Communications in dietetics

dr Kirsten Whitehead assistant professor in dietetics, university of nottingham

For article references please visit info@ networkhealth group.co.uk

kirsten whitehead worked in the nhS for over 20 years, moving into dietetic education in 2001. kirsten teaches communication skills and undertakes research in this important subject area for dietitians.

CommuniCAtion SkillS for dietitiAnS: where Are we uP to And where Are we going?

there are few dietitians who do not agree that good communication skills are at the heart of dietetic practice1,but what exactly is meant by ‘good communication skills’ and how do we know if we have got them or not? this article will discuss some of the recent relevant policy and published literature in this subject area and aims to provide some suggestions for how we could further develop these skills as a profession.

The expected capabilities of a graduate dietitian in relation to communication skills are clearly described2, 3. This includes being an effective communicator, active listening, establishing rapport with patients, demonstrating compassion, empathy and understanding. These capabilities are comparable to expectations for healthcare professionals more generally4, 5, 6 and training of healthcare professionals in communications skills to deliver patient-centred care and to support behaviour change is consistently recommended7, 8. Sadly, some healthcare professionals lack skills in communication-related areas, such as demonstrating compassion, offering reassurance and involving patients in care decisions9. To support the NHS in the future, the need for patient-centred care, working with patients and carers to set and achieve healthcare goals by engaging, empowering and listening to the views of patients and carers has been strongly re-emphasised10. The same key messages are consistently being delivered, i.e. good communication skills are important in patient care, a patient-centred approach is required and effective training for those working in healthcare is recommended.

What impaCt do CommuniCation sKills have on dietetiC praCtiCe? In dietetics there is a developing evidence base that supports the positive effects of good communication skills. One of the key areas is with the demonstration of empathy, that is, the desire to understand the patient’s experience and to demonstrate that understanding to the patient11. Demonstrating empathy in dietetic consultations has been shown to improve patient satisfaction12, 13, 14. Goodchild et al found that the more empathetic the dietitians’ response to emotional cues was, the more satisfied patients were. Greater patient satisfaction is important as it is more likely that highly satisfied patients will maintain appointments and adhere to the dietary recommendations that have been made, which is essential if dietetic practice is going to be effective14 . Empathy has also been shown to lead to higher levels of agreement about the decisions made within a consultation12, 15 and to more extensive dietary changes being implemented16. However, there is little evidence as yet to suggest that this leads to improved clinical outcomes16 .

Several studies have elicited the views of dietitians and their patients on what was desirable within consultations17, 18, 19. Although these studies were completed in different countries; the UK18, Australia17 and Israel19 and there may be different cultural views, the conclusions were very similar. Patients stated that they want to be treated as individuals17, to be listened to17, to have a rapport with the dietitian17, 18. They wanted a positive partnership17 and for the dietitian to be patient-centred18 and empathic19. Although the clinical skills of

the dietitian were considered important, patients also valued active engagement, sharing and open communication18 and the appropriate personal presentation of the dietitian17, 18, i.e. smart but not too formal. The ability of dietitians to be flexible in their communication approach was important as some patients prefer a more practitioner-led and some a more patient-led consultation18, 19 . In contrast, patients were less likely to attend follow-up consultations when the dietitian lacked a patient-centred approach, lacked empathy, did not individualise advice or focused on information giving19. This reinforces the need for good communication skills for effective practice.

One area where there is clear evidence of a need for improvement is in relation to shared decision making. In a Canadian study, Vaillancourt et al used a validated tool to assess dietitians’ consultations and found an overall mean score of 29 (±8.0%) (range 0% [no patient involvement in the decision] to 100% [high patient involvement]) which suggests that dietitians were not involving patients in the diet-related decision making process20 .

developing CommuniCation sKills postregistration The dietetic workforce includes people who trained in a variety of Higher Education Institutes (HEIs) with differing methods of teaching and learning. The pre-registration training of dietitians is constantly developing and those who trained many years ago will have had a different pre-registration education experience to those who trained more recently. Several studies have demonstrated that dietitians would like more training in communication skills post-registration and that their pre-registration training focused more on knowledge than communication skills1, 14, 21, 22, 23. There is an assumption that experience leads to skill development, but little evidence to support this.

