Eaucmom mapmm BF HOSPiTAL Emma: * mam? mews mu SAHSFACHONS; SHAMCTERISTECS names FOR commute f MEMBERSHEP ON HEALTH TEAMS ~ “Thesis for the Degree of ‘Ph. D. : MICHIGAN isms umvaksmr was; mm arm: " 21971 ‘ " ‘ ‘ ls IHIHUII I!!! I! W! Ill 1!! ”U! UN ”fl II! I!!!) NIH LIBRARY 3 1293 10284 0 85 Michigan State University This is to certify that the thesis entitled EDUCATIONAL PREPARATION OF HOSPITAL DIETITIANS: PRESENT FUNCTIONS AND SATISFACTIONS; CHARACTERISTICS NEEDED FOR CONTRIBUTING MEMBERSHIP ON HEALTH TEAMS presented by Alice Ann Spangler has been accepted towards fulfillment of the requirements for Ph . D. degree in Nutrition W quor professor Date él/Io/7/ 0-7639 ABSTRACT EDUCATIONAL PREPARATION OF HOSPITAL DIETITIANS: PRESENT FUNCTIONS AND SATISFACTIONS; CHARACTERISTICS NEEDED FOR CONTRIBUTING MEMBERSHIP ON HEALTH TEAMS By Alice Ann Spangler The study was designed to: (1) determine the present and ideal role of hospital dietitians as perceived by vari- ous health team members; (2) identify characteristics of successful dietitians who contribute to health team care of the patient; and (3) determine competences which the dieti- tians need to function as contributing health team members. Questionnaires designed to evaluate the actual and ideal functions of professional personnel in h0spital dietary departments were mailed to administrators, chiefs of staff, directors of nursing, dietary department heads, and dieti- tians in Michigan hospitals. In the follow-up study, dietitians from eleven sampled hospitals were interviewed to evaluate the influence that each dietitian had on the health care team in relation to her own personal characteristics and educational preparation. Physicians from the same Alice Ann Spangler hospitals, either nominated by one of the dietitians or selected randomly, were contacted to determine how much decision-making they thought should be done by dietitians and the competences which dietitians need. Based on responses from the questionnaires and personal interviews, the following conclusions were drawn: 1. The present and ideal functions of the dietary depart- ment were viewed differently by the administrators, chiefs of staff, directors of nursing, dietary depart- ment heads, and dietitians. Administrators were most optimistic in their description of the dietary depart- ment as a contributor to the health care teamamzadecision— making level; chiefs of staff were least optimistic. All groups, except chiefs of staff, endorsed the idea that the dietary department should contribute at a decision-making level. Dietitians felt they should perform patient-oriented activities and not kitchen operations. Responsibilities established as belonging to the dieti- tian include writing menus with patients, determining food likes, instructing patients, visiting patients, calculating special diets, and consulting the nurse regarding dietary problems. Responsibilities for which the dietitian feels she should become more involved include attending ward rounds, prescribing special diets, attending medical Alice Ann Spangler conferences, following patients on special diets after release from the hospital, making decisions on the health team, preparing dietary histories, writing the diet manual, charting dietary progress, writing special diets, and consulting with the physician. Chiefs of staff felt dietitians should supervise food preparation and tray service, record dietary progress, and prepare dietary histories more than they do. Dieti— tians and doctors should instruct patients regarding their diet, and dietitians, doctors, and nurses should attend interdepartmental conferences and prepare the dietary manual. Given the conditions of an "ideal" dietitian, physicians most often said they felt diet changes should be made by physicians, with modification by the dietitian. Competences rated most important by the physician for the "ideal" dietitian include knowledge of food composi— tion, nutrient recommendations, health team goals, food processing effects, skill in achieving patient's satis- faction, and communication skills. Dietitians rated themselves highly proficient in knowl- edge of obtaining diet history by interviews, nutrient recommendations, food attitudes, food intake, technical operations of the kitchen, food standards, and food composition. Dietitians rated all of the above compe- tences important for dietitians on the health team Alice Ann Spangler except for technical operations and food standards. Additional competences of an understanding of dietary modifications during illness and social and cultural factors were important. Neither age, personality characteristics identified by the California Psychological Inventory, nor number of continuing education hours seemed to relate to the con- tribution made by dietitians to decision-making on the health team. The six most contributing dietitians were predominantly those who had or were presently partici- pating in a three year supervised program in contrast to a dietetic internship and had worked in both therapeutic and administrative dietetics. EDUCATIONAL PREPARATION OF HOSPITAL DIETITIANS: PRESENT FUNCTIONS AND SATISFACTIONS; CHARACTERISTICS NEEDED FOR CONTRIBUTING MEMBERSHIP ON HEALTH TEAMS By Alice Ann Spangler A THESIS Submitted to Michigan State University in partial fulfillment of the requirements for the degree of DOCTOR OF PHILOSOPHY Department of Food Science and Human Nutrition 1971 .— .‘i ,__7 .1/ I J I " \J ACKNOWLEDGEMENTS The author wishes to express sincere appreciation to Dr. Charles Blackman for his insight, support, advice, and ready counsel during this study. Similarly, the author is grateful to Dr. Dena Cederquist for her ncouragement and guidance throughout the author's doctoral program. The author expresses appreciation to Dr. Kaye Funk, Dr. Rachel Schemmel, and Dr. Peter Ways for their suggestions relating to this study. Acknowledgement is given to the Allied Health Improve- ment Grant for financial support of the research. The author is cognizant of the contribution by Dr. Mary Coleman and Dr. Cecilia Florencio,formerly of Foods and Nutrition, and Dr. Betty Giuliani, Office of Institutional Research, for development of the instruments, and collection and pre- liminary analysis of the data in the first part of the study. A special acknowledgement of appreciation goes to the author's husband, Ronald Lee, for his enduring and unselfish patience and encouragement. Without his support, this study would not have been possible. ii Chapter I. II. III. TABLE OF CONTENTS INTRODUCTION Purposes of the Study . Statement and Significance of. the Problem Limitations of the Study . . . Organization of the Study LITERATURE REVIEW . . . . . . . Introduction . . . . . Health Care in the United States . . . The Allied Health Professions Health Team Practice The Hospital Dietitians' Role as Health Team Members . . . . . . . . . . Summary DESIGN OF STUDY, INSTRUMENTATION, AND DATA COLLECTION PROCESSES . . . . . . Introduction and Over-All Design Over- All Design . Phase I. Michigan Hospital Survey The Population . . . . The Instrument . Procedures for Data Collection Data Analysis . . . Phase II. In-Depth Study of Dietitians Part A. Dietitians' Interview . . . The Population . . . . . . . . The Instruments . . . . . Interview Schedule . . Competences of a Dietitian Dietitian' s Responsibilities . California Psychological Inventory Procedures for Data Collection . Data Analysis . . . . iii Chapter Description of Present and Ideal Roles of Hospital Dietitians Skills and Competences Needed by Dietitians on the Health Team . Characteristics of Successful Dieti— tians Who Contribute to Decision- Making on the Health Team . Part B. Physicians' Study The Population . . . . . . The Instrument . Procedure for Data Collection Data Analysis . . . . . . IV. RESULTS, DISCUSSION AND SUMMARY Introduction . . . . . . . . . . Phase I. Michigan Hospital Survey Characteristics of Dietitians and Dietary Departments . . . . . . Titles of Dietitians . . American Dietetic Association .Member- ship . Education of Dietitians and Dietary Department Heads . . . . Duration of Present Positions of. Dietitians and Dietary Department Heads . . . . Location of Dietary Department Offices Actual and Ideal Function of. the Dietary Department . Dietitians' Responsibilities Dietitians' and Dietary Department Heads' Report of Ideal Responsibil- ities . Chiefs' of Staff Assignment of Dietary- Related Responsibilities Frequency of Discussion Procedure for Ordering Diets Suggestions for Educational Preparation Hospital Administrators' Suggestions for the Dietitian's Education and Prediction of Future Role of Dieti— tians . . . . . . . . . Importance of American Dietetic Associ- ation (ADA) Required Courses iv Page 53 53 5A 55 56 57 57 59 59 6O 6O 6O 61 62 63 63 6A 6A 73 77 78 79 79 79 Chapter Page Phase II. In-Depth Study of Dietitians . 82 Part A. Dietitians' Study . . . . . 83 Interview of Dietitian . . . . . . 83 Biographical Data . . . 83 Dietitians' Contribution to Decision- Making on the Health Team . . . 98 Dietitians' Evaluation of Educational Preparation . . . . . . . . 103 California Psychological Inventory . . . . . . . 108 Analysis of Scores . . . . 108 Comparison of Dietitians with High School and College Students . . 112 Relation between CPI and Biographical Data . . . . . 112 The Dietitian Who Contributes to Decision-Making on the Health Team . . 113 Biographical Data . . . 116 California Psychological Inventory . . 117 Competences Needed by Dietitians on the Health Team . . . . . . 117 Dietitian' 8 Proficiency in Competences. 117 Importance of Competences . . . . . 117 Comparison of Proficiency and Impor- tance of Competences . . 120 Differences between Dietitians with an. Internship and Dietitians with Three Years Supervised Experience . . . 121 Dietitians' Responsibilities . . . . 12“ Current Responsibilities of Dietitians . . . . 12H Dietitians who Feel They Should be Responsible for Duties . . . 127 Dietitians' Perception of Whether Physicians Would Assign Responsibil- ity to Dietitian . . . 127 Responsibilities and Qualifying Expe— rience for ADA Membership . . . . 128 Part B. Physicians' Study . . . . . 128 Description of Physicians . . . . . 128 Use of Diet Therapy . . . 130 Preferred Method for Ordering Diet. Changes . . . . . . 130 Competences for "Ideal" Dietitian . . . 132 Competences and Use of Diet Therapy . . 135 Competences and Diet Order Changes . . 138 Physicians' Comments . . . . . . . 138 Chapter Discussion and Summary . . . Roles of Hospital Dietitians Competences Needed by Dietitians Characteristics of Successful Dietitians Who Contribute to Decision—Making on the Health Team . . . . . V. SUMMARY, CONCLUSIONS, AND RECOMMENDATIONS Conclusions Present and Ideal Role Competences Characteristics of Successful Dietitians Recommendations . Present and Ideal Role Competences Characteristics of Successful Dietitians Reflections Suggestions for Future Research LITERATURE CITED APPENDICES Appendix A. Discrepancies between Expectations of Profession as an Undergraduate and Realities of the Profession B. Letter of Request for Hospital Inter— views . . . . . . . . . Dietitian's Interview Schedule Dietitian's Responsibilities Dietitian's Competences 'TJWUO Physician's Cover Letter to Question- naire . . . . . . G. Physician's Questionnaire vi Page 139 1A0 1A5 1A7 1A9 150 151 152 153 15“ IBM 156 161 161 165 166 173 175 176 185 187 191 192 Table 10. 11. LIST OF TABLES Page Description of 18 personality characteristics measured by the California Psychological Inventory . . . . . . . . . . . . . A9 Professional identification of dietitians in Michigan hospitals . . . . . . . . . . 60 Percentage of dietitians and dietary department heads eligible for ADA membership in 169 Michigan hospitals . . . . . . . . . . 61 Educational preparation qualifying dietitians and dietary department heads for present posi- tions in 169 Michigan hospitals . . . . . 62 Location within the hospital of dietary depart— ment offices according to 14A dietary depart- ment heads in Michigan hospitals . . . . . 63 Extent of dietary department's actual and ideal contribution to decision-making on the health team as perceived by respondents . . . . . 65 Assignment of dietary-related duties as per- ceived by 135 chiefs of staff . . . . . . 76 Frequency of discussion with dietitian by 135 chiefs of staff when a dietary problem is involved . . . . . . . . . . . . 78 Diet order procedures followed in hospital and preferred by 135 chiefs of staff and 231 dietitians . . . . . . . . . . . 78 Hospital administrator's suggestions for edu- cational improvement of hospital dietitians and perception of their future role . . . . 80 Courses essential for therapeutic, administra- tive specialists, or both according to Michigan hospital dietitians . . . . . . . 81 vii Table 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 2A. 25. Distribution of 33 dietitians (includes five department heads) in relationship to number of beds in 11 selected Michigan hospitals Characteristics of dietitians in selected hospitals . . . . . . . . . Status of American Dietetic Association mem- bership of 33 dietitians from 11 Michigan hospitals . . . . . . . . . . . Qualifying experience leading to ADA membership by 33 dietitians from 11 Michigan hospitals Characteristics of 26 dietitians who qualified for ADA membership by internship or supervised experience . . Sequence of professional experiences of 33 dietitians Highest education attained by 33 dietitians from 11 Michigan hospitals . Distribution of 33 dietitians' contribution to decision-making on the health team . . Personality characteristics of 26 dietitians with different ADA qualifying experiences Personal profile of six dietitians contributing most to health team decision-making . Return response of nominated and randomly selected physicians in relation to their type of practice . . . . . . . Number of physicians responding to question— naire in relationship to primary specializa- tion Use of diet therapy as part of total patient care by 72 physicians . . . . Eighty- one physicians' preferred procedure for ordering diet changes if an "ideal" dietitian were accessible . . . . . . . viii Page 83 87 9O 90 91 95 98 99 119 115 129 131 132 132 Table 26. 27. Page Physicians' ratings of importance (very important, somewhat important, of little importance) of certain competences for the dietitian . . . . . . . . . . . . . 133 Importance ratings by physicians of "ideal" dietitian' s competences in relationship to physicians' use of diet therapy as part of total patient care . . . . . . 136 ix Figure 1A. 18. 1C. LIST OF FIGURES Grouping of dietary-related responsibilities requiring proficiencies of the dietitian according to dietary department head . . Grouping of dietary-related responsibilities requiring proficiencies of the dietitian according to dietary department head Grouping of dietary-related responsibilities requiring proficiencies of the dietitian according to dietary department head . . Grouping of dietary-related responsibilities requiring proficiencies of the dietitian according to dietitian . . . . . Job title of 33 hospital dietitians inter- viewed . . . . . . . . Percentage of time spent in therapeutic activities as reported by dietitians inter- viewed . . . . . . . . . . . . Work experience prior to present position of 33 dietitians interviewed Continuing education hours earned for American Dietetic Association registration prior to October, 1970 . . . . . . . Comparison of personality characteristics of 26 dietitians with female college and high school students based on the California Psychological Inventory . . . . . . . . . . . . Comparison of dietitians' perceived proficiency (O———O) with importance (O---O) of competences for dietitians on the health team . . 69 71 7A 8A 88 92 96 110 118 Figure 10. Page Comparison of dietitians with an internship or three years supervised experience in relation to their perceived proficiency and importance of competences for dietitians on the health team . . . . . . . . . 122 Dietitian's perception of her responsibilities . 125 xi CHAPTER I INTRODUCTION The rapid rise in health needs, concurrent with short- age of health personnel in all health professions, necessi- tates a re-evaluation of utilization of health personnel.1 The dietetic profession is not exempt from critical appraisal. Krehl states: All too often, the dietitian's excellent training and knowledge regarding nutrition and its application, both in health and disease, are held in limbo and not fully utilized in the overall spectrum of patient care . . . . There is little doubt in my mind that the dietitian, generally, has not attained an appropriate place in the health care team and has not had the opportunity to participate significantly in the deliv- ery of health care to patients and to communities.2 He pleads For a changing attitude by all members of the health care team to utilize the dietitian more effectively by making her a full participating member in the con- sideration of the medical problems presented by the patient.3 The health care team concept as a vehicle for various health professionals to provide care to the patient has 1C. J. Wagner, 1967, Toward fullest utilization of our health resources, Health Office News Digest, 33:6. 2W. A. Krehl, 1969, The dietitian in the regional medi- cal program, J. Amer. Dietet. Assoc., 55:107-111. 3Ibid. emerged as a result of increased medical specialization with the physician being the team leader,1 who must share his authority with others.2 Barriers often exist between dietitians and physicians or other health team members. Mayer noted that education, professional training and custom have failed in enabling the dietitian to establish necessary communication with physi- cians.3 In addition, Burling SE.§l- observed that, although the most significant groups with whom the dietitian must work are doctors and nurses, interaction between dietitians and doctors rarely occurs; nurses may have developed an unfavorable impression towards the dietitian, either due to unpleasant memories of student experiences or to the feeling that the dietitian has taken away part of the nurse's tradi- tional responsibility.” In summary, dietitians experience frustration with regard to: 1. their membership on the health team; 1L. T. Coggeshall, 1967, Planning for medical progress through education, p. 25, Evanston, Illinois: Assoc. of Amer. Medical Colleges. 2G. James, 1967, Teaching community health in schools of medicine, Arch. Environ. Health, 14:713. 