UK Dietitians' views on Communication Skills for Behaviour Change: A 10 year follow up survey

Background In 2007, a survey of UK dietitians identified that dietitians were positive about the use of Communication Skills for Behaviour Change (CSBC) in practice but barriers to implementation of skills were acknowledged. This follow up survey aimed to explore current perceptions of CSBC and compare with the previous survey.


Introduction
Patient-centred care has been referred to as a set of skills that activate patient participation, promote shared decision making, seek patient views and opinions, and facilitate a collaborative and supportive approach to care (1)(2)(3)(4) .Patient-centred care is essential to support health related behaviour change (5) .Literature remains ambiguous on what specific communication skills are required to support patient-centred care (6)(7) , however, recently a tool designed to measure patient-centred care in dietetic practice has been developed, based on review of literature as well as patient and dietitian views (8) .Further testing is required but this tool may provide the clarity needed to support training and development ofhese skills in dietitians.A survey of United Kingdom (UK) dietitians conducted in 2007, provided insight into the communication skills for behaviour change (CSBC) dietitians deemed necessary to support patient-centred care (9) .CSBC were defined as including, but not limited to, 'skills which enable clients to make appropriate choices, express their thoughts and feelings, feel heard and understood, feel valued, respected and supported'.The survey revealed a high level of perceived importance attached to CSBC, but respondents indicated that more training to support skill development was required (9) .Pre-registration education standards and training documents reflect the importance of CSBC as a core competency requirement for dietitians (10- 11) , however individual Higher Education Institutions (HEIs) may teach these skills differently leading to variation in patient-centred care.The survey also identified barriers to applying skills in practice including lack of time to implement skills, lack of confidence in skill use, and lack of support from colleagues/management (9) , suggesting that additional support is required in the workplace.
Patient perceptions of dietetic care support the importance of CSBC and patient-centred care including the adoption of a flexible approach, to allow individual preferences to be considered (12)(13)(14)(15)(16)(17)(18)(19)(20)(21) .Lack of CSBC, contributes to patients' perceptions of lack of empathy, resulting in lower agreement on choices made and potentially contributing to poor engagement (6,(21)(22) .Dietitians' inability to support patients in making their own decisions appears to have a negative impact on shared decision making (23) , creating a power imbalance that requires addressing if patient self-care is to improve (7, . In cotrast, supportive collaborative approaches result in greater adherence (25) , enhanced self-care and improved health outcomes (25)(26)(27)(28) ).
Overall, patient views suggest that there is a range of practice, but that improvements could still be made in the delivery of patient-centred care in dietetics (16)(17) .Dietitians' awareness of their communication style and its impact on patient outcomes must therefore be enhanced, from pre-registration education (both at HEIs and on placement) and into practice.How best to support skill development remains unclear.Some evidence indicates that positive attitudes towards learning communication skills declines as student dietetic training progresses (29) but recently a study has suggested that student attitudes to experiential learning with simulated patients is more positive (30) .There have also been developments in the use of technology to support learning (31) which may impact on skill development, but more data is required to substantiate how best to deliver training to support skill enhancement.
Dietitians perceive their ability to deliver CSBC to be high (9,32) , however perceived skill can vary considerably from true proficiency (33)(34)(35)(36)(37) and may contribute to variations seen in patient outcomes (38) .Validated tools to assess CSBC are therefore required to identify skill level, support skill development and application in practice (7,39) .Cultural norms (6,40) and time constraints (7,9,(41)(42) have been highlighted as potential barriers to the implementation of CSBC in the workplace.This suggests that further training and support is required to establish and develop CSBC skills once qualified.
The literature indicates that patient-centred care remains important to dietitians and patients.Understanding of what patient-centred care means in dietetic <="" span="" style="font-family: "Times New Roman";">Where there is lack of patient-centred care there may be negative impacts on patients, and dietitians have expressed a desire for further training in CSBC to support their delivery of patient-centred care.
Since 2007 there have been many developments in policy, standards, and evidence base, all indicating the importance of improved communication skills and patient-centred approach in healthcare.It is not known how much of this has been implemented into pre-and postregistration training of dietitians or if barriers have changed.This follow up survey therefore, aimed to explore current perceptions of UK dietitians towards CSBC training and use of these skills in practice, and to ascertain if barriers to implementation of skills have changed since 2007 (9) .Identifying what barriers, if any, exist, may help direct future training in CSBC and the development of patient-centred care in practice.

Methods
This cross-sectional survey of British Dietetic Association (BDA) members utilised the questionnaire from the previous BDA members' survey completed in October 2007 (9) .The Although open questions require greater respondent effort, and not all will respond (42) , they can provide explanation for closed question responses and deeper insight into respondent views that may not otherwise be captured.

