Role of Dietitians in the Leadership of Evidence Based Practice, Quality and Audit

Increasingly, there has been a drive to evidence-based practice (EBP) in healthcare, nutrition, and dietetics has as a profession incorporated into its practice. However, it is important to consider what EBP is and what it is not. In the workshop led by the Research and Evidence Based Practice committee (REBPc) of the European Federation of Associations of Dietitians (EFAD) as part of the 10th EFAD conference in Rotterdam, the role of dietitians was debated in the leadership EBP, quality, and audit. Initially, Christophe Matthys, Associate Professor from KU Leuven set the scene, by critically considering the gold standard definition of EBP as set out by Sackett (1996), with its 3 dimensions of research data, clinician experience, and patient preferences. The historic approach to practice based on clinical experience and continuing practice models have almost become habitual. To challenge and change the “we have always done things this way” mode of practice and move toward the integration of EBP in a real life setting necessitates the involvement and interaction with a range of stakeholders. These stakeholders range from clinicians themselves, in this case dietitians, through the wider healthcare team, including nurses along with patients, healthcare commissioners, and politicians. An example of how EBP guidelines have been developed and implemented by the group in Leuven is dietary advice given prior to a colonoscopy (Vanhauwaert et al, 2015, Vanhauwaert, Matthys & Joossens, 2014). Following a systematic review, on which the guideline was based, 2 major conclusions were made. Firstly, the name of the diet needed to be changed, as “low residue” had too variable meaning and could not be objectively defined. Secondly the number of days that patients needed to follow the diet could be significantly reduced, which had the potential to reduce cost if patients were in hospital as well as reducing the burden on the patient. Although, the logic to these conclusions are apparent, the first barrier these guidelines faced were that dietitians were reluctant to a change of name and a quantification of the diet. Then, the second key barrier came from nurses, who had a very specific perception of the diet, and how long it was necessary to follow, prior to the investigation. Therefore, highlighting that guidelines often have to be adapted to allow it to be implemented and their need to compromise the absolute findings from systematic reviewing of the literature in order to effectively implement into practice, healthcare teams need to be engaged and consulted in the process (Cochrane et al., 2007). This adaptive approach also means that guidelines can be adapted to suit the limitations of a healthcare system or meet the needs and priorities of the community they have been developed to treat. The need to support the effective implementation of dietetic treatment depends heavily on monitoring how dietetic interventions are delivered and their outcomes. Elke Nauman, Associate Professor from HAN, highlighted the work on data sets that need to be collected to demonstrate effective care and patient outcomes. In previous studies, the group in HAN investigated what the minimum data set should be, which needs to be collected by dietitians treating patients at risk of cardiovascular disease to be able to demonstrate the effectiveness of dietetic treatment. Following the identification of the minimum data set, further work was undertaken to investigate facilitators and barriers in collection of this minimal data set. Then this will be used to develop a digital tool that enables dietitians to register results of treatment. A semi-structured interviews methodology was used where dietitians were used to identify facilitators and barriers for data collection. Outcomes were then used to develop a (draft) digital tool, using “lean” methodology. Key facilitators and barriers were identified at the level of dietitians (e.g., experience in measurements), clients (e.g., expectation of dietetic treatment), organizations (e.g., time), and measurements (e.g., easy to use) and these were then used to develop a draft digital tool. It is important to use systematic methodologies to develop draft digital tools that facilitates registration (Cooery et al., 2017). Whether this tool will indeed create transparency of dietetic results needs to be confirmed. The theme of data collection to improve dietetic practice and patient care and outcomes was continued by Dr Alison Stieber, from the Academy of Nutrition and Dietetics who highlighted the value of ANDHII (https://www.andhii.org/info/#Intro ) as a fully functional health informatics infrastructure system. The value for this type of approach helps to systematically use nutritional diagnosis, dietetic terminology, and monitor and evaluate patient care. This allows for the economic evaluation of dietetic care, along with the standardization of care and practice, resulting in improved patient care and a greater ability to justify dietetic interventions. Alongside the approach to EBP and the need to monitor it using effective data capture, Dr Duane Mellor from Coventry University explored the often forgotten role of the patient in EBP. Building on the adaptive approach to EBP explored by Associate Professor Matthys, the importance of the patient voice was explored. The role of the patient is key, as in EBP it has tended to have been overlooked (Gravel et al., 2006). However, in a world of person- centred care, perhaps this could be seen as the most important component, since if patients do not engage and follow the dietary advice given, it does not matter how strong their evidence base is, they will be ineffective (Siminoff, 2013). This concept is perhaps even more important in dietetics, as food is part of our individual and community culture, our dietary habits forming key aspects of our identities. It is therefore essential to consider how the patient’s voice is included in developing EBP interventions that are effective in real world settings. The development of EBP needs to consider how working cultures in healthcare influence the application of guidelines along with how patients respond to these (Greenhalgh, Howick & Maskrey, 2014). After successfully achieving these challenges, robust monitoring systems are necessary to demonstrate their effectiveness and justify services. The use of evidence and research in dietetic practice will be discussed further at the 11th EFAD Conference, Rotterdam 28/29 September 2018 http://efadconference. com.