3J. Mayer, 1966, Dietetics looks to the future, Post Graduate Medicine, AO:A97-101. ”T. Burling, E. M. Lentz, and R. N. Wilson, 1956, The give and take in hospitals, p. 311, New York: G. P. Putnam's Sons. decision—making allowed the dietitian; and relationships with other health professionals such as physicians and nurses. Purposes of the Study The purposes of the study were to identify and describe: the present and ideal role of hospital dietitians; characteristics of dietitians who are most successful in contributing to the care of the patient as measured by the influence dietitians have on ordering admission diets and diet order changes, providing dietary instruc- tion, and attending medical rounds; and skills and competences which dietitians need to function as contributing health team members. Statement and Significance of the Problem If new concepts of health care necessitate change of the dietitian's participation on the health team, this participation needs to be defined, and consideration must be given to whether other professionals will accept the dietitian's potential contributions to health care. In addition, identification of the above purposes would be useful in re-evaluating and reconstructing an undergraduate curriculum for dietetic majors so that the pro- fession can increase its effectiveness on the health team. Most undergraduate dietetic programs are independent of other allied health educational curricula, and thus die— titians are not usually educated with other health team members. The American Dietetic Association (ADA) has tradition— ally emphasized dual preparation in therapeutic and adminis- trative dietetics in both the undergraduate dietetic curriculum and the dietetic internship. Membership in the association is usually gained by completing a four year baccalaureate program that meets academic requirements in addition to completing a dietetic internship; other quali- fying experiences include a three year supervised program or a Master's degree with one year of professional experience. Mayer challenged the dietetic profession: how can a person be both a generalist and a specialist with special services to render?1 Is it possible to prepare a student to possess expertise in both administrative and therapeutic dietetics--both areas which have expanded greatly with advanced technology? Consideration is now being given to specialized areas by the American Dietetic Association in its development of new Minimum Academic Requirements that will be evaluated by colleges and universities participating in a Pilot program under the proposed requirements instead of the present lMayer, op, cit. requirements.1 These new requirements allow three areas of specialty in addition to the general option: (1) food service management; (2) clinical dietetics; and (3) commun- ity nutrition. Although the four options allow more flex— ibility in specialization than the present requirements, the emphasis on specialization is most notable in specialized internships available by 1975. Despite the bleak outlook for many professions as a result of the current economic recession, the Bureau of Labor Statistics has listed dietetics, with chemistry, counseling, dentistry, and medicine, as a profession in which the "supply is estimated to be significantly below requirements".2 In 1968, the number of employed dietitians was estimated to be 30,000; expected requirements for 1980 are 42,100. The number of dietetic interns per year in- creased from 687 in 1951 to only 815 in 1969,3 or a 19 percent increase during these 18 years, which is not com- mensurate with the 40 percent increased need in projections to 1980. Since dietetic internships are presently the primary entry step into the profession of dietetics, either 1American Dietetic Association, Annual Reports and Proceedings, 1969-1970, pp. 13-14, Chicago: The American Dietetic Association. 2Bureau of Labor Statistics, Supply-demand imbalances expected in professions if past study and work patterns con- tinue, New York Times, Jan. 11, 1971, p. 55. 3U.S. Department of Health, Education, and Welfare, Health Manpower Source Book 21, 1970, Bethesda, Maryland: Public Health Service. more internships should be available or other alternatives should be examined. Supportive of the need for other alter- natives is that more than “00 college seniors, whose appli— cations were screened by the ADA Membership Department for dietetic internships between October, 1969, and May, 1970, were not placed in internships.l Apparently the barrier to increased needs for manpower in the dietetic profession is not only in recruiting dietitians but also in providing enough Opportunities for experience which meets ADA standards. Summarizing the mentioned problems would be helpful for establishing guidelines for development of a dietetic curriculum: 1. If the dietitian's contribution to health care is not as great as it could be, based on her educational prepara- tion and the unique competences she has, attention should be given to identifying present competences which are not adequate and new competences to enable dieti- tians to contribute maximally to health care. The cur- riculum then should be formulated on the basis of maximizing special competences of dietitians. 2. If the trend in health care is towards the health team approach, identification of relationships among health professionals is necessary before a realistic dietetic 1The American Dietetic Association, p. 39, op, cit. curriculum can be developed. In addition, description of individual characteristics of successful dietitians in contributing to health team care could provide fur- ther guidelines for curriculum development. 3. If there is still debate between a dual program of administrative and therapeutic dietetics and a special- ized program, identification of Job descriptions of dietitians should indicate trends in hospital dietetics in relation to administrative responsibilities which therapeutic dietitians have and therapeutic responsi— bilities which administrative dietitians have. This identification should also consider the responsibilities of dietitians who consider themselves both administra- tive and therapeutic, and the prevalence of food service being directed by someone besides a dietitian. Goals for generalized or specialized programs should be realistic and in accord with present and projected job demands. 4. If manpower needs have not been met, innovating ways to provide student experiences which would expand the opportunities dietitians have to gain the experience required for entry into the profession should be found. To establish curriculum guidelines, identification of dietitians' roles, competences needed by health team dieti- tians, and characteristics of successful dietitians in contributing to health team care was sought in Michigan hospitals. The study was in two phases: Phase I was designed to provide descriptions of dietitians' roles and responsibilities by hospital administrators, chiefs of staff, directors of nursing, dietary department heads, and dietitians by a questionnaire; Phase II further identified dietitians' roles, competences needed by dietitians, and characteristics of successfully contributing health team dietitians by personal interviews with and questionnaires from dietitians, and questionnaires from physicians. Limitations of the Study Results of the study will be influenced by the follow- ing factors: 1. Recognition that relying upon respondents to return data collection instruments, such as the questionnaires and psychological inventory used in this study, by mail often results in less than 100 percent response, in which case, inferences extrapolated to the entire popu- lation are limited. 2. Acknowledgement that hospitals' refusal to allow the researcher to visit the hospital may place a bias on the final sample of hospitals in the study. 3. Awareness that there were no large teaching hospitals selected in the random sample. Involvement of dieti- tians in contribution to health team decisions in teaching hospitals may be greater than in smaller, non- teaching hospitals. A. Recognition that activities of dietitians may be restricted by hospital policy unique to that hospital. Dietitians might contribute to health team decisions differently in another hospital without personal char- acteristics changing. 5. Hospitals selected for interviews had at least two dietitians identified by the hospital administrator in Phase I. 6. Recognition that all hospitals in the study were in Michigan; extrapolation of results in this study to a wider geographical region, such as the Midwest or the United States, should be done with discretion. Organization of the Study The remaining presentation is organized into the fol- lowing chapters: Chapter II: Review of the Literature. Aspects of health care in the United States, the Allied Health Profes- sions, health team practice, and the dietitian's traditional contribution to health care are reviewed. Chapter III: The Design of the Study. The population, data collection procedures, and data analyses are defined and described. A description of data collection instruments and their development are included. 10 Chapter IV: Results, Discussion and Summary of the Data. Description of dietitians and physicians is reported. Role and responsibilities of the dietary department and hospital dietitians are described. The relationship between various aspects of the dietitian's background and her per- ceptions of her responsibilities, competences, personality characteristics, and influence on the health team are identified. Data from the unstructured interview regarding the dietitian's specific suggestions for curriculum change are included. Physicians' identification of responsibility and important competences for dietitians and unstructured comments are summarized and categorized. Chapter V: Summary, Conclusions, and Recommendations. In this last chapter, the study is summarized, conclusions are drawn, and recommendations for curriculum development are made. The final segment of this presentation contains suggestions for further research. CHAPTER II LITERATURE REVIEW Introduction Although the main thrust of this study is the hospital dietitians' role, competences, and characteristics for decision-making on the health team, concentrating on the dietitian without consideration of the milieu in which she is functioning would be fallacious. Thus health care in the United States is reviewed to provide encompassing conditions which affect all health professions. Since dietetics is a member of the allied health professions, allied health pro- fessions are reviewed to describe concepts and problems of this alliance. The health team was reviewed to describe a situation which may involve dietitians' ideal functions and problems. The development and description of the hospital dietitians' role is presented in relation to expectations of dietitians by other health workers. The concept of role is reviewed to present possibilities for alterations of role descriptions within hospitals. 11 12 Health Care in the United States The historical development of health care in the United States provides a background for consideration of present needs. The evolution of health care in technically advanced countries was divided by McKeown into three stages: (1) no significant public responsibility; (2) public health services primarily concerned with the environment and control of com- municable disease; and (3) public responsibility emphasizing medical care of the ill, particularly the acutely ill.1 Federal commitment in support of health programs has a long history, starting with the establishment of the Public Health Service in 1798. Commitment in recent years has been further emphasized by the passage of about fifty major health bills including Medicare and Medicaid legislation in 1965, Comprehensive Health Planning, 1966, Regional Medical Programs, 1965, and the Allied Health Professions Act, 1966. Present needs in health care are complex. An insuffi- cient number of workers is critical because of an increased population, especially in age groups which require the greatest care.2 An additional challenge is for health care of higher quality and better distribution. Greenfield sug- gested that the demand in health services was generated by lT. McKeown, 1968, The complexity of the medical task, Bull. N.Y. Acad. Med., 44:83-101. 2J. A. D. Cooper, 1970, Health manpower crisis-- challenge and response, North Carolina Med. J., 31:219-222. 13 a change in consumer "tastes".l Americans expect a coordi- nated and comprehensive system of health care without dis— crimination of race, creed, color or economic circumstances.2 Froh listed five health services expected by families: basic medical services, accessible services, high quality services, responsible services, and personal and humane services.3 Lewis discussed health care in the context of politics, which he defined as "who gets what, when and how".u Manpower needs for all health occupations have been projected to 1980 by Hatch. There will be five million workers in health occupations, an increase of 1.5 million over 1967. Of the 3.5 million workers in 1967, “20,000 were in allied health occupations. He estimated that by 1975, allied health workers will increase by forty percent, and by 1980 the increase will be sixty-three percent higher than the 1967 level or about one—fifth of the total health 5 workers. Piper summarized projected needs for dietitians 1H. I. Greenfield, 1968, Manpower problems in the allied health field, J. Amer. Med. Assoc., 206:1542-154A. 2A. R. Somers, 1968, Some suggested principles for community health planning and for the role of the teaching hospital, J. Med. Ed., u3zu79—u9u. 3R. B. Froh, 1970, New systems for health care, J. Amer. Pharm. Assoc., 10:514-517. “1. J. Lewis, 1969, Science and health care—-the political problem, New England J. Med., 281:888-896. 5T. D. Hatch, 1970, Allied health personnel: an answer to the manpower crisis, Hosp. Progress, 51:69-71. I“ from 1966 to 1975, according to the U.S. Department of Labor, which estimated an increased need of 17,000 positions.1 This represents an estimate of 8,000 new positions and 9,000 re- placement positions due to attrition, death, and retirement. Levy contended that part of the health problem was the improper utilization of allied health personnel. He felt physicians resisted transfer of medical functions to others because of such factors as their conservatism, their concern for economic self-interest, increased specialization, the issue of "final medical responsibility", the concept of delegation in contrast to surrender of function, and the comprehensiveness of the allied health worker's function.2 Further he stated that physicians would relinquish only those functions which they considered non—medical or uneconomic for them to perform. To meet manpower needs, Marchmont—Robinson visualized future health care as one in which the family physician would be the central figure of the health team who would make the contact between the patient's needs and available resources, such as specialists, allied health personnel and advanced 3 machinery. 1G. M. Piper, 1970, Dietetic manpower trends in educa- tion and training, J. Amer. Dietet. Assoc., 57:225-228. 2L. Levy, 1966, Factors which facilitate or impede transfer of medical functions from physicians to paramedical personnel, J. Health and Human Behavior, 7:50-5“. 3H. Marchmont-Robinson, 1968, Today's challenge. Delivery of health care, J. Amer. Med. Assoc., 20A:155-156. 15 The emphasis in future health care will need to be more on preventive measures than on treatment or after-the- fact remedies.1 Harrell suggested that change in the char- acter of disease will require a new look at health care systems.2 James felt that future health care must be designed for chronic illness created by man-made hazards, including pollution and environmental hazards. He visualized extensive Federal programs, a decline in solo practice with more team practice in which the physician and nurse would have many helpers, more service to people in primarily urban areas, more involvement of public health in patient care, and consideration of social change.3 Health care was criti- cized by Winkelstein and French, who felt that the present health status was not related to the quality and quantity of health care because health care was curative, not preventive. The Allied Health Professions The term allied health profession describes the pro— fessional, technical and supportive disciplines involved in 1J. E. Graber, 1969, Preventing dependency: protective health services, Amer. J. Pub. Health, 59:1“13-1427. 2G. T. Harrell, 1969, Education on a health sciences campus, Ann. N.Y. Acad. Sci., 166:855-861. 3James, op, cit. “W. Winkelstein, Jr. and F. E. French, 1970, The role of ecology in the design of the health care system, Calif. Med., 113 7-12. 16 activities supporting, complementing or supplementing func- tions of health administrators and medical and health practitioners. James1 estimated lUO distinct specialties which can be identified as part of allied health manpower, although Fenninger felt that allied health professions and occupation categories are not well defined.2 Burton and Smith suggested that each profession must re-examine its roles and duties in thinking how best to deliver total health services in relation to who can do it most effec- tively and efficiently.3 The emergence of allied health professions was very rapid. In 1900, the ratio of allied health personnel to physicians was about 1:1; the present ratio is 13:1 and may exceed 20:1 by 1975.“ Points outlined the developmental stages of new health professions: (1) physician identifies the need for a helper; (2) physician trains the person to lG. James, 1969, Educational role of new health sci- ence centers in the health-related professions, Ann. N.Y. Acad. Sci., 166:862-868. 2L. D. Fenninger, 1969, Health manpower: scope of the problem, Ann. N.Y. Acad. Sci., 166:825-831. 3L. E. Burton and H. H. Smith, 1970, Public health and community medicine for the allied professions, p. 501, Baltimore: Williams and Wilkins Co. ”F. J. Moore, 1970, Information technologies and health care. II. The need for new technologies to offset the shortage of physicians, Arch. Intern. Med., 125:351- 355. l7 fill the role; (3) new personnel form organizations to repre- sent them; (A) formal collaboration with medical Specialty groups and American Medical Association Council on Medical Education who develop basic objectives for education of such personnel.1 In contrast, Light described development of the allied health disciplines as independent of physi- cians.2 Independence was also noted in the education of separate disciplines, with the frequent result of fragmenta- tion of hospital personnel who shared similar goals of excellent patient care but conflicted in individual efforts to attain this goal.3 The emergence of the Association of Schools of Allied Health Professions in 1967 helped to solidify the concept of coordinated effort among health professionals.“ The Association was established for the purpose of providing new dimensions for increasing health manpower and the devel- opment of educational programs. Allied health education programs traditionally were located within the hospital 1T. C. Points, 1970, Guidelines for development of new health occupations, J. Amer. Med. Assoc., 213:1169-1171. 21. Light, 1969, Development and growth of new allied health fields, J. Amer. Med. Assoc., 210:114-120. 3R. C. Buerki, 1965, The increasing role of paramedical personnel, J. Med. Ed., 40:850-855. “J. W. Perry, 1969, Career mobility in allied health education, J. Amer. Med. Assoc., 210:107—110. 18 organization; however, college campuses are now providing this education with supplementary utilization of community and medical services for clinical affiliation. Atwell viewed medical centers or schools as the logical place for health education to occur since, in theory at least, medical facilities allowed ideal conditions for the "team care" concept to be developed. He supported multi- disciplinary rounds and suggested that in the medical pro— gram there should be emphasis of what can be delegated to whom.1 Light, on the other hand, stressed a sharing of responsibility rather than delegation of duties.2 Atwell stated that dietitians and nutritionists have much to con- tribute to the education of the physician both during his student days and during his post-MD education.3 Perry felt that goals of education should be realistic in balancing educational preparation with actual job respon- sibility. He believed that loss of mobility in allied health occupations can sometimes be attributed to too little or too much formal education.“ Bergman described activities of allied health professions as effective when each 1R. J. Atwell, 1970, Interdependence of medical and allied health education, J. Amer. Med. Assoc., 213:276—277. 2I. Light, 1970, Growth and deveIOpment of new allied health fields, Amer. J. Med. Tech., 36:75—83. 3Atwell, 923 cit. ”J. W. Perry, 1970, Career mobility and allied health education, Amer. J. Med. Tech., 36:33-43. l9 discipline provided contributions and reduced overlap of functions through combined planning.l Moore pointed out that for a task to be delegated to an aide by the physician, the aide must be at least as well trained as the physician in that particular task. The dif— ference between the physician and the aide would be the scope and competence of decisional judgment which the physi— cian would have in a broad range of situations.2 Johnson challenged the assumption that the physician is at least as well trained as his subordinates in a specific field. She stated that "more often than not they have only a super- ficial understanding of the subject matter with which each 3 The Council on Foods and Nutrition of profession deals". the American Medical Association acknowledged that teaching of nutrition in medical schools was inadequate“ and Shank attributed the primary problem to lack of identity of nutrition in the curriculum or to difficulty in achieving definition of subject matter.5 lR. Bergman, 1970, Education of para—medical personnel, Int. Nurs. Rev., 16:161-166. 