Importance of Communication Skills for Behaviour Change
Respondents were positive about the importance of CSBC with 714 (99.5%) rating them as important and no-one rating them as not important (n=3, 0.5% neutral) (12 missing data).They were positive about the importance of CSBC for undertaking an accurate assessment of the client (n=588, 95.3%) and for taking a diet history (n=539, 87.4%).
A few respondents reported that CSBC were not applicable to some parts of practice, however, the majority were positive about the impact of CSBC in many aspects including relationship with clients (n=610, 98.7%), client satisfaction (n=606, 98.7%), ability to cope with challenging clients (n=602, 97.9%), confidence with client interviews (n=588, 95.9%) and in perceiving improvements in client clinical outcomes (n=587, 95.6%) (Table 1).The least positive was 409 (66.6%) respondents believing CSBC to be important for time keeping in client interviews.There were 15 comments relating to concern with time keeping, for example, "Using communication skills for behaviour change takes significantly longer and does not fit into NHS allocated appointment times" [465].
Over 96% respondents also reported that CSBC were important for different components of consultations.These included being able to communicate at an appropriate level for individual clients (n=612, 100%), listening attentively (n=613, 100%), recognising and responding appropriately to verbal communication (n=609, 99.8%) and greeting clients appropriately whilst putting them at ease (n= 612, 99.7%).Most respondents were positive regarding their own CSBC skills, with 513 (83.6%) rating them as one or two on a five-point rating scale (i.e. one is excellent, five is very poor).No-one rated themselves as very poor, but 101 (16.5%) were less confident about their skill level, rating them as three or four.
Pre  Half of the respondents (n=318, 50.9%) stated that CSBC were more relevant to specific dietetic roles than others and 307 (49.1%) disagreed.Those who had trained <10 years ago were more likely to believe that these skills were more relevant to some roles than others (58.9%) in comparison to those who trained >10 years ago (48.9%) (χ 2 (1, n=625) =3.952, p=0.047).When asked to explain their answers, three themes were identified (56 comments).
Firstly .Thirdly, the need for constant review or refresher sessions was highlighted, with some suggesting these should be formal or mandatory, for example, "I think that it should be mandatory that updates/refreshers are undertaken every few years to ensure "competency" and sharpening of skills as it is easy to slip into bad habits.The refreshers would re-focus peoples' attention on their communication skills" [226], and "I think there should be a baseline level of skill that should be maintained permanently post registration with the option to increase skill level as job role requires but alongside support to maintain these higher level skills year on year" [55].
Respondents who stated that dietitians do not need post-registration training in CSBC were asked to explain their reasoning.Two key themes were identified (40 comments).Firstly, that it should be covered in pre-registration education, for example, "This should be part of the although facilitating objective assessment and reflection, may lead to a higher level of anxiety for some dietitians, however there is little evidence to say that video recording has a detrimental impact on consultations, with patients reporting positive attitudes if the goal is improved healthcare communication (55) .Importantly, video recording enables fidelity checking, to assess whether training received has led to the desired changes in skill use in practice  .

Strengths and Limitations
The survey targeted all BDA members and many responded, but the response rate was only 9.4%.Respondents may have been interested in CSBC, therefore biasing the sample.It was not possible, however, to make further contacts to increase response rate.Crosssectional surveys are also subject to recall bias, but they enable large numbers of people to be accessed and are relatively economical in relation to time and resource ( 42 ) .
A paper survey may have achieved a greater response, but online surveys are less costly, easier to administer, accessible, decrease time required for data entry and decrease the risk of data entry error by researchers.
Missing data may also have affected results obtained.Why some respondents failed to answer all questions is unknown, but the questionnaire took 15-20 minutes to complete, which may have caused fatigue towards the end (58) .As the aim was to repeat the previous survey, shortening the questionnaire was inappropriate.
Both authors have undertaken teaching and research in the area of CSBC which will have impacted on the interpretation of the qualitative data (59) .To reduce this, authors reviewed qualitative data independently before discussing, and reaching agreement on identified themes.Reflexivity, however, must be acknowledged.
Statistical analysis between the two surveys was not attempted due to the cross-sectional survey design and resultant differences in the survey population.However, as a proxy, comparisons were made between those qualified since the previous survey (<10 years) and those who would have been qualified when the previous survey was undertaken (>10 years ago).Comparisons, although less robust, do provide some insight into trends over the tenyear period.
This survey has only considered dietitians views and is therefore not providing a true picture of skill level or, importantly, patient views (60) .Patient views would provide greater insight into how skills should be delivered in practice and their impact on outcomes (27)(28) and further research is needed in this area.