In the UK, there is little to guide dietitians on how to develop their communication skills, or what they should be aiming for. In the USA, the Academy of Nutrition and Dietetics has recently produced a series of documents for a variety of specialist areas of dietetics which define the skills required at three different levels of practice: competent, proficient and expert24. A competent practitioner is recently qualified, a proficient practitioner is generally three or more years postregistration and an expert practitioner is recognised within the professional as having reached the highest level of knowledge and skill. This gives dietitians a very explicit guide to what they need to do to progress in a specific clinical area, and communication skills are included as one of the six domains of professional practice within this24 . Similarly, a study undertaken to describe what is meant by advanced or expert practice concluded that advanced practice tasks are patient-centred and include the use of advanced interviewing, education and counselling strategies25 .

How do dietitians develop from competent to proficient and expert levels in relation to their communication skills? There are many opportunities for Continuous Professional Development (CPD) in communication skills available and some are dietetic specific. Whitehead et al (2009) found that the majority of dietitians responding to a survey (n=906, 79.6%) had undertaken CPD and were very positive about its effect on their work practice, but many were keen to develop their skills further, in particular, in advanced skills such as motivational interviewing and cognitive behavioural strategies1. Evidence from medicine and nursing suggests that communication skills can be enhanced by training; however, there are concerns about the difficulties of transfer of training into practice26, 27 which was also a concern of dietitians1 .

hoW do We measure sKills? One of the challenges with skill development is having an objective way of assessing skills. How do we know if attending training actually leads to positive changes in practice? Most studies have explored dietitians’ perceptions of their skills, or patients’ views of the dietitian’s skills, rather than any objective measure. For this reason, Whitehead et al (2014) developed and validated an assessment tool, DIET-COMMS, which is designed for the assessment of communication skills within dietetic patient consultations28. The tool was tested using videoed consultations with simulated patients, with students at various levels of training and qualified dietitians. DIET-COMMS is a simple form covering one side of A4 which consists of 20 items which cover the content of a dietetic consultation and the communication skills within

that. Each item can be scored with 0 (not done or not achieved), 1 (partly achieved or attempted), or 2 (fully achieved). DIET-COMMS has been comprehensively tested and it has been found to have face validity, content validity, construct validity, predictive validity, intra-rater reliability and moderate inter-rater reliability.

As with any assessment tool, there is a need for those using it to be familiar with it and to be able to assess in a consistent manner. For this reason a training package is being developed to support its use in both student training and for CPD. The training package will be open access via a web page, so no cost will be incurred for users and they will be able to return to the package as often as they wish. The package includes video-recorded mock consultations to a variety of standards. These were undertaken in out-patient clinics, a ward setting and a home setting. There are service user views on the consultations to aid understanding on how the patient might feel or react in those situations and also an expert view on how each consultation would be scored on DIET-COMMS. There are downloadable resources to support teaching and learning. For example, feedback sheets on each of the 20 items on DIET-COMMS are designed to support individuals to identify what they could do differently to improve that specific item. Guidance sheets have been developed, for example, on how to set up peer assessment in the workplace and on giving constructive feedback. The DIET-COMMS training package will be launched in 2015.

the Way ForWard There appears to be a willingness and desire within many dietitians1 to undertake CPD in relation to their communication skills post-registration. The DIET-COMMS training package may support this, but there are other questions to consider.

How good are dietitians as a profession at

the moment? Some may consider that there is no need for improvement, as dietitians are all good at communicating already. The reality is that we really don’t know the answer to this question as the research has not been completed; however, many studies suggest that there is room for improvement1, 18, 19 and considerable variation has been demonstrated28 .

Should UK dietitians develop a framework for skills required for competent, proficient and expert levels in relation to communication skills, as has been completed in the USA24? Would such a tool be helpful and would it ensure that this aspect of professional practice would be considered more formally? Should peer observation or peer assessment in the workplace be undertaken routinely?

There is evidence that this is occurring in some departments already1, but concerns have been raised that some dietitians would find this threatening and that it would not be acceptable28. However, this already happens with some other healthcare professionals regularly, such as doctors.

Is it time for a more consistent approach to

dietetic pre-registration training? This already happens in UK medical schools where a national group develops guidance and tools to support the HEIs29 .