2Moore, op. cit. 3D. Johnson, 1964, The physician and the dietitian, Amer. J. Clin. Nutr., 14:183-185. “Council on Foods and Nutrition, 1963, Nutrition teach- ing in medical schools, J. Amer. Med. Assoc., 183:955. 5R. A. Shank, 1966, Nutrition education in school of medicine, Amer. J. Pub. Health, 56:929-933. 2O McNerney cited the institutionalization of allied health personnel as a hurdle in the progress of health care. He stated that allied health workers try to emulate the phy- sician with their white coats, certification, awards, asso- ciations, officerships and technical papers. The workers are insulated from other disciplines and are occupied by the pursuit of skill, excellence and professionalism.1 Career mobility, described by Perry and Ramphal, allows an individual with adequate education requirements and capa- bilities to move from the level of aide, to assistant, and to full—fledged professional status.2 The "lattice" concept allows horizontal movement among health professions as a result of the "core curriculum" and occupational experience common to many fields.3 With regard to career ladders, Shetland questioned the effectiveness of an educa- tional system developed to accommodate change and transfer among the professions. She also felt intrinsic satisfaction in intermediate steps is deprived the professional, if the educational system reinforces achievement of status and dignity only by upward mobility.Ll 1W. J. McNerney, 1970, Does America need a new health system?, Univ. Mich. Med. Center, 35:82-87. 2Perry, 99. cit., 1970; M. Ramphal, 1968, Needed: A career ladder in nursing, Amer. J. Nurs., 68:123A—l237. 3J. Hamburg, 1969, Core curriculum in allied health education, J. Amer. Med. Assoc., 210:111—113. “M. L. Shetland, 1970, This I believe about career lad- ders, new careers, and nursing education, Nursing Outlook, 18:32-35. 21 Health Team Practice Health team practice has been viewed as a possible solution to health manpower problems of shortages, utiliza- tion of present personnel, and accessibility. Burton and Smith described the changing concept of health care in which the physician is no longer director of subordinates but, rather more like a coordinator who assumes responsibility for the total regimen. Cooperation of each team member is essential for success.1 Silver visualized the health team as replacing the functions which the general practitioner formerly performed but not as excluding the general practi- tioner as part of the team.2 Stead pointed out the physician traditionally had helpers: nurses, administrators, technicians, physiothera- pists, dietitians and social workers. However, health pro- fession organization did not allow easy movement among the groups of workers. Additionally the non-physician component of the health team was often related to institutions and was not allowed to share the satisfaction in dealing with an individual patient.3 1Burton and Smith, op. cit. 2G. A. Silver, 1958, Beyond general practice: the health team, Yale J. Biology and Medicine, 31:29-39. 3E. A. Stead, Jr., 1968, The birth of a new educational venture—-the association of schools of allied health profes- sions, Medical Times, 96:99. 22 A team was described by Pascasio as one in which all members knew their own unique function as well as the spe- cific roles of other team members. In addition, they knew how all roles related to each other.1 Szasz felt that the term "health team" was often used indiscriminately to describe groups of persons who had been thrust together either by administrative decisions, personal trust or by highly organized policies. Clarifying the con- cept of "health team" involved identification of specific goals based on needs and interests of the client and profes- sional, and fusion between preventive, diagnostic, thera— peutic and rehabilitative components of health care.2 Szasz also identified the personalities of team members as one of the basic factors of the team. There are differ- ences in goals, training and technology. Status ascription is a differential and there are often territorial conflicts because of lack of definition of responsibility. Economic compensation and institutional structure also establish barriers.3 Thomas feels that the role of the health team remains to be defined in terms of its constituents, training of lA. Pascasio, 1970, Relation of allied health education to medical education, J. Amer. Med. Assoc., 213:281-282. 20. Szasz, 1969, Interprofessional education in the health sciences, Milbank Mem. Fund Quarterly, A7:AA9-A75. 3Ibid. 23 members, and the effect of team approach on health.1 Sup- portive of this lack of definition is Darley, who observed that, despite the wide distribution in thoughts and words of the need for comprehensive health care available for everyone, the rank and file physicians and hospitals have failed to commit themselves to changing patterns of provid- ing care.2 This hesitation blocks decisions in education and use of allied health personnel. James stated that, to be generally accepted by the medical profession and general public, health specialists must make it clear who they are, what they can do, what they cannot be expected to do and the value of their services.3 Education is essential in developing a health team approach. Millis stated that professionals do not work together by instinct. Rather they learn to work together by learning their professional roles together as students.)4 Christman reinforced this in stating that university stu- dents in health fields should have shared experiences to help them arrive at shared goals and values and to develop 1J. W. Thomas, 1970, Health manpower shortages: need for nonphysician professionals, Univ. Mich. Med. Center, 35:101-103. 2W. Darley, 1969, Allied health personnel and their employment for the improvement of medical care, New England J. Medicine, 281:AA3-445. 3James, op. 913., 1969. ”J. Millis, 1970, The future, J. Med. Ed., U5:A90-A92. 24 an understanding of the contributions each could make.1 That this does not occur was evidenced by Pascasio and Light who reviewed the unilateral education of team members who have had little contact with other future team members.2 Szasz identified learning experiences which all students of health professions share at the University of British Columbia: Description of the relationship between man's cultural background and his ideas of health and illness; com- munication between patients and the health professionals and among health professionals; knowledge of social institutions and agencies available for improvement of the patient's health, economic and political influences of the patient's environment; and understanding of basiC‘ biological sciences including pathology and clinical knowledge, in which the depth is determined by the stu- dents' needs and interests. The Hospital Dietitians' Role as Health Team Members Dietetics as a profession emerged formally in 1917 as the American Dietetic Association (ADA). Prior to this time, dietitians had been developing an identification of themselves as a unique group of professionals; dietitians had no precedents on which to rely in World War I.“ -1L. Christman, 1970, Education of the health team, J. Amer. Med. Assoc., 213:28A-285. 2Pascasio, op. cit.; Light, op. cit., 1969. 3G. Szasz, 1970, Education for the health team, Canad. J. Pub. Health, 61:386-390. 4M. 1. Barber, ed., 1959, History of the American Die- tetic Association. 1917—1959, Philadelphia: J. B. Lippin— cott Company. 25 Following the formation of the Association, cooperation with other professions was exemplified by exchange of discussion with the American Medical Association, The Association of Chemists and Bacteriologists, American Public Health and the American Nurse Association. Early national ADA conventions had speakers from other professions, and one of the primary interests at the 1923 convention was how dietitians might best cooperate with physicians and what hospital superin- tendents expected of dietitians.l As early as 1925 MacEachern, a hospital administrator, identified three phases of hospital dietetics: the medical phase involving close work with the clinician and laboratory worker; the nursing phase in which dietitians are instructors of nutrition; and the business phase of the hospital in which dietitians deal with purchasing, production and super- vision.2 MacEachern felt that the dietitian should contrib- ute to accurate and early diagnosis of the patient's ill— ness, efficient and scientific treatment, and a rapid return to physical health. He reviewed the evolution of the hospital dietary department, which in earlier years was operated by a faithful cook. Transitorily housekeepers were responsible for the food until trained dietitians became available. With the new emphasis on dietetics, clinicians 1181d. 2M. T. MacEachern, 1925a, The hospital dietary depart- ment--a forecast, J. Amer. Dietet. Assoc., 1:3-8. 26 looked to the dietitian for her cooperation, particularly with diabetics and patients who suffered other diseases of metabolism.1 Additionally, MacEachern suggested the need for planned follow-up of patients who were released from the hospitals.2 In this early phase, dietitians were seen as the per- sons most able to handle food prescriptions by Howland,3 an administrator, and to provide accurately measured diets which fulfilled the requirements of the disease.“ Wilder described the ideal dietitian as a director and teacher; she was not a preparer of foods and a half-qualified- nurse. The dietitian was the teacher of patients and doctors as well as one who filled diet prescriptions.5 Myers re- ported that many dietitians devoted one-half to three— fourths of their time to teaching activities. In his study of dietitians and their department directors, 70 percent of the directors estimated that only one-fourth to one-half of the dietitians were successful in their educational lIhid. 2M. T. MacEachern, 1925b, The hospital dietary depart- ment. II. J. Amer. Dietet. Assoc., 1:63—72. 3J. B. Howland, 1925, The function of the hospital dietitian, J. Amer. Dietet. Assoc., 1:81—82. “F. W. Peabody, 1925, The function of the hospital dietitian, J. Amer. Dietet. Assoc., 1:82—83. »5R. Wilder, 1926, The hospital nutrition expert, J. Amer. Dietet. Assoc., 1:118-127. 27 responsibilities.l Morgan recognized the need for both clinical and administrative research by the dietitian in large and small hospitals.2 MacEachern visualized an ex- panded role of dietetics as a result of increased interest in the therapeutic application of proper diet,3 demonstrated by Robinson and Proudfit.” Sadow related the need for the hospital dietitian to be aware of needs and resources of her local community. Even within the hospital, the dieti- tian had an opportunity to counsel out-patients as well as instruct in-patients with regard to their social and economic situation when they left the hospital.5 Hughes summarized duties which belonged to the dietitian: control of the department through planning, supervising and contact with the hospital administrator, interpretation of diet orders, consultation with physicians, interviews and instruction of patients, teaching of professional groups and participation in clinical research.6 lM. Myers, 1950, Is the dietitian adequately prepared to teach?, J. Amer. Dietet. Assoc., 26:663-667. 2A. F. Morgan, 1939, The dietitian's place in the hos- pital research program, J. Amer. Dietet. Assoc., 15:853-859. 3M. T. MacEachern, 19A9, Advances in dietetics from the hospital vieWpoint, J. Amer. Dietet. Assoc., 25:“9A-A96. “C. H. Robinson and F. T. Proudfit, 19A9, Development of positive food therapy, J. Amer. Dietet. Assoc., 25:497-503. 5S. E. Sadow, 19A1, Coordinating the dietitian's work with related community activities, J. Amer. Dietet. Assoc., 17:321-328. 6R. A. I. Hughes, 1951, The profession studies delega- tion of duties, J. Amer. Dietet. Assoc., 27:634-636. 28 Siscoe summarized attitudes of physicians toward dietitians: dietitians lack personal contact with patients, lack ability as cooks or at least ability to see that food was properly prepared and lack flexibility in daily routine. He emphasized the need for cooperation between the patient, doctor, nurse and dietitian. Strauss, Pragoff and Thomas included the social service worker in this joint coopera- tion.2 To contribute to medical team care of the patient, dietitians must keep in contact with the physician to carry out his orders and to educate him.3 English, a psychiatrist, stated that most dietitians are relegated to the kitchen.“ Other health professionals, such as the occupational thera- pist, the nurse, the nurse's aid and physiotherapist provide additional knowledge of the patient's problem, assume respon- sibility in providing optimal health, and share close contact with the physician and his goals for treatment. The 1D. L. Siscoe, 1931, The doctor seeks the aid of the dietitian, J. Amer. Dietet. Assoc., 7:119—134. 2A. E. Strauss, 1928, The dietitian and the out-patient. J. Amer. Dietet. Assoc., 3:243-247; H. Pragoff, 1948, Areas of COOperation between medical social workers and dietitians, J. Amer. Dietet. Assoc., 24:485-490; Thomas, op. oip. 3P. Reznikoff, 1939, The relation of the dietitian to the physician in modern medical practice, J. Amer. Dietet. Assoc., 15:537-539- uO. S. English, 1951, Psychosomatic medicine and die- tetics, J. Amer. Dietet. Assoc., 27:721-725. 29 dietitian too should make these contributions.1 White encouraged the dietitian to seek information from other health workers to help her determine the nutritional needs of patients.2 The obscurity of the dietitian was attributed to time- consuming planning a dietitian needs to do, often in seclusion.3 As a result little time is left for dealing with the patient or reflecting needs of the hospital. He suggested this obscurity depended on the hospital and on the dietitian's ability and background to enable herself to be a known and recognized figure on the health team. Ross, from an administrator's vieWpoint, stated that dietitians should know the nurse and physician and avoid burying her— self in the kitchen; they should demonstrate their profes- sional competences and abilities.“ In describing the dietitian's role on the health team, Moore visualized the physician as captain of the team, although Letourneau stated that the team concept suggested lIbid. 2G. White, 1954, The patient as the focus of attention, J. Amer. Dietet. Assoc., 30:25-28. 3B. B. Kirk, 1959, The dietitian's hidden nature?, J. Amer. Dietet. Assoc., 35:1055—1057. “A. Ross, Jr., 1967, An administrator looks at the department of dietetics, J. Amer. Dietet. Assoc., 50:26-31. 30 that professions work with the doctor, not for the doctor.1 Moore felt that the physician should delegate responsibility to each team member, but still be legally responsible for the team's treatment of the patient. The dietitian as a team member would implement the physicians' orders as well as communicate with him either verbally or in writing. The physician also lends support to the dietitians' responsi- bilities.2 Graning supported the idea that dietitians should accompany the physician during hospital rounds and make specific contributions to patient management.3 Krehl endorsed the dietitians' participation in the health care team, but stated that the dietitian has not attained an appropriate position in the health team and has not had adequate Opportunity to contribute significantly to care of the patient.“ Di Laura described a nutritionists' responsibilities and activities on a team in a Children's Rehabilitation Center. She evaluated, contributed, and gave direct service with other team members. She needed support and cooperation 1N. S. Moore, 1951, Physicians and nutritionists, J. Amer. Dietet. Assoc., 27:833-837; C. U. Letourneau, 1957, Management and the profession of dietetics, J. Amer. Dietet. Assoc., 33:691-694. 2Moore, op. cit. 3H. M. Graning, 1970, The dietitian's role in "heads up" patient care, J. Amer. Dietet. Assoc., 56:299-302. “Krehl, op. cit. 31 with many professionals to meet her broad objectives; like- wise, she offered her own contribution so that other members could accomplish their rehabilitative goals.1 The American Dietetic Association defined its objec- tives as: improving nutritional status of human beings; raising the standards in dietetic service; protecting the status of the profession; and fostering cooperation between the members and workers in allied fields.2 The U.S. Employment Service defines dietitians as those: who use their knowledge of chemistry and nutritional value of food and the food needs of healthy and sick people in planning meals which will provide a balanced diet, and in buying and supervising the preparation of food for large groups of people and individuals in hospitals, schools, hotels, clubs or factories. In addition to defining "dietitian", the American Dietetic Association provided standards for responsibilities of the dietitian to the physician. She: 1. Is loyal to the physician as the director of the health team. 2. Serves as consultant to the physician in all areas of diet therapy and nutrition. 3. Suggests nutritional standards to maintain and/or improve the nutrition of the patient. 4. Consults with the physician concerning his dietary prescription. 1A. Di Laura, 1965, The nutritionist and the team approach, Hosp. Progress, 46:130-132. 20. E. Miller, 1950, Is dynamic knowledge of nutrition essential for every dietitian?, J. Amer. Dietet. Assoc., 26: 3National Roster of Scientific and Specialized Person- nel: Medical Professions, 1947, U.S. employment service description of professions, Series Pamphlet No. 4. 32 5. Implements dietary prescriptions with meals adapted to the needs of the patient. ' 6. Informs the physician, both verbally and in writing, about the patient's food intake. 7. Teaches and assists patients satisfactorily to fulfill nutritional and diet therapy needs. 8. Informs the physician, both verbally and in writing, about progress in the patient's dietary instruction. 9. Meets with staff physicians who serve as an advisory committee on nutrition and diet therapy. 10. Refers recent research developments in nutrition and related subjects to the physician.1 The dietitian's future role may be altered as a result of personnel supportive of her work.2 The American Dietetic Association listed duties for several levels of workers in 3 and Piper described the dietary the dietary department, technician who holds a two-year associate degree.“ Miller projected to the future when technological influence will alter the dietitian's role.5 Making use of new machines and supportive personnel, the dietitian will be more available 1American Dietetic Association, 1962, Responsibilities of dietitians to administrators and physicians, J. Amer. Dietet. Assoc., 40:41. 2H. Blood, 1970, Supportive personnel in the health care system, Physical Therapy, 50:173-180. 3American Dietetic Association, 1965, Duties and responsibilities in the department of dietetics, J. Amer. Dietet. Assoc., 46:179-182. “Piper, op. cit. 5G. E. Miller, 1965, To be or not . . ., J. Amer. Dietet. Assoc., 47:15-19. 33 for professional duties, and perhaps a great change in her role will occur. In considering the potential of role changes for die- titians, an exploration of the role concept is desirable. The concept of role implies that the hospital dietitian is not an isolate in defining her role. The term "role" has many definitions but the most definitive at present repre- sents the dynamic aspect of status.1 Linton defined role as the: sum total of the culture patterns associated with a particular status.2 Although traditionally designated as the basic unit of social behavior of individuals, role is now considered a composite of various social forces or mechanisms.3 With regard to decision-making roles of members of the health team, physicians wanted to be free to make their own decisions in professional matters.L4 Those who made administrative decisions which directly concerned the work 1L. J. Neiman and J. w. Hughes, 1951, The problem of the concept of role: a re—survey of the literature, Social Forces, 30:141-149. 2R. Linton, 1945, The cultural background of person- ality, New York: Appleton-Century. 3S. N. Eisenstadt, 1965, Essays on comparative insti- tutions, p. 30—31, New York: John Wiley and Sons. “M. E. Goss, 1961, Influence and authority among physicians in an outpatient clinic, Amer. Sociological Rev., 26:39-50. 