July 2, 2008
Assumptions Lead to the Devaluation of Dietitian Roles in Long-Term Care Practice Environments
By Lordly, Daphne Taper, Janette
Changing demographics in aging place new demands on dieticians related to education and subsequent employment. This study presents data from a survey illuminating dietitians' perceptions concerning the acquisition of entry-level clinical competence within a single practice setting. A purposive sample consisting of recent, employed internship graduates (n = 8) and internship supervisors (n = 6) from both long-term and active care settings completed a survey and was interviewed. While initial analysis suggested there were perceived risks and benefits associated with receiving clinical training exclusively in either of the environments, a more disturbing finding was a pervasive attitude indicating long-term care dietitian roles and training were devaluated. Thematic analysis indicated that issues related to career commitment, skill development, and philosophy of care were barriers to viewing training or working in long-term care as comparable to training or working in active care environments. Attitudes expressed were based on assumptions that could be clarified through increased education and communication, leading to a greater understanding of dietitian roles. Individual and professional efforts must be directed at creating a professional culture that fosters the valuing of all practice areas and the recognition of unique, rather than inferior, skills, knowledge, attitudes, and behaviors that support those environments. J Allied Health 2008; 37:78-81. THE AGE STRUCTURE of the population of Canada has been changing gradually over the past century. Statistical projections suggest that the percentage of older Canadians will reach 27% by 2031.1 An aging population has many social implications, including a tremendous impact on the health care system and the nutrition services it provides.2 Similar data from the United States indicate an expected doubling of the population age 65 years or older by 2030.3 As the population of North America ages, the need for dietitians to work with this segment of the population is increasing.A need for increased internship placements for clinical training of dietetic students has led to the exploration of long-term care (LTC) settings as potential sites for such training.4
As faculty members with experience in internship and also in the area of aging, we conducted a study with professional dietitians and recent interns, now employed, to examine their perceptions of the possible risks and benefits of attaining clinical competencies through an LTC setting. The overall findings suggested that entry- level clinical competence is attainable in an LTC environment. However, a negative attitude toward dietitians trained and/or working in LTC surfaced.
Our findings provide an important, although disturbing, insight into negative attitudes among current professionals toward those working in LTC settings and toward the possible use of such settings as internship placements for the clinical training of future dietitians. They point to a need to examine and question the value we place on the elderly and those professionals who care for them. Thus, the purpose of this study was to explore the assumptions concerning the devaluation of LTC dietitians and training sites that emerged during our initial investigation.
In Canada, integrated interns complete their practical professional experience in conjunction with their undergraduate degree. A purposive sample was recruited from one such program. The sample consisted of recent, now employed, program graduates who had received clinical training in either an active care (AC) (n = 4) or an LTC (n = 4) setting and intern supervisors who currently were working in either setting (AC, n = 3; LTC, n = 3). This sampling ensured a cross section of experiences from specific practice areas would be captured. All individuals who were approached agreed to participate. Ethics approval was obtained through the University Research Ethics Board. Informed consent was provided by each participant.
Data, collected in two stages, were part of a larger mixedmethods study exploring the acquisition of entry-level clinical competence within a single practice environment.5 Respondents first completed a mailed questionnaire developed by one of the researchers that was based on Dietitians of Canada entry-level competency statements.6 These statements represent the knowledge, skill, and behavior necessary for entry-level dietetic practice and address six areas, including assessment (7 questions), planning (6 questions), implementation (4 questions), evaluation (5 questions), professional practice (9 questions), and communication (14 questions). The questionnaire was pilot tested for face and content validity by a small group of dietetic interns and revised to reflect their comments. Each competency statement was listed. Participants were asked in which environments the various Dietitians of Canada competencies could be developed and which competencies were thought to be transferable from LTC to AC and vice versa. Space was left for additional comments. A sample question is shown in Table 1.