Conclusions
This survey has identified that dietitians continue to view CSBC as important in dietetic practice.There appears to have been a shift since the previous survey with perceived ability to apply CSBC increasing, alongside reported increased in pre-registration training in CSBC.Fewer barriers to implementation of skills were identified.There is support for mandatory skill review post-registration.However, financial constraints and time barriers continue to be perceived as barriers to post-registration training.Questions regarding the best way to implement evidence-based pre-and post-registration training in CSBC remain, and cost effective, pragmatic methods that enhance dietitians' skill development in a supportive way, are required.
survey was divided into sections including demographic information, experiences of both pre-and post-registration training, views on what pre-and post-registration training should include, importance of CSBC and the impact of these skills on practice, barriers to their implementation and personal training needs.Small revisions to the original questionnaire included the creation of more pre-coded responses, based both on previous responses, and recent developments, such as web-based training packages.Most questions required tick box answers, but there were some open questions requiring respondents to write their views.
Post-registration training undertakenWhen asked about post-registration training undertaken in CSBC, 520 (74.7%) had received training, 162 (23.3%) had not and 14 (2.0%) had no recollection.Those who trained >10 years ago were significantly more likely to have had post-registration (84.1%) than those who had trained within the last 10 years (37.0%)(χ 2 (2, n=696) =141.696,p<0.001).The types of training received were predominantly attending a formal training session or course (n=497), self-directed learning (n=228), observing/shadowing colleagues (n=226), and having a consultation observed by peers with informal feedback (n=181).Fewer people had audio-/video-recorded consultations for self-reflection (n=90), consultations observed by tutors with informal feedback (n=89) or used any kind of online training programme (n=9)., 99.6%), stated they had applied some of their learning into practice and two (0.4%) said they had not (4 missing data).There was no difference between those qualified <10 years (98.8%) and those <10 years ago (100%) (Fishers exact, p=0.112).The only reason identified for being unable to implement training (n=1) was that the training undertaken did not equip the dietitian to change practice.The perceived impacts of post-registration training on practice (Table4) were positive although some respondents stated that post-registration training in CSBC was inapplicable to specific aspects of practice.Recommendations for post-registration trainingMost respondents (n=594, 93.7%) stated that post-registration training in CSBC was needed (95 missing data).Those who trained <10 years ago were significantly less likely to state that most dietitians needed post-registration (89.7%) than those who had trained >10 years ago (94.7%) (χ 2 (1, n=634) =4.274, p=0.039).A range of advanced skills and strategies were deemed appropriate for post-registration training, including motivational interviewing (MI) (n=495), cognitive behavioural strategies (CBS) (n=421) and mindfulness (n=346).Work-based learning was highly rated (n=416) and training incorporating both theory and skills (n=433) was more highly rated than either theory-based (n=58) or skills-based (n=283) learning.
[673] (Supplementary information 2, terms included and counts of skills identified).Secondly, approaches, techniques and strategies which can be used to support behaviour change were identified, such as confidence scaling, The predominant methods of teaching experienced at university were lectures, observation of a skill demonstration and role-play, including those observed by peers or tutors, with feedback (Table2).On clinical placement, teaching methods were mostly consultations with real patients, with some observations of skill demonstration.Preferences for pre-registration trainingPre-registration preferences varied (Table3).Consultations with real patients were thought more appropriate for placement (n=370, 57.7%, 88 missing data).Apart from role-play with a real patient, other methods were thought more appropriate in university, or for both settings, rather than placement only.Some respondents stated that the training methods indicated were inappropriate in either setting, most commonly role-play with a real patient (n=109, 17.4%), role-play with formal assessment (OSCE) (n=59, 9.6%), audio-recorded roleplay with playback (n=53, 8.4%) and online training packages such as DIET-COMMS (31) (n=44, 7.6%).There were 42 other highly variable comments, which included reference to using a variety of methods in both locations; for example, "Currently I think a number of techniques can be employed but practice and feedback to provide guidance is essential.Some lectures are needed to help set the scene"[264].Additionally, responses suggested ensuring that tutors are skilled before assessing students, for example, "Perhaps tutors need peer assessing in their delivery of feedback on role-play/communications skills courses?" [568], and some respondents were unaware of online training packages such as Dietitians were asked to identify, in their own words, the core communication skills that should be included in pre-registration education (558 comments).Three themes were identified.Firstly, the majority of responses related to naming specific communication skills important for building relationships with patients, such as active listening, reflections, paraphrasing, open questions and empathy, for example "Reflective listening/paraphrasing to allow build-up of rapport with the patient" , that individual training needs differ, for example, "The type of post-registration training required is dependent on the individual and the amount of training received pre- were described as so important that they should be incorporated into all post-registration training, for example, "Ibelieve that communication skills should be weaved through every aspect of post-graduate training to increase client adherence to therapeutic nutritional diets."[73] This survey was not designed to assess skills but has shown mixed views as to whether assessment of CSBC should be considered in practice or not.Although over half of respondents indicated that it should be mandatory, there were almost as many resistant to the dietetic training at university."[548] and secondly, that skills are learned on the job and by experience, rather than by going on courses, for example "Because we learn the basic skills during pre-registration and then these skills are developed through experience and practice, not formal training" [133].line with what they stated post-registration training should include) was mixed (theory with opportunities for skill practice) (n=332) as opposed to solely skills-based (n=211) or theorybased (n=52) learning.The most popular options for training delivery methods were external

Table 1 .
Importance of CSBC for different aspects of practice.

Table 2 .
Methods of teaching CSBC experienced pre-registration.

Table 3 .
Respondents' views on teaching methods to use in pre-registration education.

Table 4 .
Impact of post-registration training on practice.