34 of the physicians were the physicians themselves rather than a lay person. The role attitude of the physician towards other professionals on the health team affected the success of meeting one hospital's medical goals.1 Increased strati- fication in a ward, defined by the physician's maximization of status differentials between himself and the occupants of other positions in the hospital ward, was correlated to increased patient length of stay, increased job mobility of nurses and auxiliary personnel, decreased use of consulta- tion increased medication errors, and decreased teaching quality of the wards. Burling op o1. described other influences in the hos— pital which may affect roles of personnel. The hospital board of trustees delegates discretionary authority to the administrator, but in widely varying amounts. The board must often depend on the self-regulation of the medical group. Frequently there is role conflict between the administrator and the trustees and physicians. According to Burling, the administrator must provide technical skills, humanitarian purposes, flexibility, and organization.2 Deasy suggested that successful adjustment to new roles was related to: (1) the clarity with which expected behav- iors appropriate to future roles are defined; (2) whether a lM. Seeman and J. W. Evans, 1961, Stratification and hospital care: II. The objective criteria of performance, Amer. Sociological Rev., 26:193-203. 2Burling op o1., op. cit. 35 model has been evident; (3) the kinds of transitional ritu- als built into structure; and (4) the completeness of the shift in responses and expectations by the society.1 Summary Current health manpower problems in the United States have resulted from increased population and a change of values held by the consumer who expects high quality care and accessibility to health care for everyone. The problems have challenged all health professions, including dietetics, to maximize efficiency and effectiveness of health workers. The allied health professions, of which dietetics is one, have formally organized to provide a joint effort towards cooperation among health professions, primarily in an educa- tional setting. One anticipated outcome of this educational endeavor would be strengthening of the health team concept; if students from different fields work and learn integra- tively, they may function as better health team members at a professional level. Dietitians have traditionally provided nutritional care to the patient, but developing and sharing goals for patient care with the physician, nurse and other health professionals have not been evident. 1L. C. Deasy, 1964, Social role theory: its component parts and some applications, Washington, D.C.: The Catholic Univ. of America Press. 36 In meeting health challenges, many health professionals' roles may be altered. Present and ideal roles and responsi— bilities of dietitians, competences needed for health team dietitians, and characteristics of successfully contributing dietitians on the health team are explored in the remaining chapters. CHAPTER III DESIGN OF STUDY, INSTRUMENTATION, AND DATA COLLECTION PROCESSES Introduction and Over-All Desigp This study is designed to: (1) determine the present and ideal role of hospital dietitians; (2) identify char- acteristics of successful dietitians who contribute to health team care of the patient; and (3) determine compe— tences which the dietitian needs to function as a contribut- ing health team member. To achieve these objectives, it was necessary to identify a suitable over-all design, describe the population, obtain or develop suitable data collection instruments, establish and implement procedures for data collection, and determine appropriate methods for data analysis. Over-A11 Design The over-all designon_n=2m GOO... mwomo MJDowrom Zorrosoomn. 000.... .mo_>mmm >> wozmmmummm coo... ZO_._.¢04a2w 000... mwomo 338107 Zorrozooma ooolm// mo_>mwwl/'/ >m0._.w_I ._.w_o woznom axis a . mozwmwmmmn— coon. Zop/Um’uammn. coon. om> wazms. wozmmwn—zoo v.10; xmmo \ mfimqmomn. ww>04n§w / coon. mmomo t mgaoonm Zorronooma 000... wo_>mmm >5": 2mm._.z_ NVZJPVM/VFmMQKMPZ. /Vu EMA-.0... Mykmzzo 20....03mhmz. .rzm_._.mO._.m.I PEG 2 mozaom 015$ \\ mozwmmummm 000m ZO_._.555 73 activities often did so at the exclusion of kitchen- oriented duties. Note should be made that the group of kitchen-oriented duties are similar to the ones that less than half the die- titians and dietary department heads had identified as not requiring unique competences of the dietitian. The group of patient-oriented duties are identified as those which require competences of the dietitian. Contrary to the dietary department heads' consistent division of activities, the dietitian associated attending ward rounds, instructing interns, and attending interdepart-‘ mental meetings with writing and/or revising the diet manual as well as with preparing the food production sched- ule; attending interdepartmental meetings was also associ- ated with preparing the food production schedule (Figure 2). Thus dietitians did not make a distinct separation of kitchen-oriented and patient-oriented responsibilities. Chiefs' of Staff Ideal Assignment of Dietary-Related Responsibilities Chiefs of staff assigned dietary-related duties ideally to the dietitian, physician, or nurse alone, to two or more of the health personnel or none of these three health per- sonnel. All responses which included the dietitian as a participant were summed and compared with those duties which the dietitian should perform alone (Table 7). 74 Figure 2.-—Grouping of dietary-related responsibili- ties requiring proficiencies of the dietitian according to the dietitian. Responsibilities connected by double-headed arrows were both listed as requiring proficiencies of the dietitian at a correlation level of 0.600-0.699. Responsibilities included: Determining patient's food pref- erences; attending ward rounds; preparing dietary histories of patients prior to diet prescription; instructing patients following prescription of special diets; recording on charts dietary progress of patients; following-up patients on special diets after release from hospital; participating in interdepartmental conferences and consultations on nutri- tional needs of patients; participating in intern instruc- tion; preparing and/or revising dietary manual; writing routine menus; participating in conferences, staff meetings, profession-related committee work; handling routine desk work such as payroll, accounting, inventories, and adminis- trative report writing; handling employee problems such as hiring, training, counseling, and scheduling; ordering food, preparing food production schedules; supervising tray service, and supervising food preparation. 75 mmm.-oom.u. 44524.2 Fmall'zmwhz. /, mnzms. w._._m;> oz_._.mm_2 humor—whg wozmmwmzoo $730.30... x103 xmwo 02_.rm<_.._o mSMJmomn. . mm>on_n__2w ZOEmeEbZ. ._.ZM_._.> mo_>mwm >4": wozmmwmwmm 000... // zoi¢_._. pmmpIm mo cofipmofloch ** .cmAAAAon AcmAmAmma u .Ao .A.mm< AcmAAAAon LmAzo u .Ao omAco mcmAAAAon m>AAmAAwAcAEB< u .Ao .cAsta AcmAAAAon 0Apsmgmtmne tame u .Ao .tmne emmm AcmAAAAon 0AAzmgtAch u .Ao .Amne H mpowmpmo comm m H m a m a ma ca Lonasz o H o H cm H mA H MA H AA H mm H Ansom AOOAQ AA 0 ma am wA Am ms ma co Amnssz .2 A A o A A A A A A A A A A A Ammmm H m m a m z m :a mpwmw I l I I I l l cam on .m.z ma + o + s + m + z + m + m + maszMmmww AH mH OH ma ma ma m letm mammw .m.z o H o H m H m H m H m H OH H ama CA 0 0H m w :m MH 0 whom» . . ma H o H m H OH H m H m H ma H mm m 2 mm Am mm A: a: A: mm a I I I I I I I ARV AAA>AA0< o + o + mm + m + mm + m + ma + oflusmd A. 00A 0A a: a: mm mm mm -AAAAB AA pcodm oEHB mmocmoA ..Ao swam .Ao chAAAon ..Ao . .Ao ..Ao oAcmAm A.mm< mAmAon omflco cAEB< more ommm tone 0AAmAtmpomtmzo HmcmAAApon co mHAAe .mHmpfiawon Umpomfimm CH wcmfipflpmfic %0 mofipmfihmpomLMEOIl.ma mqm2 kzhlm. .335 k0 NQQLIMOtNt 90 TABLE 14.--Status of American Dietetic Association member- ship of 33 dietitians from 11 Michigan hospitals. Number % Member 27 82 Presently in 3 Year Supervised Experience to 2 6 Qualify for Membership Not Eligible 4 12 Two-thirds of the ADA dietitians qualified for member- ship through a dietetic internship (Table 15); one-third, from a three year supervised experience. In comparison with the initial study, the proportion of former dietetic interns' and those who were in the three year experience was similar. The two dietitians who were presently in the supervised experience program were included as part of the six dieti- tians who were not presently eligible for ADA. TABLE 15.--Qualifying experience leading to ADA membership by 33 dietitians from 11 Michigan hospitals. Number % Internship 18 55 3 Years Supervised 9 27 Experience Not Presently Eligible 6 18 Characterizing dietitians for ADA membership eligibility had the three years supervised by the route which they chose showed that dietitians who experience had been in their 91 present position significantly longer than dietitians who had an internship, but had been an ADA member fewer years (Table 16). As a group, dietitians with supervised experi— ence were also older. TABLE l6.—-Characteristics of 33 dietitians who qualified for ADA membership by internship or supervised experience. Supervised Does Not Signifi- Internship Experience Apply cance 38 45 32 Age i 12 i 11 i 11 Tr. Years 13 8 O * in ADA : 11 i 6 i 0 Years in 3 6 2 Present * Position 1 3 i 3 i 1 Number in 18 9 6 Each Category * 1Indication of F-test values: 0.01 < P i 0.05; Tr. 0.05 < P i 0.10. Previous Work Experience.—-A variety of work experience combining both administrative and therapeutic dietetics was evident in previous work experience and the present position (Figure 5). Almost half of the therapeutic dietitians had previous experience in both therapeutic and administrative dietetics or in administrative dietetics alone. The seven dietitians who were presently in both the administrative and therapeutic aspects also had variety in their backgrounds. Only six dietitians, all therapeutic, had one phase of 92 Figure 5.——Work experience prior to present position of 33 dietitians interviewed. Previous experiences are indi- cated on the left side of the arrow. Present position is indicated on the right side of the arrow. Experiences include therapeutic dietetics only, (Ther.); administrative dietetics only, (Admin.); or a combination of therapeutic and administrative dietetics, (Both). Dietitians who are presently in their first position are indicated, (lst Posi- tion). 93 Ibooll.z_zo< zhomlluémzh .z_39<+u.¢m:._. .mmxhtl.z_ao< 20.5.50“. :— :homfzhon .cuzhllémzh .mmxblll than 20?:m01 bzmmNtt Ob t9~tm Mothstmtxm ktbi 94 dietetics in both previous and present experience. Four dietitians were in their first position, and no comparison of previous and present position was possible. Age and years of professional experience were signifi- cant factors in sequence of work experiences (Table 17). The average age of the two administrative dietitians who had previously been in therapeutics was 49; these two also, on the average, had the most experience. Two other groups with previous experience in both aspects and who were presently assuming a dual role were older and had more professional experience than most dietitians. Dietitians in their first position were youngest and had the least years of profes- sional experience. Educational Preparation.--The highest education attained by eight dietitians was a college degree (Table 18). One die- titian had attended college but had not completed her degree. The highest educational level for ten dietitians was a dietetic internship. Aside from the one respondent who had not completed college, the dietitians not eligible for ADA had completed college in a Home Economics or Die— tetic program. Continuing Education Hours.--Continuing education hours accumulated prior to October, 1970, averaged 26 hours, with a range from 0 to 91 hours (Figure 6). Six of the seven dietitians with no hours were not members of ADA. 95 .mo.o.w A v Ao.OA AmmsAm> Ammpum Ac coAAAOAocAm COApAmoa pummmpa pammmpawp sopmm mo Aswan so mpmupmq COApAmoa m50A>mAQ ucmmopomp zoppm mo pmmA co mumpqu < cum 9 nuom u m mOApopon m>ApmAumAcAEp< n < mOApmpmAQ ofipzoamnmne u E COApamoa umpfim n pmHH Apom : m A AA o m m : Impmo comm CA Amnesz I I I I I I I I ocm Q A m + A + o + m + A + 0A + A + A + mAmcwmmmww 2A 0A HA ma m HA ma m loam mpmmw AA A w A o H NA H m A mA A m A A H mw< A A: mm o: m: mm mm a: mm mmocmo lfihficwfim m Aim m film—H. m Al¢ .H. film AH. AIAH. pH. A|< .4 AIL... PWH AmmocmApomxm AmCOAmwomogm .mcmAuApmAp mm mo mmocmAAonm Am:0Ammmmopa mo mocosvomII.~A mqm._._I_opa mm.< mwsmno Amopo pon wcAcAEAmpmo MQA< u pvo coAmmAEom wcAcAEmemo "CA chxmelcoAonmo op mcmApApvo wcApsoAAucoo pmochmA Am Am on Am mm mm 6w< m A AA m 0 mA A6986: «GA mammw MA mm mm cm 0 ms mpsom COAA Imosom wcAchpcoo .Lmze .Aone .Aone zuom coApAmom .pone mocmAmexm I.AD:E I.cAEo< Inpom I.pm£B pmA Inpom xpoz mo mocmsvom :oAuAmom m m z A A m ucowopm :A whom» mocmApmmxm AmcoAm m m 0A m A om Immmopm mamm» oAcm QAnm pcmozum AAo< om 00A om m» om 00A 0Apsoamnmne cmAuApvo chpAquo .AQ OACAAQ a cmApApmAQ :mApprAo cmApApoAQ .Lmse .pmze .Amce comm mmAco .meB .Ach comm m m a o m < AmcmApApon .wchmE IcoAonoc Emma :pAmon op pmoE wcApsnAppcoo mcmApApvo wa wo mAAmopQ AmcompmmII.Am mqm<9 116 hospital in which policy allowed dietitians routinely to instruct patients without a physician's order. Biographical Data Five of the six dietitians were therapeutic dietitians who spent 90 percent or more of their time in therapeutic activities; one was a chief dietitian who spent 75 percent of her time with therapeutic duties. All were members of the American Dietetic Association except for one who was in a three year supervised experience to qualify for ADA. Of particular note was that of the five dietitians who were ADA members, three had been in a three year supervised experi- ence. These three dietitians plus the student dietitian represented four of the six contributing dietitians who qualified or are presently qualifying for ADA by three years experience. The remaining two dietitians had dietetic internships. Four of the dietitians had a combination of administrative and therapeutic dietetics in their present and previous work experiences. One dietitian was in her first position. Neither age nor number of years of profes- sional experience seemed to be a contributing factor; age ranged from 23 to 55, and the years of professional experi- ence ranged from one to twenty years. Continuing education hours ranged from O to 75 hours. Continuing education sought prior to registration was similar to that sought by the entire group. Most frequent were reading professional 117 journals and attending meetings to increase professional skills. California Psychological Inventory The six most contributing dietitians were all higher than the average for all dietitians in dominance, capacity for status, sociability, social presence, and self- acceptance. They were frequently higher for responsibility, tolerance, communality, psychological-mindedness, but often lower in socialization, self—control and good impression. Similar traits included sense of well-being, achievement via conformance, achievement via independence, intellectual efficiency, flexibility, and femininity. Competences Needed by Dietitians on the Health Team Dietitian's Proficiency in Competences A list of competences that were hypothesized to be important for dietitians on the health team were rated by 26 dietitians. The dietitians' self—description of pro— ficiency in the various competences is presented in Figure 8. Importance of Competences In addition to self—description of competences, dieti- tians rated the importance of these skills for a dietitian on the health team (Figure 8). The ordering of importance 118 Figure 8.--Comparison of dietitians' perceived profi- ciency (O———O) with importance (O--—O) of competences for dietitians on the health team. Solid and dashed lines con- nect discrete variables. Ratings indicate relative profi- ciency and importance of competences, as rated by 26 dietitians. Proficiency ratings (O———O) of 24 competences were measured and divided into three equal groups from the lowest, (A) to the highest, (C). Part A includes competences in which dietitians are least proficient: evaluates research findings in the sciences; understands relationship between nutrient intake, structure and function of the body at various stages of life; under- stands abnormalities in structure and function during disease; understands relation between food and drugs; recog- nizes relation between hereditary and environmental factors in structure and regulatory functions; recognizes life styles of groups and individuals; knows laws and regulatory agencies related to food quality and safety; integrates biological and social sciences into a comprehensive concept of human nutri- tion. Part B includes competences in which dietitians are interme- diate in proficiency: understands interpretation of labora- tory data; analyzes physical and chemical changes in food during storage, preservation and preparation; understands structure, processes and functioning of various systems of the human body; understands relationship between nutrient intake, structure and function of the body during disease; uses knowledge of socio-economic, cultural and ethnic status in designing dietary plans; understands process of managing human, material and financial resources; understands prin- ciples of education; and understands social needs, attitudes, concerns and habits. Part C includes competences in which dietitians are most pro- ficient: knows methods of obtaining dietary histories; knows nutrient recommendations for individuals in various environ- ments and stages of life; knows methods of interviewing patients; recognizes uniqueness and depth of food attitudes and habits; identifies changes in food intake necessary for treating disease; understands technical operations involved in production, distribution and service of food; knows food standards and factors affecting food quality; uses food com- position knowledge in designing dietary plans. RATINGS 119 o-- -0 Importance e——e Proficiency HIGH A ,,-<>.~ ‘0’" “~ MEDIUM ,x' ‘QA‘ ”o I \ I O ‘s‘ ' ' LOW Research Nutrient Disease Drugs Hereditary Lite Style Food Biology and Intake Structure Environmental Laws Social Health Factors Science HIGH 8 9" ‘ \ 0. ’ ‘\ O ’ ‘ s n I ~ ’ ’ ‘ §~ MEDIUM \ ,I ‘0' “\7 LOW Laboratory Changes Physiology Nutrient Socio- Management Education Social Tests In Food Anatomy Intake Economic Needs Intake Illness Status HIGH C MEDIUM LOW Dietary Nutrient Interview Food Food Technical Food Food History Recom men - Attitudes Intake Operations Standards Composition dations COMPETENCES 120 of these competences begin with the least important: "heredity environmental factors", "change in food", "food laws", "life style", "research", "management", "social needs", "biology and social science", "drugs", "laboratory tests", "food standards", "nutrient intake health", "tech— nical operation", "education", "disease structure", "physi- ology anatomy", "dietary history", "nutrient recommenda- tions", "socio-economic status", "food attitudes", "inter- view", "nutrient intake illness", "food composition", and "food intake", with the latter being the most important. Comparison of Proficiency and Importance of Competences The ratings of importance of all competences for a dietitian on the health team were higher than the self- ratings of proficiency with six exceptions. Five compe- tences were similar in rating of importance and self- proficiency: "technical operations", "food standards", "heredity environmental factors", "life style", and "food laws". The importance of analyzing chemical and physical changes in food during processing, etc., was rated lower than the self-proficiency, suggesting that a dietitian on the health team may not need as much background in this area of competence as dietitians presently have. Generally, competences which dietitians rated as most important for dietitians on the health team were also those in which they were most proficient (Figure 8). Two 121 competences, "technical operations" and "food standards", were rated among the highest proficiencies, although their importance for health team dietitians was not as high as other competences in group C. Wide discrepancies were noted between proficiency and importance of competences in Figures 8A and 8B, suggesting that certain competences in which dietitians perceived them- selves as least competent were those which they considered most important for dietitians on the health team. Wide differences were observed for the following competences: "nutrient intake health", "disease structure", "drugs", "physiology anatomy", "nutrient intake illness", and "socio- economic status". Differences Between Dietitians with an Internship and Dietitians with Three Years Supervised Experience All competences listed in Figure 8 were evaluated to determine differences between dietitians with an internship and dietitians with three years supervised experience in relation to their self-perceptions of proficiency and impor- tance of competences for health team dietitians. Figure 9 illustrates only competences for which there were statistical differences between dietitians with an internship and dietitians with three years supervised eXperience for either self-description or importance of these competences. Comparison of Figures 8 and 9 shows greater differences between these two groups of dietitians 122 Figure 9.