A comparison of patients’ and dietitians’ perceptions of patient‐centred care: A cross‐sectional survey

Abstract Aim The aim of this study was to compare patients’ and dietitians’ perceptions of patient‐centred care (PCC) in dietetic practice. Methods Participants were as follows: (a) adult patients who had attended ≥1 individual dietetic consultation with an Accredited Practicing Dietitian (APD) working in primary care; and (b) APDs with experience working in primary care. A cross‐sectional survey was undertaken using a patient‐ and dietitian‐reported inventory to measure PCC in dietetic practice. The inventory comprised of five previously validated scales: The Communication Assessment Tool; the 9‐item Shared Decision‐Making Questionnaire; the Patient‐Doctor Depth of Relationship Scale; the Schmidt Perception of Nursing Care Scale‐Seeing the Individual Patient sub‐scale; and the Person‐Centred Practice Inventory—Staff ‐Providing Holistic Care sub‐scale. Descriptive statistics were used to analyse participant characteristics and to compute total scores for the five scales. The Mann‐Whitney U test was used to compare median scores between patients and dietitians. Results One‐hundred and thirty‐three patients and 180 dietitians completed the survey. Patients reported significantly higher scores compared to dietitians for “shared decision‐making” (P = 0.004), but significantly lower scores for “providing holistic and individualized care” (P = 0.005), “knowing the patient/dietitian” (P = 0.001) and “caring patient‐dietitian relationships” (P =0.009). Conclusion This study highlighted potentially important differences between patients’ and dietitians’ perceptions of PCC and identified key aspects of dietetic care requiring practice improvements. Strategies are needed to bridge gaps between dietitians’ and patients’ perceptions and enhance PCC in dietetic practice. These findings suggest that dietitians should focus on individualizing nutrition care, gaining a holistic understanding of their patients and knowing/understanding each patient.


| INTRODUC TI ON
The concept of patient-centred care (PCC) has been topical since the 1950s and is widely recognized as an essential component of health care. 1,2 PCC refers to care that considers patients' unique values, needs and preferences and is tailored accordingly. 3,4 A number of dimensions of PCC have been described in the literature, including shared decision-making; clinician-patient relationship; personalized/individualized care; providing holistic care; and good clinicianpatient communication. [5][6][7] Patient-centred care has been associated with significant benefits for patients, particularly patients with chronic disease. [8][9][10] Benefits for patients include increased satisfaction, improved quality of life, enhanced engagement in care, improvements in biomedical markers of disease, reduced symptom burden (eg, reduced nausea, improvements in depression) and decreased healthcare utilization. 9,[11][12][13] Patients' desires for PCC have also been frequently documented. [14][15][16][17] Further, in the absence of PCC, patients have reported feeling disengaged, uncomfortable and uncertain about care plans, describe challenges with understanding the information provided and perceive care plans as unhelpful and unrealistic. 14,16,18 Considering the benefits of and patients' desires for PCC, it is important that healthcare professionals adopt these practices.
Dietitians are trained to support patients to achieve a healthy diet and lifestyle for the prevention and management of chronic disease. 19 However, findings from a systematic review of randomized controlled trials reported mixed evidence of dietitians being effective at helping patients decrease risk factors of chronic disease. 20 The review suggested there is room for improvement regarding dietitians' practices. Since patient-centred practices by health professionals have been associated with significant benefits for patients in other contexts, 9,[11][12][13] and are clearly valued by patients, [14][15][16][17] enhanced PCC in dietetics may contribute to dietitians' effectiveness in this area.
Gaining patients' feedback regarding their care experiences is essential to making meaningful improvements to health care. 1,21 However, to effectively change practice, it is important to understand the perspectives of various stakeholders and any differences in their views. 22 Thus, the aim of this study was to compare patients' and dietitians' perceptions of PCC in dietetic consultations. This understanding will help identify any discrepancies between patients' and dietitians' perceptions, and aspects of care requiring improvements, to inform the development of strategies that align care with patients' needs and expectations, which is key to providing PCC.

| Sample and setting
Participants were as follows: (a) patients who were ≥18 years, English speaking and had attended at least one individual dietetic consultation with an Accredited Practicing Dietitians (APD) working in primary care in Australia and (b) Australian APDs who self-reported previous or current experience working as a dietitian in primary care.
Six dietetic practices across Queensland (n = 3), New South Wales (n = 2) and Victoria (n = 1) participated in the recruitment of patients to complete the survey. While some practices employed multiple dietitians, other practices comprised a single dietitian working independently.

| Measures
The recently validated patient 23 and dietitian versions 24 of an inventory to measure PCC in dietetics were used in this study. The inventory was comprised of five previously validated scales, modified slightly to reflect the dietetic context (eg 'doctor' or 'nursing staff' replaced with 'dietitian').

| The Communication Assessment Tool
A 14-item self-report measure of patients' perceptions of their physicians' communication skills with a five-point response scale ranging 1 (poor) to 5 (excellent). 25 Example items include the following: (1) the dietitian greeted me in a way that made me feel comfortable; (2) treated me with respect; and (3) showed interest in my ideas about my health.