All questionnaires that were administered were completed and returned. Subsequently, individual interviews, conducted in person or by telephone by a trained research assistant, provided an opportunity to confirm and expand on respondent questionnaire responses and to gather qualitative data regarding respondent thoughts on the acquisition of clinical skills. The tape-recorded interviews were transcribed and thematically analyzed7 with the assistance of Data Management Software QSR N6 (The Praxis Group, Calgary, AB). The questionnaire responses were manually tabulated and frequencies established. Qualitative comments collected were independently analyzed for emerging themes and collaboratively discussed to reach agreement on final coding by both the researchers and the research assistant.8 Member checking of survey comments by respondents, ongoing discussion with the researchers and the assistant, and detailed documentation of methods and interpretations both to minimize researcher bias and to provide an audit trail contributed to data trustworthiness.7,9,10
The themes that emerged in relation to the risks and benefits of receiving clinical training in either setting included issues around philosophy of care, approach to practice, attitude, working environment, depth and breadth of experience, relationships (both client and professional), practice outcomes, and employment opportunities. During this initial risk/benefit analysis, several assumptions surfaced that indicated an undervaluing of the LTC environment and LTC dietitians. Thus, a second level of thematic data analysis was completed to explore these apparent negative assumptions and is reported in this article. Themes were not predetermined; rather, they emerged from the data. Selected respondent quotes are included for illustration.
The devaluing of the LTC practice environment and dietitians appeared to be built on a number of interrelated assumptions that served to position the LTC training environment and dietitians as "less than" the AC environment and dietitians. While all interns receive a comprehensive approach to dietetic education,6 based on entry-level competency statements, complemented by a view to lifelong learning, respondents differentiated experiences by practice area. This tendency is supported by an attitude that devalues LTC. Results suggest that perhaps there is not enough cross- communication between AC dietitians and LTC dietitians for them to fully understand and appreciate what the other does in their respective positions. Career commitment, skill development, and philosophy of care emerged as themes related to the devaluation of LTC roles and are discussed in the following text.
Respondents suggested that individuals who chose to work in an LTC environment did so with a lesser level of commitment. Several quotes supported this assumption: ". . . with clinical dietitians in my experience, there's a perception that if you work in LTC, it's not a serious career choice. Like that's someone who didn't really want to work but they wanted to get out of the house might choose.""I sometimes perceive in students, they sort of like, well that's [LTC] kind of a second choice.""Some people would take a LTC position ... filling in the gap until they got what they really wanted."
The value that is placed on the experiences of AC dietitians seems to be centered on their technical skills; the value of the experiences of LTC dietitians appears to be centered on their interpersonal skills. It was suggested that AC allowed for a vast quantity of data assessment in a short period and provided more technical challenges. In comparison, LTC fostered an understanding of quality of life and provided more human psychosocial challenges. Even though LTC dietitians were acknowledged to have "maybe stronger interpersonal skills . . . greater patience . . . better skills at working on an interdisciplinary or multidisciplinary team," it was felt that the knowledge deficit on the technical aspects would be a major barrier to their employment in AC. Interestingly, respondents did not view a lack of interpersonal or social skills as a barrier to working in LTC. These results suggest there are differences in the amount of value that is placed on these respective skill sets. PHILOSOPHY OF CARE
There are diverging philosophies of care that exist between AC and LTC; AC tends to focus on immediate care based on the generation of laboratory values and facts intended on extending life, whereas LTC focuses on quality of life based on a more holistic assessment of the client. It would appear that such a holistic approach is devalued. As one individual pointed out "the philosophy of care in LTC has an emphasis on quality of life, maintenance, and a dietary emphasis on enjoyment and pleasure . . . versus being therapeutically correct." This philosophy of care may mean that the role of the dietitian is "sort of looking after ... a caregiver kind of role." Another respondent did worry though that "the danger in AC is that people could be reduced to a set of lab values and the humanity is lost." Such concerns seemed to be explained or dismissed by the fact that more "down time" in LTC allowed dietitians to focus on "extras" of patient care. Practicing within a distinct philosophy of care may contribute to assumptions about practice, both one's own and others.
These differences in career commitment, skill development, and philosophy of care ought to be viewed as appropriate and valued responses to very different work environments. Assumptions contribute to the attitudes AC and LTC dietitians share toward one another's practice. The relationship between the attitudes and the values placed on AC and LTC experiences may be cyclical in nature in that as the attitudes are formed and acted on, values are shaped and formed; as the values are shaped, attitudes develop. One respondent admitted, "stereotypes are very different than the realities in most cases. But people base things on stereotypes."