--Comparison of dietitians with an internship or three years supervised experience in relation to their perceived proficiency and importance of competences for dietitians on the health team. Ratings indicate relative proficiency and importance of competences, as rated by 26 dietitians. Part A includes competences in which the total group of die- titians are least proficient: evaluates research findings in the sciences; understands relationship between nutrient intake, structure and function of the body at various stages of life; understands abnormalities in structure and function during disease; understands relation between food and drugs; recognizes relation between hereditary and environmental factors in structure and regulatory functions; recognizes life styles of groups and individuals; knows laws and regu- latory agencies related to food quality and safety. Part B includes competences in which the total group of die- titians were intermediate in proficiency: understands inter- pretation of laboratory data; analyzes physical and chemical changes in food during storage, preservation and preparation; understands structure, processes and functioning of various systems of the human body; understands relationship between nutrient intake, structure and function of the body during disease; uses knowledge of socio-economic, cultural and eth- nic status in designing dietary plans. Part C includes competences in which the total group of die- titians were most proficient: knows methods of obtaining dietary histories; recognizes uniqueness and depth of food attitudes and habits; identifies changes in food intake nec- essary for treating disease; and knows food standards and factors affecting food quality. 123 020235 too... :2... v8... 32:: too... mwozwbwaioo 52:: £220 .33 econ 3.2m 932.com -325 2.5 e... nee: _ 32... 20:32 :23... 52.63:».5 >352... 2.222 £923.95 e'e'e'e'e'e'e'e'e'd 32o :-:-:-:-:-:-:-:-:-:-:-‘ .. 3.2.... coo... c. 39.28 232:5 3°35 85:35 -3523... aegiodam 3.36:2... - 3.3.39... c.3333... 3:239... - 2.35:... 3.52.8... - 2558... 5.0.: 88.. 5232.3 1 558.: 3.2... 2.2.3: [IIEI SONILVH l 1 I I 30.— >¢u> 30.. tan—m! to...- 30.. 53> ’04 2:39: :2: 12“ in skills which dietitians self-rated themselves as least competent (Figure 8A) than for skills in which they were more competent (Figures BB and 8C). Except for "dietary history", dietitians with an internship rated themselves more proficient than dietitians with three years supervised eXperience. In rating the importance of competences, dietitians with an internship rated "heredity environmental factors", "food laws", and "changes in food" higher in importance than the dietitian who had three years supervised experience. Comparisons between self-description and importance of a competence for a dietitian on the health team show that frequently there were greater differences for dietitians with three years supervised experience than dietitians with an internship. Dietitians' Responsibilities Dietitians reported current responsibilities which they presently do; these were compared with duties for which they should be responsible and their perceptions of whether phy- sicians would assign these responsibilities to dietitians. Current Responsibilities of Dietitians Responsibilities are arranged in Figure 10 in order of the percentage of respondents who perform these duties. The seven responsibilities least often performed by dietitians are presented in Figure 10. Three of these seven duties, 125 Figure lO.--Dietitian's perception of her responsibili— ties. Responsibilities include those she does, thinks she should do, and those she perceives the physician feels she should do. Responsibilities were grouped according to the percent of 26 dietitians who presently (white bar) perform the responsibilities from the smallest percent, (A) to the largest, (C). PERCENT OF RESPONDENTS 126 DIETITIANS' PERCEPTIONS OF HER RESPONSIBILITIES E SHE oozs - sue suoum A I00 r- so I 60 ~ 5,. 4o — é; - 2%: 20 - I g: s I Supemlel Allende Ward Prescribe: Allende Medical Tallies Followe Food 0 Special Conlerencu Die! Food Poluenu Preparalion Die" fifvz‘fifié' :‘x‘ y :34 .4 ‘2" 3 355% x.” a. Malle- deal-lane on Health Team Prepare: w'ile: D Supervues y Wnles Coneum Diel Hinory Manual Tray Sevvice NOMPIIMIIIMI Proqven Special Die" Phyeician C ” Zi¢3§}§i?€&£%3§9€€r .. 'fiml § . My Wrivu Menus Vieils Calculalee Coneulle Delevmlnee "lemme with Pollen" Pavienn Dien Nuru Food Lllee Pelleme RESPONSIBILITIES 127 attending ward rounds, prescribing diets, and making deci- sions on the health team further reflected the small contri— bution made by dietitians to selected activities in decision-making on the health team, discussed in a previous section. The six duties most frequently performed by dietitians appear in Figure 10. The responsibility of providing dietary instruction supported earlier findings of the high contribu— tion dietitians made in diet instruction to decision—making on the health team. Dietitians Who Feel They Should Be Responsible for Duties Dietitians stated which of these responsibilities they should perform. There was little discrepancy between the actual and ideal duties for the six most frequently per- formed (Figure lO). Greater differences were observed for several responsibilities in Figures 10A and 10B, which represented the lower two-thirds of percentage frequency in activity. Dietitian's Perception of Whether Physicians Would Assign Responsi- bility to Dietitian Dietitians also described their perceptions of what they thought physicians felt they should do. Again, little difference was noted for the six most frequently performed duties. In certain duties generally related to kitchen operations, the dietitian perceived physicians as believing 128 the dietitian should perform these duties much more fre- quently than she does or thinks she should do; these included supervising food preparation, tallying food serv— ices, supervising tray service and nourishments. For other duties dietitians described the physicians' thoughts and their own thoughts similarly with regard to the dietitians ideally doing the Job; these responsibilities included: making decisions on the health team, preparing diet histo- ries, writing the diet manual, charting dietary progress, and writing special diets. Responsibilities and Qualifying Experience for ADA Membership Eighty percent of the dietitians with an internship experience believed physicians felt dietitians should pre- scribe diets, but only 40 percent of the dietitians who followed a three year program agreed to this belief. Part B. Physicians' Study Of the 130 questionnaires sent to physicians, 91 were returned; 54 came from physicians who had been nominated by dietitians, and 37, from those selected randomly. Description of Physicians Eighty-two physicians returning the questionnaire were either full-time general practitioners or practiced a specialty full-time (Table 22). 129 TABLE 22.--Return response of nominated and randomly selected physicians in relation to their type of practice. M.D.'s M.D.'s Total Type of Nominatedl gagdomlyg M.D.'s Practice e ected Con- Re— Con- Re- Con- Re- tacted sponded tacted sponded tacted sponded Full-time GP or Full-time 58 A9 55 3A 113 83 Specialty GP With Some Specialty l l 5 2 6 3 Practice Intern 0 O O O O I 0 Resident or Fellow Other Full- time Staff in Hospital Service Full-time Medical School Faculty Administra- tive l l l l 2 2 Medicine Not Listed 3 2 O O 3 2 TOTAL 65 SN 65 38 130 92 lDuring interview of dietitian. 2From American Medical Directory. 130 A large portion of physicians nominated by dietitians had a primary specialty of internal medicine (Table 23). Next most frequently occurring was the general surgery group and general practitioners. These were also the three largest areas in the group selected randomly. Of the 130 physicians contacted, 97 did not have a secondary specialty. The 20 physicians nominated by the dietitian that had a secondary specialty listed cardio- vascular disease or internal medicine most frequently. Thirteen randomly selected physicians most often listed cardiovascular disease or general surgery as their second- ary specialty. Use of Diet Therapy Sixty of the 92 physicians returning the questionnaire stated they used diet therapy routinely as part of total patient care (Table 2“). Preferred Method for Ordering Diet Changes Physicians were asked the method they preferred for ordering diet changes on the assumption that an "ideal" dietitian (Table 25) was accessible. Twenty-seven thought the dietitian could modify the doctors' diet change. Twenty- two said the dietitian should make the diet change. 131 TABLE 23.--Number of physicians responding to questionnaire in relationship to primary specialization. I M.D.'s Rgggém: Total Primary Nominatedl S l yg M.D.'s Specialty e ected Con- Re- Con— Re- Con- Re- tacted sponded tacted sponded tacted sponded Allergy A A A 4 Cardiovascular Disease 2 2 ' 2 2 golon & Rectal 2 2 2 2 urgery General Practice 6 5 18 ll 24 16 General Surgery ll 6 ll 7 22 13 Internal Medicine 27 2“ 15 9 “2 33 Neurological 1 O 1 0 Surgery Neurology 1 O l 0 Obstetrics & Gynecology 5 5 5 5 grthOPedic 2 2 10 u 12 6 urgery Pathology 1 l 1 Pediatrics 3 3 3 Radiology 1 l l l Thoracic l l l O 2 1 Surgery Urology 3 l 3 l Unspecified (retired, not in practice, 1 1 1 1 not specified) Other 2 l 2 Not Listed 2 2 2 TOTAL 65 54 65 38 130 92 lDuring interview of dietitian. 2From American Medical Directory. 132 TABLE 2A.--Use of diet therapy as part of total patient care by 72 physicians.1 Number Percent of Total Physician Uses Routinely 6O 83 Physician Uses Sometimes A 6 Physician Does Not Use 8 ll lTwenty physicians did not respond to this question. TABLE 25.--Eighty—one physicians' preferred procedure for ordering diet changes if an "ideal" dietitian were accessible. Diet Changes Made By: Number Percent of Total - Physician ' 11 1A Physician, upon Consultation 19 23 with Dietitian Physician, with Dietitian Modifying Diet Subject to 27 33 Approval by Physician Dietitian, with Approval from 22 27 Physician Other _ 2 3 lEleven physicians did not respond to this question. Competences for "Ideal" Dietitian Competences of the "ideal" dietitian who participates in ordering diets the way physicians suggested were rated by all physicians (Table 26). The most important compe- tences included: "utilizes food composition knowledge", "utilizes nutrient recommendations", "assures patients' satisfaction", "uses communication skills", "understands 133 TABLE 26.-—Physicians' ratings of importance (very impor— tant, somewhat important, of little importance) of certain competences for the dietitian. J I Utilizes knowl- M.D.'s l sgigétid Total Signif— I edge of Nominated Randomly2 M.D. s icance Numerical Rating of Importance“ Nutrient 2.61 2.39 2.52 N S Recommendations i .765 i 1.17 i .95 ° Food 2.63 2.39 2.53 N S Composition 1 .76 i 1.17 i .95 ' ' Socio-Economic 2.AU 2.13 2.32 N S Status 1 .79 i 1.17 i .97 ' 2.50 2.03 2.30 * Diet History 1 .82 i 1.15 i .99 2.63 2.18 2.u5 * Communication 1 .85 i 1.20 i 1.03 Physiology and 2.24 1.97 2.13 N S Anatomy : .82 i 1.22 i 1.01 ' ' Heredity/ 1.93 1.61 1.79 N S Environment 1 .82 i 1.15 i .98 ' Food Intake 2.A6 2.05 2.29 Tr in Disease : .84 i 1.23 i 1.03 ° Nutrition and 2.11 1.61 1.90 * Drug Therapy 1 .86 i 1.13 i 1.01 Abnormal Data for 2.AA 1.87 2.21 ** Diet Changes 1 .84 i 1.19 i 1.03 Research 2.00 1.89 1.96 N S Findings 1 1.06 i 1.16 i 1.10 ’ ° Goals of Health 2.61 2.13 2.A1 * Team Members : .83 i 1.26 i 1.05 Manages 2.17 1.97 2.09 N 3 Resources : 1.00 i 1.20 i 1.09 ' ' Processes 2.A1 2.18 2.32 N S Affecting Food 1 .86 i 1.25 i 1.04 ' ° 134 TABLE 25.--Continued. I Utilizes knowl- M.D.'s 1 Sglgctgd Total Signifg I edge of Nominated Randomlyz M.D. s icance 2.19 1.87 2.05 Food Laws 1 .93 i 1.19 i 1.05 N.S. 2.26 2.05 2.17 Food Service i .9“ i 1.23 i 1.07 N.S. Assuring Patient's +2.83 + 3.28 + 3.3? Tr' Satisfaction — ' — ° — ' Number of 54 38 92 Respondents lBy dietitian during interview. 2From American Medical Directory. *‘K‘ * 3Based on F—test value: P g 0.01; 0.01 < P 530.05; Tr. 0.05 P 0.10; N.S. = non—significant. “Average of the following responses: 3 = Very Impor- tant; 2 = Somewhat Important; 1 = Of Little Importance. 5Standard deviation. 135 goals of health team", and "understands effects of food processing". The least important were "manages resources", "knows food laws", "applies research findings", "modifies food intake in disease", and "understands heredity and environmental factors". Physicians nominated by dietitians rated the compe- tences "uses communication skills", "understands goals of health team", "obtains diet history", "applies abnormal data to diet changes",and "modifies food intake in disease" more important than physicians randomly selected. Competences and Use of Diet Therapy The use of diet therapy by the physicians as a part of total patient care seemed to be related to several of the competences which physicians rated for dietitians (Table 27). Significant differences were noted for "nutrient recommenda- tions", "food composition", "communications", "heredity and environmental factors", "food intake in disease", "goals of health team", and "effects of food processing". In all cases physicians who used diet therapy routinely rated the compe- tences as more important than physicians who did not use diet therapy. The physicians who sometimes used diet therapy usually rated the competences higher than those who routinely used diet therapy, except for "communication", "food intake in disease", and "manages resources". 136 TABLE 27.--Importance ratings by physicians of "ideal" die- titian's competences in relationship to physi- cians' use of diet therapy as part of total Utilizes Knowl- edge of Yes patient care ;— __ Uses Diet Therapy Sometimes No Significancel Nutrient Recommendations Food Composition Socio-Economic Status Diet History Communications Physiology and Anatomy Heredity/ Environment Food Intake in Disease Nutrition and Drug Therapy Abnormal Data for Diet Changes Research Findings Goals of Health Team Members Resource Management Processes Affecting Food 2.8 -3 2.8 .3 2.5 -5 2.5 .5 2.8 .4 |+ I-I- l-I- |+ |+ 2.3 .7 2.0 .7 2.6 .6 |+ |+ |+ 2.1 .8 2.4 .6 I+ |+ 2.2 -9 2.6 .7 I+ I+ |+ oo |+ Numerical Rating of Importance2 3 3.00 2.22 83 .00 1.30 2 3.00 2.00 9 .00 1.22 5 2.75 2.22 9 .50 1.30 9 2.50 2.11 5 .58 1.36 2 2.50 2.11 9 .58 1.27 8 3.00 2.11 4 .00 1.27 0 2.50 1.33 6 1.00 1.12 5 2.50 1.78 7 .58 1.09 2 2.25 1.1414 1 .50 1.13 7 2.75 1.89 8 .50 1.45 6 2.25 1.56 7 .50 1.01 8 2.75 2.00 l .50 1.22 0 2.25 1.56 8 .96 1.13 9 3.00 1.44 8 .82 1.13 96* ** *‘II' ** Tr. Tr. Tr. ** 137 TABLE 27.--Continued. Utilizes knowl- Uses Diet Therapy; 1 edge of Yes Sometimes No Significance 2.32 2.25 1.67 N.S. Food Laws 1 .81 .95 1.12 2.45 2.50 1.67 * Food Service i .79 .58 1.22 Assuring 2.76 2,75 1.56 ** Patient 5 + 56 50 l [42 Satisfaction — ' ° ° Number of Respondents 66 4 9 1 *x * Based on F-test value: P i 0.01; 0.01 < P i 0.05; Tr. 0.05 < P :_0.10; N.S. = non-significant. 2Average of the following responses: 3 = Very Impor- tant; 2 = Somewhat Important; 1 = Of Little Importance. 3Standard deviation. 138 Competences and Diet Order Changes The method preferred for changing the patient's diet order after admission did not reflect the physician's rating of competences important for "ideal" dietitians who would participate as the physician had indicated. The two excep- tions included "obtains diet history", which is rated most important by physicians who feel the doctor should order the diet, with modifications by the dietitian. The lowest rat- ing of importance was by the group of physicians who felt that the doctor should order the diet after consulting with the dietitian. Physicians who felt diet orders should be made by the doctor with no interaction with the dietitian rated the competence "manages resources" highest of all groups; lowest was the group who stated that dietitians should be consulted prior to the physicians' ordering a change in diet. Physicians' Comments In addition to objective sections of the questionnaire, 35 physicians provided additional comments. The following comments summarize comments made by physicians. Dietitians must be aggressive, involved and encour- aging in their institutions. I feel today's dietitian is nothing more than a high class cook. The future dietitian will be more of a chemist and physiologist. Instead of using terms such as carbohydrate, fat, protein, it will be nec- essary to be more specific in use of such terms as amino acids, linolenic acid, fructose and sucrose. 