Is there a need for a BDA Specialist Group on

communication skills? It is a subject relevant to all, but may provide support and guidance for those who want to develop their skills.

There are many unanswered questions and a lot of potential for research which can take the dietetic profession forward. Developments in this area could help dietitians to consistently deliver the high quality, patient-centred, effective services that we are capable of and which are required to meet professional standards and current guidance. What part can you play?

VitAmin d in PregnAnCy

Cordelia Woodward Bsc rd Freelance dietitian

For article references please visit info@ networkhealth group.co.uk

Cordelia is a freelance dietitian and owner of www. cwdietetics.co.uk. She has worked previously for nhS trusts as a specialist dietitian and has keen interests in pregnancy, diabetes, weight loss and cardiovascular disease.

Pregnant women are considered to be at risk of low vitamin D levels amongst other subgroups4 . there is a close link between a mother’s vitamin D level during pregnancy and a new born baby’s vitamin D status5 . the mother needs to ensure adequate stores for herself and her baby.

Adequate stores of vitamin D in pregnancy can help prevent rickets in babies and in infancy (especially for exclusively breastfed babies)1. Although we may think of rickets as a problem from the past, there is concern that it is re-emerging in children

Figure 1: adapted from (3). 25(oh)d - 25hydroxy vitamin d; this is used to assess vitamin d status, 1,25(oh)2d - 1 25dihydroxy vitamin d - this is the active form of vitamin d.

in the UK6. In addition, although not conclusive, some studies have shown vitamin D deficiency may be associated with an increased risk of gestational diabetes, preeclampsia, low birth weight and caesarean section7 .

vitamin d: BaCKground Vitamin D is a fat soluble vitamin which plays several important roles within the body. One of its key roles is to help absorb calcium and phosphate and, in doing so, it helps to keep our bones strong and healthy. Whilst we get some vitamin D from dietary sources, we make most of it through the action of sunlight on our skin through a series of reactions (Figure 1). Plasma 25(OH)D (also known as 25-hydroxy vitamin D) concentration is used to assess vitamin D status1. In the UK, we can

sKin 7-dehydrocholesterol

previtamin d3

vitamin d3

sunlight ultraviolet B

Circulation

liver

2h(oh)d

Circulation

Kidney vitamin d2 and d3 (from diet or supplements)

The NICE guidelines advise that UK healthcare professionals should recommend a vitamin D supplement of 10 micrograms for all pregnant and breastfeeding mothers

only make vitamin D between April and October (the sunlight is only at the correct wavelength in the summer months) and the latest National Diet and Nutrition Survey (NDNS) highlighted that the UK population has lower levels during the winter months2. During winter months the body’s stores of vitamin D from the summer and dietary sources are needed to maintain adequate vitamin D status.

requirements In 1991, the Committee on Medical Aspects of Food and Nutrition Policy (COMA) set a Reference Nutrient Intake (RNI) of 10 micrograms of vitamin D per day for all pregnant and breastfeeding women (COMA, 1991)8. The Scientific Advisory Committee on Nutrition (SACN) reiterated the above recommendation in 2007 in their update of vitamin D1. This is in contrast to most children and adults, for which there is actually no RNI set, as it is assumed they will get enough vitamin D from sunlight exposure5. This is, however, currently being reviewed by SACN.

supplementation The NICE guidelines advise that UK healthcare professionals should recommend a vitamin D supplement of 10 micrograms for all pregnant and breastfeeding mothers9. This is also supported by the Royal College of Obstetricians and Gynaecologists7. All pregnant women should be informed about the importance of vitamin D supplementation at their first appointment with their healthcare professional5. Some women are at greater risk of vitamin D deficiency, including those with darker skin and women with limited exposure to sunlight and so extra care must be taken to ensure that these women are taking a daily vitamin D supplement9 .

Whilst the advice for vitamin D supplementation is not new, evidence suggests that it is not necessarily being implemented as well as intended. To highlight this, the Infant Feeding Survey10 suggested that the majority of women do not take vitamin D supplements during pregnancy.