Questionnaire (patient and physician version)
A 9-item self-report measure of patients' and physicians' perceptions of shared decision-making, respectively, with a six-point response scale ranging 0 (completely disagree) to 5 (completely agree). 26,27 Example items include the following:

| The Patient-Doctor Depth of Relationship Scale
An 8-item self-report measure of patients' perceptions of the physician-patient relationship with a five-point response scale ranging 0 (disagree) to 4 (totally agree). 28 Example items include the following: (1) I know this dietitian well; (2) this dietitian knows me as a person; and (3) this dietitian really knows how I feel.

| The Seeing the Individual Patient sub-scale (from the Schmidt Perception of Nursing Care Scale)
A 5-item self-report measure of patients' perceptions of nursing staffs' provision of individualized care with a five-point response scale ranging 1 (strongly disagree) to 5 (strongly agree). 29 Example items include the following: (1) the dietitian treated me like a special person; (2) I knew my dietetic care was specifically tailored to my needs; and (3) the dietitian took time to find out more about me as a person.

| The Providing Holistic Care sub-scale (from the Person-Centred Practice Inventory-Staff)
A 3-item self-report measure or nursing staffs' perceptions of holistic care with a five-point response scale ranging 1 (strongly disagree) to 5 (strongly agree). 30  For this study, only items that had comparable results for both the patient and dietitian versions during psychometric testing 23,24 were included in analyses so that accurate comparisons could be made. For example, results from factor analysis revealed that Communication Assessment Tool (CAT) items 6, 11 and 14 loaded strongly on the communication factor in the patient sample but failed to load strongly on any component in the dietitian sample.
Therefore, these items were excluded for the purpose of this study.
A total of 29 items were included from a potential total of 39 items (for details, refer to Table 1).

| Data collection
Dietitians briefly explained the study to consecutive, eligible pa-

| Data analysis
Data were entered into Statistical Package for the Social Sciences (SPSS) version 24 (IBM, Chicago, IL, USA) and subject to data cleaning. There were no missing data for the dietitian survey, and very few missing data for the patient survey (ranging 0.7%-3.8% for each item on the inventory and 0.75%-4.5% for demographic data).
Exploratory factor analysis was performed to evaluate the factor structure of the modified 29-item inventory, and Cronbach's alpha (criteria ≥0.70) was computed to evaluate the internal consistency of each scale. 31 Descriptive statistics were analysed using absolute (numbers) and relative (%) frequencies of the total scores for each of the five scales, and to evaluate the distribution of the data (ie, skewness and kurtosis). Using the Shapiro-Wilk test, 32 continuous variables (participants' age, years' practice experience, hours worked per week and scale scores) were non-normally distributed and therefore analysed using median and interquartile range (IQR).
Total scores were computed for each scale of the inventory. The Mann-Whitney U test was used to determine whether there were differences in the median scores between patients and dietitians (ie, whether one group had values higher than the other). 33 Differences between patients and dietitians were considered statistically significant at or below P < 0.05. There were statistically significant differences between patients and dietitians on each scale in the inventory, except for "patientdietitian communication" (Table 2). Patients reported significantly higher median scores compared to dietitians for "shared decisionmaking," but significantly lower scores for "providing holistic and individualized care," "knowing the patient/dietitian" and "caring patient-dietitian relationships" (Table 2). Despite these statistically significant differences, scores were relatively high across all scales for both groups.