139 I feel that the more opportunity the dietitian has to work with the individual patient, the more influence that good diet will have on con- structive patient management. Dietitians should practice more common sense. I regularly invite the hospital dietitians to take part in weekly clinical conferences where all aspects of cancer patient care is reviewed. The dietitians make good use of and contribute well to this conference. Dietitians should be available for clinical rounds and should be a part of all teaching rounds as well. Good communications among all members of the therapeutic team is vital. We need further work on standardization of diet nomenclature. Dietitians should, above all else, see to it that food is prepared and served in a palatable fashion. Too few dietitians seem to understand what the doctor is trying to achieve. There should be more clinical orientation so that the dietitians can intelligently review a chart. I feel the dietitian is an important member of the health team with much to contribute in con- sultation with other team members in delivering nutritional therapy and maintenance. Discussion and Summary The stated purposes of this research were: to determine the present and ideal role of hospital die- titians; to determine skills and competences which dietitians need to function as a contributing health team member; and 140 3. to elucidate characteristics of successful dietitians who contribute to care of the patient. The following discussion is presented on the premise that the above stated purposes are not separate entities and unrelated to each other. Identifying general and specific roles of hospital dietitians helps to determine competences that are needed by dietitians to fulfill these roles and responsibilities. Elucidating characteristics of dieti- tians who are successful contributors to health team care of patients may suggest other characteristics, in addition to skills and competences, which may be important for dieti— tians on the health team. Roles of Hospital Dietitians Disagreement between present and ideal roles was evi- dent when five groups of participants were asked to describe the function of the dietary department in Phase I. Not only did the groups of hospital administrators, chiefs of staff, directors of nursing, dietary department heads, and dietitians view the ideal function differently, but present function was also conflicting. Hospital administrators were most optimistic in their description of the dietary depart- ment being at a decision-making level on the health team; chiefs of staff were least optimistic. The low percentage of chiefs of staff who felt that dietary departments should be at a decision-making level possibly reflects the 141 physician's typical reaction of not wanting to relinquish authority. It may further exemplify his present opinion of the limited contributions a dietary department makes to the care of the patient; or it may be the chiefs' of staff genuine lack of information about the potential contribution of the dietitian. Chiefs of staff may not be representative of all physicians, but the authority of their position may influence contributions a dietary department would be allowed to make by determining hospital dietary policies. The directors' of nursing enthusiastic support of greater participation by the dietary department in health team decision-making contradicted observation by Burling £2.21: 1 The of conflict between the nursing and dietary staff. director of nursing may visualize an increased participa- tion of the dietary department in decision-making as a change in hospital policy which could enhance the level of responsibility in her area of nursing. Since the question- naire asked about the dietary department rather than the dietitian, implications for the dietitian's role in decision- making are limited to the extent to which dietitians represent to other team members the dietary department; in most hospitals, dietitians are the primary professional spokesmen to other health professions for the dietary department, even if they are not heads of the departments. lBurling gt EL. op. cit. 142 Dietitians stated conflict between the actual and ideal role of the dietary department to such an extent that one specu- lates that their individual present roles contradicted their perception of an ideal role for a dietitian. In Phase I dietitians differentiated between responsi- bilities which required their unique competences and those which should be performed by someone else. Generally die~ titians felt that therapeutic activities such as determining dietary histories should be performed by them; administra- tive activities such as supervising tray service should be performed by someone else. In Phase II, dietitians rated several responsibilities which they performed and which they felt they should perform. There were certain responsibilities which, with little doubt, belonged to the dietitian, according to both dietitians in Phase II and chiefs of staff from Phase I. These duties include writing menus with patients, determining food likes, and instructing patients; these were presently being per— formed by the dietitian. The high contribution by dieti- tians to making decisions for diet instruction reinforces the fact that diet instruction is apparently a responsibil— ity that has been delegated to the dietitian. Physicians' comments in Phase II also emphasize the function of dietary instruction for dietitians. Some duties, which the dietitians are and feel they should be doing, but were not listed in the chief's of 143 staff questionnaire, are visiting patients, calculating special diets, and consulting the nurse regarding dietary problems. There were several duties for which dietitians in Phase II felt they should be more responsible than they are presently: supervising food preparation, attending ward rounds, prescribing special diets, attending medical conferences, following patients upon release from the hospital, making decisions on the health team, preparing dietary histories, writing the dietary manual, charting dietary progress, and consulting the physician. Except for the first responsibility listed, these duties are patient—oriented. Their perceptions of the physicians' assignment of these duties suggest that physicians are not as enthusiastic in assigning these duties to dietitians as dietitians think they should be, especially for duties related directly to patient care. However, evaluation of job assignments by chiefs of staff in Phase I showed that chiefs of staff assigned these duties to dietitians, except for attending ward rounds and charting dietary progress, much more frequently than what dietitians believed they would. Frequently the chief of staff did not assign the responsibility to the "dietitian alone", but involved the dietitian with other health personnel in fulfilling the responsibility. Carroll noted that status cannot be demanded; it must be earned by performance, and dietitians, 144 members of a young profession compared to professions of law, theology, and medicine, are often impatient for recog- nition.1 General agreement on how diets should be ordered was noted among chiefs of staff, and dietitians in Phase I, in that both groups of respondents felt the doctor should make the diet order, subsequent to consultation with the dieti- tian. Physicians in Phase II most often stated that diet order changes should be made by the physician with modifi- cations made by the "ideal" dietitian. The next preference was that diet order changes be made by dietitians. Dietitians easily and readily nominated physicians whom they described as having a positive attitude towards dietitians' contribution to health team care. However, physicians whom dietitians perceived as having negative attitudes were few. Hesitation may be attributed to: l) the dietitian's not wishing to be negative; 2) there were not many physicians with negative attitudes towards dieti— tians; or 3) lack of contact with the vast majority of physicians. As a consequence, the dietitian would not know many of the physicians on the staff well enough to identify their attitudes towards dietitians participating on the health team. ls. 0. Carroll, 1959, Status of dietitians in the hospital, J. Amer. Dietet. Assoc., 35:1027-1031. 145 Dietitians selected three groups of physicians most frequently: general practitioners, general surgeons, and internal medicine specialists; however, these were also the most frequently occurring M.D.'s in the random list. The few physicians receiving negative nominations were fre- quently those whose specialty, such as allergy or colon and rectal disease, may reflect unappetizing diets which these physicians often ordered for treatment in their specialty. Patients may have expressed dissatisfaction to the physician, who projected negative feelings towards the dietitian. Competences Needed by Dietitians In Phase II dietitians rated themselves highly pro- ficient in "diet history", "nutrient recommendations", "interview", "food attitudes", "food intake", "technical operations", "food standards", and "food composition". Importance of competences for dietitians on the health team was highest for the above competences excluding "technical operations" and "food standards", and including the addi- tional competences of an "understanding of dietary modifi- cations during illness", and "knowledge of social and cultural factors". Physicians rated the following competences most impor— tant for the "ideal" dietitian: "utilizes food composition knowledge", "utilizes nutrient recommendations", "assures 146 the patient's satisfaction", "uses communication skills", "understands goals of health team", and "understands effects of food processing". Different procedures preferred by physicians in order- ing diets did not reflect different ratings of competences. A factor which made a difference on physicians' rating of competences was whether physicians had been nominated by the dietitian or selected randomly. Frequently competences were rated of higher importance by nominated physicians than by those selected randomly. In addition, physicians who routinely used diet therapy rated several competences higher- in importance than those who did not routinely use diet therapy. The previous experience of dietitians in Phase II sup- ports the actuality of a general education combining both administrative and therapeutic dietetics, since most dieti- tians not in their first position had dual work experience. This was cited as an advantage of general education for dietitiansl although Mayer questioned how a dietitian can be both a generalist and specialist with specialized services to offer.2 lC. Florencio and D. Cederquist, 9p. ci 2J. Mayer, op, cit. 147 Characteristics of Successful Dietitians Who Contribute to Decision-Making on the Health Team The outstanding characteristic of the six most success— ful dietitians as measured by contribution of dietitians to decision-making in certain activities on the health team was that four of the six dietitians had qualified or were pres- ently qualifying for ADA membership by the three year pre- planned experience program. Perhaps these dietitians have felt need to "prove" themselves, since prestige is usually placed on the dietetic internship. The supervising dieti- tians in the case of these four dietitians might have been influential in developing the dietitians' abilities to contribute on the health team. A third alternative would be that the dietitian must have had endurance and a strong desire to be an ADA member by completing the three-year program. There was great variation in ages, number of continuing education hours attained, and previous work experience. It was hypothesized that there would be distinct dif- ferences in personality characteristics between the success- ful group and the remaining dietitians. Ross stated that dietitians must be educated for: adaptability, flexibility, creativity, self-reliance, resourcefulness, steadfastness to human values, inter— cultural understanding, and a concern for the common good. 1M. L. Ross, 1970, The long view, J. Amer. Dietet. Assoc., 56:295-298. 148 However, no sharp differences were noted in any of the eighteen personality characteristics. One of the limitations of this study was that hospital policies unique to one hospital might restrict the dieti- tian's activities. Without altering her personal character- istics, a dietitian might contribute either more or less to decision-making on the health team if she were in another hospital. Supportive of this is that two of the 11 hospitals in Phase II each had two of the six dietitians who were most successful in contributing to decision-making on the health team. One of these hospitals allowed dietitians to provide routine dietary instructions without a physician's order; two of the four dietitians from this hospital were most con- tributing to decision-making for dietary instruction. Specific policies which might influence the dietitian's contribution in other hospitals with "successful" dieti- tians were not identified. The doctors' willingness, at least on paper, to relin» quish some authority to dietitians in prescribing diet changes raises the question of what conditions would be necessary before this would occur in actuality since compe— tences of the "ideal" dietitian were not significantly diff ferent among groups of physicians who suggested different levels of participation by the dietitian. CHAPTER V SUMMARY, CONCLUSIONS, AND RECOMMENDATIONS Because of rising demands in health delivery systems, all health professionals have been challenged to evaluate their contributions and determine how utilization of all health professions can be most efficient and effective. A facet of this challenge for the dietetic profession is to determine the contribution hospital dietitians make to the health team care of the patient. Although an ideal role has often been suggested in which interaction among the die- titian, physician, nurse, and other health professionals occurs frequently and freely with an exchange of ideas, the ideal role is rarely actuated. As Darley noted, the rank and file physicians and hospitals have apparently not been convinced of the contributions health workers could make if given more authority or included in the total health serv- ices given by the physician to the patient.1 For the above reasons, this study was conducted to determine the present and ideal role of hospital dietitians; to elucidate characteristics of successful dietitians who 1Darley, op, cit. 149 150 contribute to health care of the patient; and to determine skills and competences which the dietitians need to function as a contributing health team member. The first phase included an evaluation of the actual and ideal function of the dietary department by hospital administrators, chiefs of staff, directors of nursing, dietary department heads, and dietitians. Chiefs of staff and dietitians further evaluated specific roles and respon- sibilities of hospital dietitians. The second phase included an interview with dietitians from selected hospitals to evaluate the influence dietitians' had on the health care team in relation to personal back- ground characteristics. Dietitians were also asked specific questions about their educational preparation. Physicians were contacted by a questionnaire to determine their feel- ings about decision—making delegated to the dietitian and competences which dietitians need. Conclusions Based on responses given by participants, the following conclusions are related to the three stated objectives of this study. 151 Present and Ideal Role of Hospital Dietitians The present and ideal functions of the dietary depart- ment were viewed differently by the administrators, chiefs of staff, directors of nursing, dietary depart— ment heads, and dietitians. Administrators were most optimistic in their description of the dietary depart- ment as a decision-maker on the health team; chiefs of staff were least optimistic. All groups, except chiefs of staff endorsed the idea that the dietary department should be at a decision-making level. Dietitians felt they should perform patient—oriented activities such as determining patient dietary histories and not kitchen Operations such as supervising food preparation. Responsibilities established as belonging to the dieti- tian include writing menus with patients, determining food likes, instructing patients, visiting patients, calculating special diets, and consulting the nurse regarding dietary problems. Responsibilities for which the dietitian feels she should become more involved include attending ward rounds, preSCribing special diets, attending medical conferences, following patients on special diets after release from the hospital, making decisions on the health team, preparing dietary histories, writing the 152 diet manual, charting dietary progress, writing special diets, and consulting with the physician. Chiefs of staff felt dietitians should supervise food preparation and tray service, record dietary progress, and prepare dietary histories more than they do. Die— titians and doctors should instruct patients regarding their diet, and dietitians, doctors, and nurses should attend interdepartmental conferences and prepare the dietary manual together. Given the conditions of an "ideal" dietitian, physi— cians most often siad they felt diet changes should be made by physicians, with modification by the dietitian. Competences Needed by Health Team Dietitians Competences rated most important by the physician for the "ideal" dietitian include knowledge of food compo- sition, nutrient recommendations, assuring patient's satisfaction, communication, goals of health team, and knowledge of effects of food processing. Dietitians rated themselves highly proficient in knowl- ledge of obtaining diet history and interviews, nutrient recommendations, food attitudes, food intake, technical operations of the kitchen, food standards, and food composition. All of the above competences were rated important for dietitians on the health team except for 153 technical operations and food standards. Additional competences include an understanding of dietary modifi- cations during illness and social and cultural factors. Dietitians felt there was inadequate integration of theory and application, especially in nutrition and diet therapy. Dietitians felt inadequately prepared in the specific areas of diet therapy and communication skills; they felt that more medical and biological sciences and social and behavioral sciences were necessary. There was a definite polarity between the importance of courses for therapeutic specialists and administrative specialists. Dietitians in Phase II felt that dieti- tians do not need to be equally trained in both admin- istrative and therapeutic dietetics. Although hospital administrators felt dietitians should have more administrative courses, they believed that hospital dietetics of the future would have more empha- sis on therapeutic dietetics. Characteristics of Dietitians Who Contribute to Decision-Making on the Health Team Of the four activities in which dietitians' contribu- tions to decision-making on the health team were measured, contribution to dietary instruction was much 154 greater than ordering diets at admission, ordering diet changes, and attending medical rounds. Neither age, number of continuing education hours, nor distinct differences in personality characteristics seemed to be related to the contribution made by dieti- tians to health team care, measured by the Health Team Contribution Index. Four of the six most successful dietitians had or were presently participating in a three year supervised program in contrast to two dietitians who had a dietetic internship. Four of the six had worked in both administrative and therapeutic dietetics.. Recommendations The following recommendations are based on conclusions of this study. Integration among the three objectives is reflected in relating dietitians' roles and characteristics of successful health team dietitians to competences needed by dietitians who function as contributing members of the health team. Present and Ideal Role of HOSpital Dietitians Disagreement among health personnel's descriptions of present and ideal roles of hospital dietary departments and dietitians is evidence of a need for better 155 understanding of the contribution dietetics could make at present and in the future. Utilizing dietitians' comments and suggestions from the literature, clarification of the roles of dietitians and dietary departments should occur during the profes- sional's formal education. Ideally, students from several fields, including dietetics, would together participate in identifying the contributions of their specialties. In addition to clarifying the function of dietitians, this procedure might instill better coopera- tion among health team members. The ideal role of the dietary department suggests goals for the dietetic program. Most professionals felt dietary departments should be at a decision-making level on the health team. Dietetic curricula should provide appropriate education so that dietitians can be leaders in their departments. Since physicians were especially reluctant to describe the ideal dietary department as a contributing decision- maker to health team care, special attention could be given to the "art of delegation" in medical schools. Dietitians' education should prepare them to perform responsibilities well, assuming the responsibilities require their professional expertise. Present respon- sibilities which she feels she should do include: 156 writing menus with patients; determining food likes; instructing patients; visiting patients; calculating special diets; and consulting the nurse regarding patients' dietary problems. In addition to present responsibilities, dietetic cur- ricula should emphasize duties which the dietitian feels she should do, but presently does not. These include: following-up patients with special diets upon release from the hospital; making decisions on the health team; preparing dietary histories; writing the diet manual, charting dietary progress, writing special diets, and consulting with the physician. This recommendation assumes that, if a dietitian can demonstrate great com- petences, she may achieve the recognition that she seeks. Competences Needed by Health Team Dietitians Specific competences which have been rated as important for dietitians by physicians and dietitians and should be emphasized in a dietetic curriculum include: knowl- edge of food composition; knowledge of nutrient recom- mendations; ability to assure patient's satisfaction; communication skills; knowledge of health team goals; knowledge of effects of processing on food; ability to obtain dietary histories and interviews; understanding food attitudes, and making needed changes in food intake. 