The generation and perpetuation of negative stereotypes about older adults and the aging process is well documented in Western culture.11-15 Such negative stereotypes marginalize the elderly population within our youth/younger adult-centered society.
Studies indicate that the attitudes of many students concerning older adults are consistent with negative aging stereotypes.16-18 Even with changing demographics, students training for health care professions (nursing, medicine, and social work) did not consider work with older adults to be a high priority and ranked caring for older adults as their least preferred choice of practice setting.19 Social work students have been shown to have negative attitudes toward older adults and their service providers, which negatively impact the choice of geriatric social work as a desired area of practice among undergraduate social work students.20 Kaempfer et al.21 report that dietetics students had a low knowledge about aging and neutral attitudes toward older adults. When asked which of 10 age groups they preferred to work with, respondents ranked the three oldest age groups (65 to 74 yrs, 75 to 84 yrs, 85 yrs and older) lowest.
Current undergraduate preparation may include geriatric nutrition as an elective22 with limited coverage in other applicable required courses (i.e., life cycle nutrition), representing a small proportion of overall dietetics training. Geriatric exposure within internship is not mandatory; however, students may choose such an experience. The majority of our students opt for internship in AC environments. The current positioning of geriatrics in both the undergraduate and internship programs may not foster an appreciation of this area of study as a desirable choice.
While evidence indicates that negative attitudes held by health professionals about the elderly adversely influence the quality of services provided,23 there is a lack of research describing how current professionals view their colleagues who have chosen to work with the elderly population. It is possible that negative stereotypes also carry over to this group of professionals. Worldwide, informal caregiving by family and friends is the predominant form of care to seniors as they age.11 It is possible that individuals providing care services in LTC settings are simply viewed as an extension of this informal, rather than professional, caregiving. Negative attitudes about geriatric/gerontology professionals and practice settings may mean that students will be less interested in working with older adults despite the dramatic increase in size and needs of the older population. This could have detrimental consequences for the increasing demand for professionals in this area and negatively impact the nutritional health of the elderly.
Given the pervasiveness of negative stereotypes about aging in our society, future research must be designed to focus on factors that enable individuals to overcome such stereotypes. Additional training may be a first step toward a more age-sensitive health care system either through inclusion of information on aging and exposure to geriatric/ gerontology professionals in university curricula or continuing education opportunities. Cohen et al.20 have demonstrated the positive effect of focus groups to deconstruct negative attitudes and replace them with more positive and accurate information about older adults. When students' misconceptions about older adults were confronted, they became more interested in choosing geriatric social work as a career option. Kaempfer et al.21 also suggest that more aging education in dietetics curricula could improve student attitudes. It would be hoped that aging education provided by knowledgeable and experienced professionals would help to eliminate stereotypes and increase respect for LTC professionals and the practice areas in which they work.
Although the results of this study cannot be generalized due to the small sample recruited from a single internship program, they do suggest the need to further investigate existing perceptions related to career commitment, skill development, and philosophy of care held by current practitioners. Our results may reflect the experiences, academic and internship, available through this program. However, current training is based on Dietitians of Canada accreditation standards, which are nationally applied. As dietetic professionals, we need to be cognizant that ageism, as constructed by and within our society, may shape professional opinion and bias professionals as they evaluate training programs and formulate hiring policies.
Individual and professional efforts must be directed toward creating a professional culture that fosters the valuing of all practice areas and the recognition of the development of unique, rather than inferior, skills, knowledge, attitudes, and behaviors that support those environments. Increased communication may lead to a greater understanding and appreciation of dietitian roles.
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Daphne Lordly, EdD(c), MA, PDt
Janette Taper, PhD
Dr. Lordly is Associate Professor and Dr. Taper is Professor, Department of Applied Human Nutrition, Mount Saint Vincent University, Halifax, Nova Scotia, Canada.
Received October 11, 2006; revision accepted June 28, 2007.
Address correspondence and reprint requests to: Daphne Lordly, EdD(c), MA, PDt, Department of Applied Human Nutrition, Mount Saint Vincent University, Halifax, Nova Scotia B3M 2J6, Canada. Tel 902- 457-6259; fax 902-457-6134; e-mail [email protected]
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