by Dr Judith Maher & Claudia Harper

 

Dietitians in private practice in Australia, work within a pressured environment. This influences how they practice, and shapes the strategies they use to develop crucial therapeutic relationships with their clients. Sound familiar?

In our study we examined how dietitians in source, utilise, and integrate practice philosophies. What we found was fascinating.

Just quickly, we defined philosophies according to Aristotle – yes that guy. He defined three philosophies –episteme – scientific knowledge – like knowing evidence based guidelines for nutrition interventions and counselling techniques, techne – technical knowledge – like knowing how and when to apply this knowledge and phronesis – Phronesis is most usually translated as wisdom and is akin to …. when you just know something – no one has directly taught it to you but you just know.

So… within the private practice environment, our study shows that dietitians in PP use intrinsic and intertwined forms of episteme, techne, and phronesis. This allows them to respond both practically and sensitively to their clients’ . Although technical knowledge (techne), and scientific knowledge (episteme) that diet therapy is based on is important, the role of phronetic knowledge – that is, wisdom developed and applied in the context of working with clients, is fundamental to effective therapy.

Do you feel isolated at times? lacking professional support? time burdened? unable to switch of from the job? These are characteristics of the pressured environment that is private practice.

Wondering how this fits with practice philosophies? Well consider a pressure cooker…all you cooks out there will know – the pressure cooker intensifies the pressure inside the cooker in order to produce edible, delicious food more quickly. The pressure cooker is the time poor cooks friend. Private practice as a pressured environment forces one to quickly develop strategies that enable survival (business/personal) and kick goals for clients. It is in this context that Dietitians are learning and integrating these philosophies within their own practice experience. Dietitians in PP have to adapt and do this through experience, feedback, and reflection.

We developed the following pressure cooker model that shows visually how dietitians in private practice source, utilise, and integrate practice philosophies and the key strategies and processes that dietitians use in the context of private practice.

 

We have briefly unpacked this model for you here:

  1. The private practice environment directly influences how dietitians practice

We found that dietetic private practice in Australia is characterised by feelings of isolation, a lack of professional support, heavy time burdens and an inability to switch off from the job (lifestyle career). Of interest to us was how monetary considerations drive dietitians to develop, learn and nurture strategies that produce deep synergistic, long lasting therapeutic relationships with clients. They make professional and business decisions that in the long run benefit the client and as a by-product themselves as a dietitian.

  1. Strategies to produce deep therapeutic relationships with clients

The key strategies that enabled dietitians to develop deep therapeutic relationships with their clients were: nurturing change, collaboration and evolving and adapting their practice to the context of the moment.

Nurture change

Dietitians nurture change through skilful rapport building, showing empathy, providing tailored support and accountability. Added to this mix, we found that having ‘phronesis’, that is, being able to ‘read’ the client using instinct and intuition, was valued just as highly as a skill with the dietitians in this study. Most dietitians felt they either ‘had it or they didn’t’, thus suggesting there was a ‘type’ of dietitian that was more suited to private practice.

Collaborative practice

Collaboration was the cornerstone of advice giving and there were many reasons why the dietitians in this study chose to use a collaborative approach with their clients. They felt that working within their clients’ needs, abilities and environments would enable better success but also because this approach builds relationships and trust.

Using evidence was essential, but incorporating or applying that evidence to the clients’ personal context was far more important than giving a strict prescriptive diet. In this way, the dietitians traded evidence for applicability, to ensure compliance, thereby hoping for better uptake of therapy or protocol. This concept is not new, but it very rarely shows up in protocol papers or best practice protocols. Dietitians in PP are aware that they may practice outside of strict protocol but garner positive feedback and results from their interactions with their clients. PP is an environment that enables personalised therapies based on the best therapies and applications but also entails very intrinsic and specialised skills of utilising professional knowledge entwined with ‘gut feelings’ that are honed inside the context of one – on – one interactions. These skills grow over time thus affording a much deeper understanding of the client and a more personal approach to therapy.

Evolution and adaption

To stay current within the profession and practice dietitians in PP use a multitude of avenues; however, social media plays a big part in keeping up to date with what is happening in the wider community. This avenue provided both pain and pleasure to dietitians. Internet resources such as PEN and Google Scholar were widely accessed and appreciated. PEN was deemed as trusted source of evidence despite some dietitians feeling they did not have the skills to assess whether the source of information was relevant or not. Feedback in the form of continued clientele was used as a gauge of success of efficacy and also a motivator to perform at a higher standard. There is no reward to performing at substandard levels in PP and a lack of performance becomes apparent very quickly in a lack of income. This drives dietitians in PP perform at peak in delivering a responsive and personal service to every client they see.

Reflecting on practice is a constant habit to ensure that both the business (and possibly livelihood) and clients thrive. This, in effect creates an atmosphere that pushes PP dietitians to continually improve and better themselves. Not least of which is attributed to the ability to use episteme, techne and phronesis to respond with compassion and intuition when applying evidence to the context of their clients’ situations.

So what does this mean??

This research highlighted the importance of establishing long term relationships with clients over time in order to be effective in business and as a means to better support long term lifestyle changes in clientele. This model shows that continuity of care that is often lacking in the public sector due to constraints and shows that PP is well placed to provide successful outcomes in the wider community. Research aimed at developing better support structures for PP dietitians so they can continue to nurture this fledgling area of dietetic business could contribute to long term health benefits for the wider community.

PP also provides a unique context to develop the skills needed to form long lasting beneficial alliances with members of the community and deal with complex issues that are particular to the nutrition and dietetic profession. Using episteme, techne and phronesis as a practice model in research would enable more thorough exploration into areas of practice that are necessary to effect health changes in clients but are often neglected in more narrow models of practice.

 

For more on this research including our robust methods see http://www.mdpi.com/2076-328X/7/1/11 for a link to the open access article.

Claudia Harper is undertaking further research for her PhD into the practices of dietitians, specifically dietitians who work in the area of obesity and weight management. If you would like to give your experiences anonymously or would like more information, please email [email protected]