157 Emphasis should be given to competences in which dieti- tians are not as proficient as they should be to con- tribute to the health team. These include understanding relationships between disease and structure, knowledge of nutrient intake in illness and health, socio-economic considerations, physiology, anatomy, and relationship between nutrients and drugs. Based on dietitians' comments the dietetic program should integrate formal classroom instruction with practical experience rather than following the tradi- tional plan of four years of didactics followed by a fifth year of experience in the internship. Diet therapy should occur earlier in the curriculum so that greater integration with subsequent courses is possible. Two areas of knowledge should be more emphasized in the program. Diet therapy should be more comprehensive, with greater inclusion of disease and its relationship to diet. The second area, deveIOpment of communication skills, is very important but presently lacking. Oppor- tunity to practice the learned skill could occur in other classes or in suitable settings during field expe— rience. Communication skills should enable dietitians to communicate with many groups of people, including employees and physicians. Communication skills should also enhance teaching skills. 158 Dietitians' evaluations of their education and the demands of their present positions suggest that the following areas of preparation should form the basis of the program for hospital dietitians, primarily in the area of therapeutics. A. Experiences which contribute to an understanding of the physical and biological sciences. The purposes of such preparation would be to provide dietitians with an understanding of basic principles which can be related to nutrition and food. Courses providing such understandings include: inor- ganic and organic chemistry, biochemistry, physiology, and anatomy. B. Experiences which contribute to an understanding of the social and behavioral sciences. The purposes of such background would be to provide dietitians with an understanding of basic principles of these sciences which can be related to dietary needs such as trying to understand the patient as a whole individual, trying to establish rapport with the patient, and teaching. Further, ability to motivate other people and effect changes might be useful in establishing better relations with other health profes- sionals. 159 Courses providing such background may be titled: com- munication, psychology, sociology, education-~including adult education. C. Experiences which provide the dietitians with strong competences in understanding nutritional needs of the healthy and the ill. Provided with an understanding of physical, biological, and social sciences, dietitians should be able to inte— grate all facets of individual's social and physiologi— cal needs into a comprehensive program of dietary care. High competences in this area should also encourage greater self-confidence when working with the patient and physician. Courses providing such understanding are often titled: human nutrition, diet therapy, patterns of food selec— tion, food composition, cultural and social aspects of food, and readings and research in nutrition and diet therapy. The area of pharmacology would aid the dieti— tian in understanding interaction between nutrients and drugs, and knowledge of normal and abnormal physiological levels would help the dietitian understand needs of the patient. D. Experiences which provide the dietitian with an acquaintance of technical kitchen operations. 160 This background would enable the therapeutic dietitian to understand administrative components of the dietary department. A course providing such background is an introductory course to food service systems. E. Experiences which provide the dietitian with ability to manage people, time, money, and other resources. Such experiences would allow the dietitian to assume a leadership role either among her colleagues, subordi- nates such as dietary technicians, the entire dietary department, or even at higher administrative levels in the hospital. Areas dealing with this aspect include: personnel man- agement, economics, management of resources, business, cost analysis and systems analysis. F. Experiences which contribute to an understanding of the unique contributions dietitians make to the health team and contributions made by other health team members. Such experience might lead to implementation of COOpera- tion and sharing among health team members. Experiences might include common "core" courses, per- haps involving the physical, biological, and sociologi- cal courses. In addition, student health teams should 161 practice together, so that each can observe the other and clarify the contribution of each profession. Characteristics of Dietitians Who Contribute to Decision-Making on the Health Team 1. The small contribution dietitians make in ordering admission diets, ordering diet changes, and participat- ing in medical rounds reinforces the need for providing more team work during student preparation and providing dietitians with competences and self—confidence to con- tribute at a decision-making level on the health team. 2. A standardized personality evaluation could be developed to provide useful information in counseling and selection of prospective dietitians on the basis of profiles established by successful dietitians. 3. Since the extent of contribution to decision-making on the health team was not apparently related to personal characteristics investigated in this study, pursuit of other factors, such as role relationships, is recom— mended. Reflections Upon reviewing this study, several thoughts emerge which require reflection. Although not based on the research data, these ideas were gained during the process of 162 designing the study, developing the instruments, and col— lecting data. The first cognition is whether dietitians want to change their roles, or is it easier and less disruptive to maintain their status quo. In addition, if roles change, what adjustments would dietitians personally need to make, aside from the many other alterations that would need to occur externally to dietitians. Or is it assumed that die- titians have already the competences and motivation needed and are waiting to capture any opportunity directed to enhancing their status on the health team. Another consideration should be given to the reality of trying to create a new role for dietitians through a restructured program. When she graduates, what happens if the role for which she was trained does not exist? Does she become frustrated and ultimately leave hospital dietetics? This becomes another justification for health fields to coOperate in clarifying health team roles. Clarification should occur among the working professions as well as among students in health careers. In considering frustration of dietitians, the relation- ship between the beginning dietitian and her supervising dietitian may reflect conflict in the high number of con- tinuing education hours the head or only dietitians had accumulated in contrast to the fewer hours the staff dietitians had. This might be a reflection of the head 163 dietitians' aggressiveness, initiative, and enthusiasm for self-improvement in a professional sense; on the other hand, this differential may indicate increased opportunities and flexibility the head dietitian has to attend conventions and other meetings which provide continuing education hours. In identifying the dietitians' present and ideal role on the health team, one is faced with the issue of how much decision-making should be allowed. Should the dietitian ideally have jurisdiction over the patient's diet order? In developing the questionnaire for the physicians, review of the instrument with physicians showed that the decision could not be only the dietitians'. She could contribute at many levels-—from little contribution to actually making the order--but all contribution was subject to the physician's approval. If team effort and not complete decision-making by the dietitian is the goal for health care, then dieti— tians should work in the team framework, and not feel that their status is not high enough until they have complete jurisdiction in such areas as ordering diets. A similar case can be constructed for diet instruction. The highest level of decision-making would be that the die- titian determines the extent of diet instruction and pro- ceeds accordingly, without the physician's specific consent. Frequently dietitians who instruct routinely without initi— ation from the doctor glibly provide dietary instructions without checking with the doctor to see which medical goals 164 should be incorporated into the diet instruction, consulting with a social worker to determine social and economic needs of the patient, or the nurse to define dietary needs in relation to nursing goals. In this instance, the dietitian may be high in decision-making but has not contributed or received from team effort and COOperation. In interviewing dietitians, the researcher was very impressed by extreme differences in dietitians. There was variety in age, previous work experience, the way ADA membership had been gained, educational background and marital status. Surely a "typical" dietitian could not be defined. One concern noted was that there is some very good talent among dietitians who have a bachelor's degree in a dietetic program, but who have not completed ADA requirements of qualifying experience. These dietitians, although fre- quently doing the same work as ADA dietitians and identified by administrators as dietitians, are on a different pay scale. In addition ADA makes it difficult for these dieti- tians to complete the qualifying experience. This situation may result eventually in a loss of excellent talent if these dietitians become discouraged, unless the American Dietetic Association provides support to exploration of new channels for meeting the experience qualification. 165 Suggestions for Future Research This study was initiated to evaluate present and ideal needs of hospital dietitians for the purpose of developing a dietetic curriculum. Suggestions for future research include: 1. Determining the physician's concept of "ideal" dieti- tian. Determining whether physicians would actually allow the authority they indicate on paper, if dietitians met their "ideal" definition. Establishing norms which would be useful in counseling and selection of dietitians by administering the Cali- fornia Psychological Inventory to a larger sample of dietitians. Determining who is most influential in defining the die—' titian's role in the hospital. Elucidating relationships of dietitians with other allied health workers such as nurses or medical tech- nologists. Evaluating which duties of a dietitian can be delegated to someone else so that the dietitian's time is available for maximum utilization. LITERATURE CITED American Dietetic Association. Annual Reports and Proceed- ings, 1969—1970. Chicago: The American Dietetic Association. American Dietetic Association. 1965. Duties and responsi- bilities in the department of dietetics. J. Amer. Dietet. Assoc. 46:179-182. American Dietetic Association. 1962. 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Smith. 1970. Public health and community medicine for the allied medical professions. Baltimore: Williams and Wilkins Co. 166 167 Carroll, S. C. 1959. Status of dietitians in the hospital. J. Amer. Dietet. Assoc. 35:1027-1031. Christman, L. 1970. Education of the health team. J. Amer. Med. Assoc. 213:284-285. Coggeshall, L. T. 1967. Planning for medical progress through education. Evanston, Illinois: Assoc. of Amer. Medical Colleges. Cooper, J. A. D. 1970. Health manpower crisis--challenge and response. North Carolina Med. J. 31:219—222. Council on Foods and Nutrition. 1963. Nutrition teaching I” in medical schools. J. Amer. Med. Assoc. 183:955. ..-e—';4‘ --' 44— Darley, W. 1969. Allied health personnel and their employ- ‘ ment for the improvement of medical care. New England E; J. Medicine. 281:443-445. 1; -., a. Deasy, L. C. 1964. Social role theory: its component parts and some applications. Washington, D.C.: The Catholic Univ. of America Press. Di Laura, A. 1965. 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The dietitian's role in "heads up" patient care. J. Amer. Dietet. Assoc. 56:299-302. Greenfield, H. I. 1968. Manpower problems in the allied health field. J. Amer. Med. Assoc. 206:1542-1544. Hamburg, J. 1969. Core curriculum in allied health educa- tion. J. Amer. Med. Assoc. 210:111-113. Harrell, G. T. 1969. Education on a health sciences campus. Hatch, T. D. 1970. Allied health personnel: an answer to the manpower crisis. Hosp. Progress. 51:69-71. Hays, W. L. 1963. Statistics. New York: Holt, Rinehart and Winston. Hillway, T. 1964. Introduction to research. Boston: Houghton Mifflin Co. Howland, J. B. 1925. The function of the hospital dieti- tian. J. Amer. Dietet. Assoc. 1:81-82. Hughes, R. A. I. 1951. The profession studies delegation of duties. J. Amer. Dietet. Assoc. 27:634-636. James, G. 1967. Teaching community health in schools of medicine. Arch. Environ. Health. 14:713. James, G. 1969. Educational role of new health science centers in the health related professions. Ann. N.Y. Acad. Sci. 166:862-868. Johnson, D. 1964. The physician and the dietitian. Amer. Kerlinger, F. N. 1967. Foundations of behavioral research. New York: Holt, Rinehart and Winston, Inc. Kirk, R. B. 1959. The dietitian's hidden nature? J. Amer. Dietet. Assoc. 35:1055-1057. Krehl, W. A. 1969. The dietitian in the regional medical program. J. Amer. Dietet. Assoc. 55:107—111. Letourneau, C. U. 1957. Management and the profession of dietetics. J. Amer. Dietet. Assoc. 33:691-694. 169 Levy, L. 1966. Factors which facilitate or impede transfer of medical functions from physicians to para-medical personnel. J. Health and Human Behavior. 7:50-54. Lewis, I. J. 1969. Science and health care-—the political problem. New England J. Med. 281:888-896. Light, I. 1969. Development and growth of new allied health fields. J. Amer. Med. Assoc. 210:114-120. Light, I. 1970. Growth and develOpment of new allied health fields. Amer. J. Med. Tech. 36:75-83. Linton, R. 1945. The cultural background of personality. New York: Appleton-Century. MacEachern, M. T. 1925a. The hospital dietary department-- a forecast. J. Amer. Dietet. Assoc. 1:3-8. MacEachern, M. T. 1925b. The hospital dietary department. II. J. Amer. Dietet. Assoc. 1:63-72. MacEachern, M. T. 1949. Advances in dietetics from the hospital vieWpoint. J. Amer. Dietet. Assoc. 25:494- 496. Marchmont-Robinson, H. 1968. Today's challenge. Delivery of health care. J. Amer. Med. Assoc. 204:155-156. Mayer, J. 1966. Dietetics looks to the future. Post Grad- uate Medicine. 40:A97-101. McKeown, T. 1968. The complexity of the medical task. Bull. N.Y. Acad. Med. 44:83-101. Miller, G. E. 1950. Is dynamic knowledge of nutrition essential for every dietitian? J. Amer. Dietet. Assoc. 26:600-606. Miller, G. E. 1965. To be or not . . . J. Amer. Dietet. Assoc. 47:15-19. McNerney, W. J. 1970. Does America need a new health sys- tem? Univ. Mich. Med. Center. 35:82-87. Millis, J. S. 1970. The future. J. Med. Ed. 45:490-492. Moore, F. J. 1970. Information technologies and health care. 11. The need for new technologies to offset the shortage of physicians. Arch. Intern. Med. 125: 351-355. 170 Moore, N. S. 1951. Physicians and nutritionists. J. Amer. Dietet. Assoc. 27:833—837. Morgan, A. F. 1939. The dietitian's place in the hospital research program. J. Amer. Dietet. Assoc. 15:853- 859. Myers, M. 1950. Is the dietitian adequately prepared to teach? J. Amer. Dietet. Assoc. 26:663—667. National Roster of Scientific and Specialized Personnel: Medical Professions. 1947. U.S. employment service description of professions. Series Pamphlet No. 4. Neiman, L. J. and J. W. Hughes. 1951. The problem of the concept of role: a re-survey of the literature. Social Forces. 30:141-149. Pascasio, A. 1970. Relation of allied health education to medical education. J. Amer. Med. Assoc. 213:281-282. Peabody, F. W. 1925. The function of the hospital dieti- tian. J. Amer. Dietet. Assoc. 1:82-83. Perry, J. W. 1969. Career mobility in allied health educa- tion. J. Amer. Med. Assoc. 210:107-110. Perry, J. W. 1970. Career mobility and allied health educa- tion. Amer. J. Med. Tech. 36:33-43. Piper, G. M. 1970. Dietetic manpower trends in education and training. J. Amer. Dietet. Assoc. 57:225-228. Points, T. C. 1970. Guidelines for development of new health occupations. J. Amer. Med. Assoc. 213:1169- 1171. Pragoff, H. 1948. Areas of cooperation between medical social workers and dietitians. J. Amer. Dietet. Assoc. 24:485-490. Ramphal, M. 1968. Needed: A career ladder in nursing. Amer. J. Nurs. 68:1234-1237. Reznikoff, P. 1939. The relation of the dietitian to the physician in modern medical practice. J. Amer. Dietet. Assoc. 15:537-539. Robinson, 0. H. and F. T. Proudfit. 1949. Development of positive food therapy. J. Amer. Dietet. Assoc. 25: 497-503. 171 Ross, A., Jr. 1967. An administrator looks at the depart- ment of dietetics. J. Amer. Dietet. Assoc. 50:26-31. Ross, M. L. 1970. The long view. J. Amer. Dietet. Assoc. 56:295-298. Sadow, S. E. 1941. Coordinating the dietitian's work with related community activities. J. Amer. Dietet. Assoc. 17:321-328. Seeman, M. and J. W. Evans. 1961. Stratification and hos- pital care: II. The objective criteria of perfor- mance. Amer. Sociological Rev. 26:193-203. Shank, R. A. 1966. Nutrition education in schools of medi— cine. Amer. J. Pub. Health. 56:929-933. Shetland, M. L. 1970. This I believe about career ladders, new careers, and nursing education. Nursing Outlook. 18:32-35. Silver, G. A. 1958. Beyond general practice: the health A team. Yale J. Biology and Medicine. 31:29-39. Siscoe, D. L. 1931. The doctor seeks the aid of the dieti- tian. J. Amer. Dietet. Assoc. 7:119-134. Somers, A. R. 1968. Some suggested principles for commun- ity health planning and for the role of the teaching hospital. J. Med. Ed. 43:479-494. Stead, E. A., Jr. 1968. The birth of a new educational venture--the association of schools of allied health professions. Medical Times. 96:99. Steele, R. G. D. and J. H. Torrie. 1960. Principles and procedures of statistics. New York: McGraw-Hill Book Company, Inc. Strauss, A. E. 1928. The dietitian and the out-patient. J. Amer. Dietet. Assoc. 3:243-247. Szasz, G. 1969. Interprofessional education in the health sciences. Milbank Mem. Fund Quarterly. 47:449-475. Szasz, G. 1970. Education for the health team. Canad. J. Pub. Health. 61:386-390. Thomas, J. W. 1970. Health manpower shortages: need for nonphysician professionals. Univ. Mich. Med. Center. 35:101-103. 172 U.S. Department of Health, Education, and Welfare. Health Manpower Source Book 21. 1970. Bethesda, Maryland: Public Health Service. Van Dalen, D. B. 1962. Understanding educational research. New York: McGraw—Hill Book Company, Inc. Wagner, C. J. 1967. Toward fullest utilization of our health resources. Health Office News Digest. 33:6. White, G. 1954. The patient as the focus of attention. J. Amer. Dietet. Assoc. 30:25-28. Wilder, R. 1926. The hospital nutrition expert. J. Amer. Dietet. Assoc. 1:118-127. Winkelstein, W., Jr. and F. E. French. 1970. The role of ecology in the design of the health care system. Calif. Med. 113:7—12. APPENDIX A DISCREPANCIES BETWEEN EXPECTATIONS OF PROFESSION AS AN UNDERGRADUATE AND REALITIES OF THE PROFESSION 173 mHmCOHmmomopm m.m o H.H H H.: m Ho omooHsosx oHooHH . . . wooHOHQem m H a a H H a m m Ho omoonosx oHooHH ~.mH mm H.0H 5 :.mm m m.:H mH :.m m monopm HwCOHmmomomm . . . . . some s HH mm o mH m m m H a mH mm S OH m soHsom soHs soHpaoHssasoo nsosoo son oHonsoHoeHom . . o>HoosoanHEo< m m m H m mmoH .oHpsoompoce who: . . . . oHosooososa : m :H H 0H m m H m m OH m mon .o>prmpchHEo< who: m. m :.H H m. H mompsoo oopwHoLCD o.OH mm H.0H m m.wH m m.m mH m.w : ESHSoHLLSQ OHHmHHmoHCD _ ESHSOHHLSQ ow oopmHom mocmdopomHQ R z a z w z a z u z nseHoHooHo ceHaHooHo soHoHooHo :mHoHooHo seHoHooHo Heooe ooom .oooo wsHpHsnsoo .sose .sHeoa .COHmmomopo map mo moHpHHmop pom mcoprpoooxo coospoo wchmeo noHoseoosonHo--.