Vitamin D supplements can be obtained from a pharmacy, a supermarket, or on prescription. They are also included in ‘Healthy Start vitamins’ (eligible for some women) and ‘pregnancy multivitamins.’ Although most commercial multivitamins are likely to contain vitamin D, these are best avoided in pregnancy due to their vitamin A content (which can harm the unborn baby). Vegan pregnant women should ensure that their vitamin D supplement is not from an animal origin by checking the label.

Where to get Healthy Start vitamins from:

• Health clinics • Children’s Centres • Sure Start Centres • Outreach programmes • GP surgeries

Food sourCes Sunlight is the main source of vitamin D and food sources are limited. For most people, diet only provides 10-20% of total vitamin D intake with 80-90% coming from cutaneous synthesis following sunlight exposure11. The main sources are shown in Table 2. Cooking methods can impact the vitamin D content of a food; for example, baking fish has no effect, whereas fry-

table 2: sources of vitamin d in the diet (data obtained from dietplan7, Forestfield software). μg - micrograms

Vitamin D (μg) Per 100g

salmon, fresh, wild 8.60 salmon, fresh, farmed 4.70

Canned salmon, pink, 1.60 drained smoked salmon 8.90 tuna, raw 3.20 tuna, canned 1.10 pilchards, canned in 14.00 tomato sauce mackerel, raw 8.00 sardines, canned in oil, 3.60 drained eggs, whole, raw 3.20 eggs, yolk, raw 12.80 eggs, white, raw nil

Beef, mince, raw 0.70

Fortified breakfast cereals 3.00-8.4

Fortified fromage frais 1.25

Fortified yoghurt 4.00

Fortified fat spreads 5.00-7.5

Fortified dairy free milk 0.75-0.8 alternative drinks

ing fish reduces the content by 50%12. Whilst oily fish is a good source of vitamin D, it must be noted that pregnant women are advised by the government to limit oily fish to twice per week due to pollutants in the fish. The advice is also to limit tuna to no more than four cans per week (or no more than two tuna steaks per Whilst oily fish is a good source of vitamin D, it must be noted that pregnant women are advised by the government to limit oily fish to twice per week due to pollutants in the fish.

week) due to the mercury content. Moreover, eggs, another source of vitamin D, need to be thoroughly cooked to prevent the risk of salmonella. Cod liver oil (5μg vitamin D per capsule) and liver (1.1μg/100g) should also be avoided completely during pregnancy due to their high vitamin A content13 .

High street food retailer Marks & Spencer have recently added vitamin D to their bread and bread rolls, with a minimum of 0.75 micrograms per 100g. It will be interesting to see if other food retailers do likewise.

Can too muCh vitamin d Be harmFul? In the UK, the Expert Group on Vitamins and Minerals reports that taking 25 micrograms or less a day of vitamin D supplements is unlikely to cause any harm14. Our body does not make too much vitamin D through sunlight; however, individuals need to be aware of sun safety and should cover up/protect skin if they are out for long periods4 .

assessing vitamin d adequaCy There is much debate regarding the appropriate cut-off values for optimal vitamin D status15; however, the National Osteoporosis Society, in a document entitled Vitamin D and Bone Health: A Practical Clinical Guideline for Patient Management, in 201316 proposed the following thresholds for bone health with regard to assessing vitamin D status (using 25-hydroxy vitamin D as a marker): • Less than 30nmol/litre - deficient • Between 30-50nmol/litre - may be inadequate in some people • Greater than 50nmol/litre - sufficient for almost the whole population

Whilst not at a national level, several studies have demonstrated that pregnant women have low vitamin D status.

NICE guidelines5, on the other hand, define deficient as less than 25nmol/litre.

sCreening pregnant Women Currently, it is not routine for women to be screened for vitamin D deficiency in pregnancy because there is no data to support this in terms of health benefits or cost effectiveness7 .

Current intaKe/status - ndns Results from the NDNS 2014 reported evidence of an increased risk of vitamin D deficiency in all age/sex groups. Almost one fifth of UK adults were found to have a low vitamin D status (in this case, defined as less than 25nmol/litre)2 .

Whilst not at a national level, several studies have demonstrated that pregnant women have low vitamin D status1. For example, a study by Brough et al (2010) found that 70% of women in their first trimester from a diverse ethnic group in London had 25-hydroxy vitamin D below 50nmol/litre (insufficiency)15 .

