It is not feasible for a provider to be expert in everything

Since I’ve always had an interest in food and nutrition, as a young nurse and student, I just assumed that all health care providers assessed nutrition. After all, we know how important it is. However, as a staff nurse in the ER and a nurse practitioner doctoral student, I learned that wasn’t true. Many providers in both arenas reported it was not the priority that medication and disease management were.

Throughout my doctorate program, I had been researching nutrition guidelines for people with HIV and AIDS. I reviewed 26 charts with a tool I developed based on the Los Angeles Dietitians’ nutritional guidelines in AIDS Care. The chart review revealed that physicians, residents, and nurse practitioners caring for those with HIV and AIDS were not assessing nutritional status according to guidelines. The guidelines report that all persons with HIV and AIDS should see a dietitian at time of diagnosis regardless of nutritional status.  This started my journey to my clinical inquiry project.

Originally, I was going to facilitate nutrition training and provide a nutrition assessment tool for nurse practitioners and physicians caring for those with HIV and AIDS. I would work with dietitians to create an easier process for patient referral and then evaluate the project for success with the tool I had used in my initial chart review.

However, the summer before I was set to implement the project, I shadowed a registered dietitian. During that time, I came to fully appreciate dietitians’ expertise. I realized such expertise was imperative to adequately assessing a patient’s nutritional status. I couldn’t just teach nurses how to do this in one training program.

At that same time, I was completing my nurse practitioner clinicals at a busy adolescent HIV clinic, and I saw firsthand that there simply wasn’t time to adequately assess patient nutrition. My original plan to turn nurses and physicians into “mini-dietitians” and expect them to do another in-depth assessment during an already tight visit no longer seemed feasible. What if we could instead have the dietitian in the clinic seeing patients at the time of the visit, which would decrease transport issues with follow-up and save the provider time and allow nutrition to be adequately assessed? Thus my project was born.

The dietitian that I had shadowed was able to convince her supervisor to allow her to come to the HIV clinic once per week to see patients. To get even more coverage, I contacted the chair of the Wayne State University Nutrition and Food Science program to see if we could have students in the clinic. The chair then put me in touch with the Dietetic Program, and they were overjoyed. The dietitian then agreed to take the students on, so they would spend three days per week seeing patients at her office and one day per week seeing HIV patients at our clinic.

Once the dietitians were in place and the provider nutrition pocket guide tool was developed, we executed the program. During each patient visit, the primary provider would ask the five nutrition assessment questions and if the patient answered “yes” to one or more, he or she was to see the dietitian who was already at the clinic. In the event that a patient wouldn’t see the dietitian, the provider was to assess the patient’s personal beliefs related to nutrition to determine barriers, but this never happened.

All patients seen during the study period who met criteria saw the dietitian. Patients seen in the clinic reported they enjoyed talking to the dietitian and appreciated learning about the importance of food choices. Poor nutrition is associated with an increased risk of death in people with HIV and AIDS; patients seen during this study potentially have a decreased risk of morbidity and mortality.  Ultimately this study helped save lives.

It was also an exercise in team-based care. The dietitian enjoyed being able to interact with both the providers and patients in the clinic and was able to discuss patient care plans directly with the providers versus trying to call or email them. The project also benefited the dietitian students because they were able to get experience working with HIV, which is lacking in their program, while learning how to work alongside other health care providers as part of a team – an experience any trainee needs in primary care. The fact that 100% of patients meeting criteria chose to see the dietitian proved for me the benefit of having services at the point of care and that an integrated approach to primary care is crucial. It is not feasible for an individual provider to be expert in everything, but rather we must build teams and rely on the expertise of each member.

Patrice Wade is a nurse practitioner who blogs at Primary Care Progress.

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