< xHozmaaa 174 w mpomopmo nowm CH mcoHu oom up mmH mm IHpoHQ mo noncommmm proe zmowoumo comm CH mcpr omm mo mmH a: :HooHo Ho sooasz Hsooe o.m a m.a m m.m m. H H.m H oncomwom ossaoHosaH o.mm so m.om HH m.mm H.3m om 0.3m SH onsoooom oz H.mH a: w.mH MH m.HH m.mH am o.sH m HocoaoaonHo oz . . . oHoooa w m a H H m m ans pcoEm>Ho>cH who: . . . ooooooxm can» w m a H H w H moHpso o>HumpuchHE©< who: . . . . ooooooxm m m m m s m a m m H m H case sopoom ooe oxHH . . . oooooaxm can» m H m a H H m m : mpHHHoncoamom poumonw m.H a m. H 3.0 m noHoHHoa .HnsoHeoe m.s HH m.a m m.m m.m a a.o m ado; one: .nssom .HsoHom m.o mH m.mH mH a.o m aoHsHoo< HssoHnnoHoaosoz s.m s m.a m m.m w.H m H.m H nEoHoosa sooeH zocwmomomHQ oopmHom now .UmSCHpCOOIl.< xHDzmmm< APPENDIX B LETTER OF REQUEST FOR HOSPITAL INTERVIEWS 175 November 9, 1970 Mr. John Smith, Administrator Jones Memorial Hospital Escanaba, Michigan 49829 Dear Mr. Smith: As you may already know, the Department of Human Nutrition and Foods (formerly Foods and Nutrition) at Michigan State University and Michigan Hospital Association are conducting a study of the role of the hospital dietitian in the State of Michigan. We appreciated very much your hospital's par- ticipation in the first phase of our study, which included a questionnaire sent to all Michigan hospitals. The data provided a general description of the role of the hospital dietitians (Michigan Hospitals 6:2, 1970). Now we are very, interested in gaining more in-depth information of the dietitian's role and responsibility to help provide a basis for curriculum evaluation in the dietetic program. Since you have been interested enough to complete the first part - of the study, we have selected your hospital for further study. We hope to eliminate any bias in selection but yet include hospitals that would be willing to cooperate in this second phase. Since a much smaller number of hospitals have been selected to participate in this study, personal interviews will be feasible. Dietitians will also be asked to keep a day's record of communication activities. In addition I would like to discuss with some of your physicians their percep- tion of the dietitian's role. I hope that you will accept this Opportunity to help further our knowledge of the dietitian's present and future role. All information will be held confidential, and all hospitals and individuals will be assigned a code number and the data analyzed accordingly. Neither individual respondents nor hospitals will be identified in the resulting report. I would like to visit your hospital some time during Novem- ber or December, on a convenient date for you and your dietitians. If you agree to participate in the study would you please return the enclosed postcard by November 20? I will then contact you to confirm a date for my visit. Sincerely yours, Alice A. Spangler, Instructor Department of Human Nutrition and Foods Enclosure: Postcard APPENDIX C DIETITIAN'S INTERVIEW SCHEDULE 176 ROLE AND RESPONSIBILITY OF THE HOSPITAL DIETITIAN-PHASE-II We have selected your hospital for further study from hos- pitals that participated in an initial study conducted by the Department of Human Nutrition and Foods (formerly Foods and Nutrition) at Michigan State University and the Michi- gan Hospital Association to describe the role and responsi- bility of hospital dietitians. We appreciated very much your hospital's participation in Phase I of the study, which included a questionnaire sent to all hospitals in Michigan. Now we are interested in gaining in-depth knowledge about the dietitian's role on the health team to help us examine the adequacy of this aspect of the undergraduate dietetic curriculum. In addition, the information should be helpful to those with whom the dietitian comes in contact. Before we begin, I would like to mention that all of these data will reflect characteristics of dietitians as a group and not individuals. You and your hospital will be identified only by a code number. First I would like to know about your background. A. 177 (1) (2-3) (4-6) What is the title of your position in this hospital? Head administrative dietitian Administrative dietitian Head therapeutic dietitian Therapeutic dietitian Teaching dietitian Research dietitian Dietitian (Both Therapeutic and Administrative) Dietary Department Head Other (Specify) \OCI) \IQWSUOIUH What percent of your time is spent in "therapeutic" activities? What type of educational preparation has qualified you for your present position? 1. College or university degree in dietetics; or foods and nutrition; or institution administration 2. College or university degree in hotel or restaurant administration 3. College or university degree in home economics 4. Hospital food service supervisor course requiring one year or less to complete 5. Other (Specify) What is your status with regard to American Dietetic Association member- ship? 1. I am a member of ADA 2. I am eligible for membership in ADA but do not belong to ADA 3. I am not eligible for ADA member- ship How did you originally qualify for mem- bership in ADA? l. Dietetic internship 2. Advanced degree 3. Three years of supervised experience 4. Not eligible (77 (8-9) _(1o> __ __(ll-12) ‘___(13) _ ___(15) 178 What has been your highest formal education attainment? 1. 2 3 4 5. 6. 7 8 9 Attended high school, but did not graduate High school graduate Attended college, but did not graduate College graduate Dietetic internship Post-graduate courses not termi— nating in M.S. or M.A. degree M.S. or M.A. degree Graduate courses beyond Masters, but not resulting in Ph.D. Ph.D., Ed.D. How many years of professional experience have you had following the Bachelor's Degree? List the type of position chronolog- ically beginning with present position (include internship) _(l6) _ _<17-18> Years in this position _ _<19-20) Sequence of experience _<21) 179 H. Are you a registered dietitian? (22) O. No ' 1. Yes I. How many clock hours had you accumu- lated by Oct. 3, 1970? (23-24) J. How many years prior to registration (began Aug., 1969) have you been an ADA member? (25-26) Since we are looking at dietitians as a group rather than individually, we would like to know what types of contin- uing education dietitians sought prior to registration. K. Prior to Aug., 1969, did you 1. Attend meetings to increase pro- fessional skills 2. Attend classes to increase pro- fessional skills Seek self-study to increase professional skills Write for professional and lay people Present papers to professional and lay groups Read professional journals Other (Specify) UT \10\ Does dietitian seek continuing education? (27) 0. No 1. Yes Did she seek continuing educa- tion prior to registration? (28) 0. No 1. Yes L. What is your age? (29-30) M. What type of food service do you have in this hospital? (31) 180 Since we are in the process of evaluating our curriculum we are especially interested in your ideas about your work and the educational preparation which you have had. First, I would like to ask you about your work. One area which we would like to know about is the management activ- ity in which you are involved. 1. Another the day. What employees do you most work with? Which of these do you supervise? Do you evaluate employees for hiring, promotion, dismissal? If so, which employees? Who is your immediate supervisor? Does your dietary department use the computer? If yes, in what way? Are you involved with using the computer? If yes, in what way? Who is in charge of purchasing? Who is in charge of storage? Who is in charge of distribution of food? Are you involved with any of the above 3 items? If yes, in what way? What influence do you have regarding quality of food? What influence do you have regarding preparation of the food, either for regular or modified diets? What other managing aspects do you do, such as planning, organizing, controlling, evaluating in both therapeutics and administration? area of interest is what you typically do during Could you give me a time sequence shcedule of your typical day? 181 What percentage of diets are ordered for the patient at admission by the following procedures: 1. Physician orders diet with no conference with you 2. Physician orders diet after consulting with you 3. You order diet after consulting with physician and/or patient record 4. Other (Specify) INDEX I What percentage of diet changes are made following admission by the following procedures: 1. Physician changes diet order without consulting with you 2. Physician changes diet order after consulting with you 3. You change diet order after consulting with physician and/ or patient record 4. Other (Specify) INDEX II What percentage of diet instruc- tions do you give subsequent to the following procedures: 1. Physician orders diet instruc- tion without consulting with you 2. You give diet instruction after conference with physician 3. You give diet instruction routinely without request from physician 4. Other (Specify) INDEX III What percentage of the wards for which you are responsible observe the following procedures: 1. You do not attend ward rounds 2 You attend ward rounds at special request 3. You attend ward rounds routinely ___ ___ 4 Other (Specify) INDEX IV V OVERALL INDEX 182 (32-34) I (35-37) II (38-40) III (41-43) IV (44-46) V Part of this study involves learning what groups of people dietitians work with, especially physicians and the spe- cialty they are in. Are there certain physicians with whom you work more than other physicians? Which ones? What is their specialty and in what way do you work with them? Are there certain physicians with whom you do not usually work? Which ones? 183 I would also like to know how you felt about your educa- tional preparation. Did you feel the level and amount of diet therapy in your undergraduate education was sufficient? If not - what else should have been included? What areas of diet therapy from your undergraduate education have been most valuable to you? Did you feel the level and amount of diet therapy in your internship was sufficient? If not — what else should have been included? What areas of diet therapy from your internship have been of most value? Did you feel the level and amount of normal nutrition in your undergraduate education was sufficient? If not - what should have been added? What areas of normal nutrition from your undergraduate education have been of most value? Did you feel the level and amount of normal nutrition in your internship was sufficient? If not - what else should have been added? What areas of normal nutrition from your internship have been of most value? Did you feel the level and amount of cultural and socio— economic emphasis on diet planning in your undergraduate education was sufficient? If not - what else should have been included? What areas of cultural and socio-economic emphasis on diet planning have been of most value to you? Did you feel the level and amount of cultural and socio- economic emphasis on diet planning in your internship was sufficient? If not — what else should have been included? What areas of cultural and socio-economic emphasis on diet planning have been of most value to you? 184 Did you feel the level and amount of development of com- munication skills in your undergraduate education was sufficient? If not - what else should have been included? What areas of development of communication skills have been of most value to you? Did you feel the level and amount of development of com- munication skills in your internship was sufficient? If not - what else should have been included? What areas of development of communication skills have been of most value to you? Did you feel the level and amount of food composition in your undergraduate education was sufficient? If not - what else should have been included? What areas of food composition from your undergraduate education have been most valuable to you? Did you feel the level and amount of food composition in your internship was sufficient? If not - what else should have been added? What areas of food composition from your internship have been most valuable to you? What do you feel was important in your undergraduate cur- riculum? What do you feel was unimportant in your undergraduate curriculum? Was your internship necessary for effective functioning on your present work? What did you learn from the internship that was not gained in your undergraduate preparation? Was your advanced degree necessary for effective function- ing on your present work? What did you learn from this degree that was not gained in your undergraduate or in- ternship background? What would you like to see changed in the educational prep- aration of a dietitian? 185 mpoHo HmHommm mcH>HoooA mpcoprQ pom magma HmscH>HocH oquz .5. COHpmHonsQ ooom mmH>ponm . . stcws poHp omH>oH so\vcm mammosn .mm mwcHooom Home coozpon omH>Hoqsm . H 00H>pmm Mona mmH>LoQ3m .MH HmuHomoc Eopm owmoHos com: proHumn mo moOHpome MpmuoHo onHOD .mH Emop anoon :o mCOHm IHooU ManpoHp wconE CH opmaHOprmm .HH pcoHuma Ho memo: pcoHdec wchhmon ompsc omH>om Ho pHSmcoo .OH pCmemm mo homo: COHpHLpsc wcH Ipswwoh :wHonMDQ omH>©m Lo HHSmcoo .m muoHo HmHoomm oanomoLD .m moocogomcoo HooHomE pcopu< .H mosses who: pcopu< .m moOHpowLQ MLMpoHU Lo COHuHLusc meQwHo ou mucmHqu prH> MHmchsom .m mpcoHpmm mo mmopwosm MLMpoHp ppmco .z wpoHp HmHome LHonp ou opmwoh CH mucoprQ podspmcH .m mucoHumm Mame Hop MHOpan poHo m maddmpm .m moxHHch pew moxHH poem pcoHpma mcHEHopoD .H DHDODm H mmzHDE DOBHoooh mucoHme pom magma HmscH>HocH opan .om mooom poHo HmHooam no mwcH>Hmm MHHmB .mH pom: MHoch Inch uoc mpch HwHoon oumHonmo .mH APPENDIX D DIETITIAN'S RESPONSIBILITIES 187 Describe the importance of the following competences for a dietitian on the health team using the description: 1. Very important 2. Important 3. Somewhat important 4. Not important at all 1. Knows nutrient recommendations for individuals in various environments and stages of life. 2. Uses food composition knowledge in designing dietary plans. 3. Uses knowledge of socio-economic, cultural and ethnic status in designing dietary plans. 4. Recognizes uniqueness and depth of an individual's L food attitudes and habits. 1 5. Understands the individual's basic social needs, developmental processes and culturally acquired attitudes, concerns and habits. 6. Recognizes similarities and differences in family 3 groups and individual life styles in technically E developed societies. '~ 7. Understands the relationship between nutrient in- take and the biochemical and biophysical structure and function of the body at various stages of life. 8. Understands the relationship between nutrient in— take and the biochemical and biophysical structure and function of the body during illness. 9. Understands abnormalities in structure and func- tion of a diseased tissue and effects of the abnormality upon total body metabolism. 10. Identifies changes in food intake necessary for treating the disease and its complications. ll. Understands the structure, processes, functioning and interrelationship of various systems of the human body. 12. Recognizes relationships between hereditary and environmental factors in structure and regulatory functions. 13. Evaluates and interprets research findings in the sciences. l4. Understands relation between food and drugs. 15. Understands influence of previous diets on labo- ratory tests and the consequent interpretation of laboratory data. 16. Integrates biological and social sciences into comprehensive concept of human nutrition. 17. Knows different methods of patient interview and when to apply each. 18. Knows different methods of obtaining dietary his- tories, advantages and disadvantages of the methods, and usefulness of dietary histories. l9. Understands process of managing human, material and financial resources. 20. 21. 22. 23. 24. 25. 188 Understands the principles of education that are basic to effective learning by individuals and groups. Analyzes physical and chemical changes occurring in food during storage, preservation and prepara- tion in terms of food composition and quality. Knows food standards and the factors affecting food quality. Understands the technical operations (menu plan— ning, purchasing, facilities, finance) involved in the production, distribution and service of high quality food in food service systems with varying organizational structure and objectives. Knows laws, regulatory agencies and/or processes responsible for food quality and safety. Other APPENDIX E DIETITIAN'S COMPETENCES 189 Describe yourself with regard to the following competences using the description: 1. Very competent 2. Competent 3. Somewhat competent 4. Not competent at all 10. 11. 12. 13. 14. 15. 16. 17. 18. Knows nutrient recommendations for individuals in various environments and stages of life. Uses food composition knowledge in designing dietary plans. Uses knowledge of socio-economic, cultural and ethnic status in designing dietary plans. Recognizes uniqueness and depth of an individual's food attitudes and habits. Understands the individual's basic social needs, developmental processes and culturally acquired attitudes, concerns and habits. Recognizes similarities and differences in family groups and individual life styles in technically developed societies. Understands the relationship between nutrient in- take and the biochemical and biOphysical struc- ture and function of the body at various stages of life. Understands the relationship between nutrient in- take and the biochemical and biophysical struc- ture and function of the body during illness. Understands abnormalities in structure and func- tion of a diseased tissue and effects of the abnormality upon total body metabolism. Identifies changes in food intake necessary for treating the disease and its complications. Understands the structure, processes, functioning and interrelationship of various systems of the human body. Recognizes relationships between hereditary and environmental factors in structure and regulatory functions. Evaluates and interprets research findings in the sciences. Understands relation between food and drugs. Understands influence of previous diets on labo- ratory tests and the consequent interpretation of laboratory data. Integrates biological and social sciences into a comprehensive concept of human nutrition. Knows different methods of patient interview and when to apply each. Knows different methods of obtaining dietary his- tories, advantages and disadvantages of each, and usefulness of dietary histories. 19. 20. 21. 22. 23. 24. 25. 190 Understands process of managing human, material and financial resources. Understands the principles of education that are basic to effective learning by individuals and groups. Analyzes physical and chemical changes occurring in food during storage, preservation and prepara- tion in terms of food composition and quality. Knows food standards and the factors affecting food quality. Understands the technical operations (menu plan- ning, purchasing, facilities, finance) involved in the production, distribution and service of high quality food in food service systems with varying organizational structure and objectives. Knows laws, regulatory agencies and/or processes responsible for food quality and safety. Other APPENDIX F PHYSICIAN'S COVER LETTER TO QUESTIONNAIRE 191 March 8, 1971 F. William Jones, M.D. Suite 418 Medical Arts Building 1322 East Michigan Lansing, Michigan 48912 Dear Dr. Jones: We need your assistance. The Department of Food Science and Human Nutrition at Michigan State University is con- templating a revision of the dietetic curriculum to meet future health needs. TO meet this objective we have been conducting a study of the role of dietitians at Smith Memorial Hospital. Your Opinion would be very valuable in helping us define the dietitian's contribution to the delivery Of health care. In addition, your feelings re- garding the competences that are needed by a dietitian would be most helpful in our development of a new program. I realize that you have a very busy schedule, and we have made every effort to keep the information requested from you to a minimum. Other comments which you might have would also be very valuable, and I would encourage you to express these ideas on the back of the questionnaire. If you will accept this Opportunity to help increase our knowledge of the dietitian's future educational needs, will you please complete and return the enclosed form in the stamped and addressed envelope by March 15. All informa— tion will be held confidential, and individual respondents will be identified only by a code number. Thank you for your cooperation. Sincerely yours, Alice A. Spangler Instructor Food Science and Human Nutrition Enc. 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