants.
Time frame: Through study completion, an average of 2 months
| Arm | Measure | Group | Value (COUNT_OF_PARTICIPANTS) |
|---|---|---|---|
| Patient Group 1 | Experience of the Dietetic Consultation (Number of Participants With Dietetic Consultation Experience That Relate to Each Theme) | 4. Influences and realities of professional practice | 10 Participants |
| Patient Group 1 | Experience of the Dietetic Consultation (Number of Participants With Dietetic Consultation Experience That Relate to Each Theme) | 1. Building a therapeutic alliance | 10 Participants |
| Patient Group 1 | Experience of the Dietetic Consultation (Number of Participants With Dietetic Consultation Experience That Relate to Each Theme) | 3. Dynamics of expectations, power and satisfaction | 10 Participants |
| Patient Group 1 | Experience of the Dietetic Consultation (Number of Participants With Dietetic Consultation Experience That Relate to Each Theme) | 2. Navigating changes beyond the consultation | 10 Participants |
| Patient Group 2 | Experience of the Dietetic Consultation (Number of Participants With Dietetic Consultation Experience That Relate to Each Theme) | 3. Dynamics of expectations, power and satisfaction | 11 Participants |
| Patient Group 2 | Experience of the Dietetic Consultation (Number of Participants With Dietetic Consultation Experience That Relate to Each Theme) | 1. Building a therapeutic alliance | 11 Participants |
| Patient Group 2 | Experience of the Dietetic Consultation (Number of Participants With Dietetic Consultation Experience That Relate to Each Theme) | 2. Navigating changes beyond the consultation | 11 Participants |
| Patient Group 2 | Experience of the Dietetic Consultation (Number of Participants With Dietetic Consultation Experience That Relate to Each Theme) | 4. Influences and realities of professional practice | 11 Participants |
| Dietitians | Experience of the Dietetic Consultation (Number of Participants With Dietetic Consultation Experience That Relate to Each Theme) | 3. Dynamics of expectations, power and satisfaction | 13 Participants |
| Dietitians | Experience of the Dietetic Consultation (Number of Participants With Dietetic Consultation Experience That Relate to Each Theme) | 4. Influences and realities of professional practice | 13 Participants |
| Dietitians | Experience of the Dietetic Consultation (Number of Participants With Dietetic Consultation Experience That Relate to Each Theme) | 1. Building a therapeutic alliance | 13 Participants |
| Dietitians | Experience of the Dietetic Consultation (Number of Participants With Dietetic Consultation Experience That Relate to Each Theme) | 2. Navigating changes beyond the consultation | 13 Participants |
| Key Stakeholders | Experience of the Dietetic Consultation (Number of Participants With Dietetic Consultation Experience That Relate to Each Theme) | 2. Navigating changes beyond the consultation | 5 Participants |
| Key Stakeholders | Experience of the Dietetic Consultation (Number of Participants With Dietetic Consultation Experience That Relate to Each Theme) | 3. Dynamics of expectations, power and satisfaction | 5 Participants |
| Key Stakeholders | Experience of the Dietetic Consultation (Number of Participants With Dietetic Consultation Experience That Relate to Each Theme) | 1. Building a therapeutic alliance | 5 Participants |
| Key Stakeholders | Experience of the Dietetic Consultation (Number of Participants With Dietetic Consultation Experience That Relate to Each Theme) | 4. Influences and realities of professional practice | 5 Participants |
Other Pre-specified
Consultation Type
New (i.e. new episode of dietetic care) or review/follow-up (had previous consultation in current episode of care) re the dietetic consultation. Data collected for patients only.
Time frame: At enrollment.
| Arm | Measure | Category | Value (COUNT_OF_PARTICIPANTS) |
|---|---|---|---|
| Patient Group 1 | Consultation Type | New | 2 Participants |
| Patient Group 1 | Consultation Type | Review/Follow-up | 8 Participants |
| Patient Group 2 | Consultation Type | New | 2 Participants |
| Patient Group 2 | Consultation Type | Review/Follow-up | 9 Participants |
Other Pre-specified
Dietitian AfC Banding
The NHS AfC Banding for consulting dietitians included. NHS Band 5 = entry level dietitian, NHS Band 6 = more experienced and specialised dietitian, NHS Band 7 = more advanced level dietitian. Data were collected on the NHS Banding (determined by their employer) for each dietitian included to understand how their experiences differed by seniority. Data collected for dietitians only.
Time frame: At enrollment.
| Arm | Measure | Category | Value (COUNT_OF_PARTICIPANTS) |
|---|---|---|---|
| Patient Group 1 | Dietitian AfC Banding | Band 5 | 3 Participants |
| Patient Group 1 | Dietitian AfC Banding | Band 6 | 6 Participants |
| Patient Group 1 | Dietitian AfC Banding | Band 7 | 4 Participants |
Other Pre-specified
Dietitian Speciality
Clinical speciality of consulting dietitians included. Data collected for dietitians only.
Time frame: At enrollment
| Arm | Measure | Category | Value (COUNT_OF_PARTICIPANTS) |
|---|---|---|---|
| Patient Group 1 | Dietitian Speciality | Community | 4 Participants |
| Patient Group 1 | Dietitian Speciality | Stroke / Elderly Care | 3 Participants |
| Patient Group 1 | Dietitian Speciality | Oncology | 2 Participants |
| Patient Group 1 | Dietitian Speciality | General | 2 Participants |
| Patient Group 1 | Dietitian Speciality | Gastro | 0 Participants |
| Patient Group 1 | Dietitian Speciality | Renal | 2 Participants |
| Patient Group 1 | Dietitian Speciality | HIV | 0 Participants |
Other Pre-specified
Family Support
Whether the patient had family support or not at the time of study enrollment. Data collected for patients only.
Time frame: At enrollment.
| Arm | Measure | Category | Value (COUNT_OF_PARTICIPANTS) |
|---|---|---|---|
| Patient Group 1 | Family Support | Yes | 7 Participants |
| Patient Group 1 | Family Support | No | 3 Participants |
| Patient Group 2 | Family Support | Yes | 9 Participants |
| Patient Group 2 | Family Support | No | 2 Participants |
Other Pre-specified
Relationship to Patient
Relationship of key stakeholder to patient. Data collected for key stakeholders only.
Time frame: At enrollment.
| Arm | Measure | Category | Value (COUNT_OF_PARTICIPANTS) |
|---|---|---|---|
| Patient Group 1 | Relationship to Patient | Spouse | 3 Participants |
| Patient Group 1 | Relationship to Patient | Other relative | 2 Participants |
Other Pre-specified
Type of Intervention
Type of nutritional support intervention the patient received during dietetic consultation. Data collected for patients only.
Time frame: At enrollment.
| Arm | Measure | Category | Value (COUNT_OF_PARTICIPANTS) |
|---|---|---|---|
| Patient Group 1 | Type of Intervention | FB only (Food-based intervention only) | 0 Participants |
| Patient Group 1 | Type of Intervention | COMB intervention (ONS + FB) | 10 Participants |
| Patient Group 1 | Type of Intervention | ONS only (Oral nutritional supplements only) | 0 Participants |
| Patient Group 2 | Type of Intervention | FB only (Food-based intervention only) | 0 Participants |
| Patient Group 2 | Type of Intervention | COMB intervention (ONS + FB) | 9 Participants |
| Patient Group 2 | Type of Intervention | ONS only (Oral nutritional supplements only) | 2 Participants |