| D ISCUSS I ON
To our knowledge, this study is the first to compare patients' and dietitians' perceptions of PCC in dietetic practice. We have gained an initial understanding of differences between patients' and dietitians' perceptions. These findings suggest that work is needed to address these discrepancies to ensure care is aligned with patients' needs and expectations.
It is important to note that the Mann-Whitney U test can detect differences in spread even when the differences in median values are small. 35  to influence the extent to which patients and dietitians know and understand one another. The patient-health professional relationship is an integral component of PCC. 5 Further, the importance of positive patient-dietitian relationships has been emphasized by patients 36,41 and referred to by international dietetic professional standards. [38][39][40] Clearly, it is important to consider strategies for dietitians to foster 100% = high patient involvement). Further, findings from a recent qualitative study indicate that patients sometimes perceive dietitians as being dictatorial and controlling the encounter, inhibiting patients' participation in decision-making. 36 It is important to note that patients have traditionally been "passive" recipients of care, with healthcare professionals assuming the "expert" role. 44 Therefore, if patients have limited experience with being actively involved in care, their expectations regarding their level of involvement may be low, 44 and this may partly explain patients' high overall ratings in this study. However, it is also possible that the group of dietitians whom patients were referring to were particularly skilled in shared decision-making practices, and/or that patients' subjective ratings of dietitians shared decision-making behaviours were more "generous" than observational data.
There are several factors that may influence dietitians' perceptions of their shared decision-making practices. In a qualitative study exploring dietitians' salient beliefs regarding shared decisionmaking, dietitians perceived that time constraints, disapproval from physicians and patient factors (eg, patients' personalities, motivation, level of understanding) were barriers to engaging patients in shared decision-making. 45 These barriers were also identified in an observational study using the OPTION scale; dietitians' likelihood of adopting shared decision-making was influenced by the patient's health condition, lifestyle habits and having insufficient time. 42 It is also possible that dietitians' attitudes towards shared decisionmaking influenced their responses; dietitians have previously described potential disadvantages of presenting options to patients, such as making patients feel less secure and increasing dietitians' feelings of incompetence. 45 Further, dietitians do not always agree with the importance of recognizing patients' as experts in their own nutrition care. 46 It is possible that discrepancies between patients' and dietitians' perceptions were influenced by differences in the group of dietitians who responded to the survey, and the group of dietitians whom patients were evaluating. We recommend that future research sample dyads of patients and dietitians whereby they both complete the survey individually following the consultation. This would allow individual dietitians to better understand their own strengths and weaknesses regarding their PCC practices. It could also help dietitians to develop their own practice improvement goals and establish practical strategies, perhaps with input from mentors/peers, as to how they can advance their skills in specific areas. If this was performed across several sites/dietetic practices, it would also be possible to combine the results to highlight areas that are consistent "weaknesses" across different practices and signal opportunities for group education/quality improvement.

| S TRENG TH S AND LIMITATI ON S
A strength of this study is the use of valid and reliable patientand dietitian-reported inventories. Further, the anonymous, selfadministered nature of the survey was designed to reduce response bias and maximize honesty, and both surveys were able to be completed at a time most convenient to participants, without the influence of others. To reduce the risk of dietitians distributing patient surveys selectively (eg, giving surveys to patients who would provide a desirable assessment), dietitians were instructed to invite consecutive patients, and it was clearly communicated to practices that individual dietitians would not be identifiable. However, we were unable to directly prevent or monitor this and therefore cannot say it did not occur. It is important to note that while patients were asked to rate the dietetic consultation in which they received the survey, dietitians rated their delivery of care in general and therefore may have been referring to any number of consultation experiences. This is not a direct comparison; patients may be referring to dietitians other than those who responded to the survey (ie, the sample of dietitians may or may not include the pool of dietitians whom recruited patients/ patients were reflecting on).
Finally, due to the violation of assumptions (eg, non-normality of continuous data, even after data transformation), we were unable to employ a robust method such as regression analysis to explore characteristics that might influence participants' scores. This may be an important gap for future research to address.

| PR AC TI CE/RE S E ARCH IMPLI C ATI ON S
It is important that dietitians are made aware of these survey results along with suggestions on how to ensure patients' and dietitians' perceptions and experiences are aligned. Communicating these findings may stimulate dietitians' self-reflection and awareness regarding their PCC practices, providing an initial step to bridge any gaps between dietitians' and patients' perceptions. After all, a patientcentred healthcare professional should be self-reflective. 5 These findings could be incorporated into workshops and online webinars for continued professional development, including audio or video learning tools; and in presentations/in services, particularly to those practices who participated in this study.
There is potential for the inventory to be used as a tool to stimulate dialogue between patients and dietitians regarding their perceptions of and preferences for PCC. For example, the inventory could be modified and used as a "checklist" of actions/behaviours.
Dietitians and patients could then consider and discuss the importance of these actions/behaviours at the beginning of the consultation. This would provide dietitians and patients with a better understanding of one another's needs and preferences.
Establishing a shared understanding at the beginning of the con- were significantly lower compared to dietitians for "providing holistic and individualized care," "knowing the patient/dietitian" and "caring patient-dietitian relationships." Finally, these findings may promote self-reflection and awareness regarding PCC practices, and provide an initial step to bridge gaps between dietitians' and patients' perceptions.

ACK N OWLED G EM ENTS
The authors wish to thank all individuals who assisted with the distribution of the surveys, and the patient and dietitian participants for taking the time to complete the survey and share their views.

CO N FLI C T O F I NTE R E S T
None.

E TH I C A L A PPROVA L
The approval was obtained from the institution's Human Research