In addition, a study on 160 women in South Wales found that 50% of women had levels below 20nmol/litre (deficiency) on their first antenatal visit17 .

summary In summary, vitamin D plays an important role in the body, helping to absorb calcium and keep our bones strong and healthy. In pregnancy, having adequate vitamin D can help prevent rickets in babies as well as having other potential benefits.

Pregnant women are considered to be at risk of low vitamin D status, as highlighted in several studies, and the current advice is that all pregnant women take a supplement of 10 micrograms of vitamin D everyday throughout pregnancy and breastfeeding.

Dietitians have a role to play in educating patients about the importance and reasoning behind such supplementation advice and helping to ensure that it is being implemented.

references 1 Scientific Advisory committee on Nutrition (2007). Update on Vitamin D. London: tSO. Available at: www.gov.uk/government/uploads/system/uploads/ attachment_data/file/339349/SAcN_Update_on_Vitamin_D_2007.pdf [accessed: 18/06/2015] 2 bates b et al (2014). National Diet and Nutrition Survey. results from years 1-4 (combined) of the rolling Programme (2008/2009 - 2011/12), London: Public

Health england 3 Zhang and Naughton (2010). Vitamin D in health and disease: current perspectives. Nutrition Journal 9:65 4 National Health Service (2015). Vitamin D. Available at: www.nhs.uk/conditions/vitamins-minerals/Pages/Vitamin-D.aspx [accessed 17/06/2015] 5 National Institute of clinical excellence (2014). Vitamin D increasing supplement use among at risk groups. Available at: www.nice.org.uk/guidance/ph56/ resources/guidance-vitamind-increasing-supplement-use-among-atrisk-groups-pdf [accessed: 26/04/2015] 6 Pearce SHS & cheetham tD (2010). Diagnosis and management of vitamin D deficiency. british Medical Journal; 340:1420147 7 royal college of Obstetricians and Gynaecologists (2014). Vitamin D in Pregnancy. Available at www.rcog.org.uk/globalassets/documents/guidelines/ scientific-impact-papers/vitamin_d_sip43_june14.pdf [accessed 17/06/2015] 8 committee on Medical Aspects of Food Policy (1991). report on Health and Social Subjects 41 Dietary reference Values (DrVs) for Food energy and

Nutrients for the UK, report of the Panel on DrVs of the committee on Medical Aspects of Food Policy. the Stationary Office. London 9 National Institute of clinical excellence (2008). Antenatal care. Available at: www.nice.org.uk/guidance/cg62/resources/guidance-antenatal-care-pdf [accessed: 18/06/2015] 10 bolling K et al (2007). Infant Feeding Survey 2005. the Information centre 11 Food and Health Innovation Service (2012). Fish as a dietary source of healthy long chain n-3 polyunsaturated fatty acids (Lc n-3 PUFA) and vitamin D.

Available at: www.abdn.ac.uk/rowett/documents/fish_final_june_2012.pdf [accessed: 18/06/2015] 12 chen tc et al (2007). Factors that influence the cutaneous synthesis and dietary sources of vitamin D. Arch biochem biophys; 460:213-7 13 National Health Service (2015). Foods to avoid during pregnancy. Available at: www.nhs.uk/conditions/pregnancy-and-baby/pages/foods-to-avoid-pregnant. aspx#close [accessed: 18/06/2015] 14 Foods Standards Agency (2003). Safe Upper Levels for Vitamins and Minerals, Available at: http://cot.food.gov.uk/sites/default/files/vitmin2003.pdf [accessed: 18/06/2015] 15 brough L et al (2010). effect of multiple-micronutrient supplementation on maternal nutrient status, infant birth weight and gestational age at birth in a lowincome, multi-ethnic population. the british Journal of Nutrition 104(3): 437-45 16 National Osteoporosis Society (2013). Vitamin D and bone Health: A Practical clinical Guideline for Patient Management. Available at: www.nos.org.uk/ document.doc?id=1352 [accessed 17/06/2015] 17 Datta S et al (2002). Vitamin D deficiency in pregnant women from a non-european ethnic minority population - an interventional study. bJOG 109, 905-908