Critical Perspectives in Clinical Nutrition Practice

Abstract

The aim of this chapter is to familiarize readers with forms of power including power over and being powered over, to outline how these may be present in clinical nutrition practice, and to suggest possible actions to disrupt forms of power that negatively affect client-centeredness.

Appendices

Assignment

At ward rounds, a nurse asks you (the clinical dietitian) how compliant one of the patients is with their low-sodium diet prescription. Outline and describe the forms of power imbedded in this statement. Describe actions one might take in this situation.

A surgeon who is a member of a large multigenerational family of physicians who have worked for decades at the hospital (a wing is named after them) writes an order for a dietitian to see a patient before discharge for a weight-loss diet. The person for whom the consultation was ordered is surprised when they meet you, not knowing that the surgeon thought their weight was an issue. Outline and describe the forms of power imbedded in this statement. Describe actions one might take in this situation.

Your friend, a fellow intern/practicum student, came to you with concerns about an incident that deeply troubled her. She had been working that day with the outpatient dietitian. A trans woman, Susan, came in for information about transitioning and redistribution of body fat. The dietitian insisted on using the ‘he’ pronoun and using her legal name, David. The intern was seeking your help to deconstruct what happened as she could not figure out why she felt so upset. Outline and describe the forms of power imbedded in this statement. Describe actions one might take in this situation.

Definitions of Keywords and Terms

Forms of power:

Forms of power refer to the many ways that power is a factor in social relationships. These include one’s position within an organization; historical contribution(s) (of oneself or one’s family members); expertise or authority; serving as a funding decision-maker (deciding who or what projects get funded and by how much); determining who has decision-making authority (including who has a voice, to what voices to attend, and how messages will be conveyed); one’s personal or one’s group’s physical force or strength; gender; wealth; recognition and notoriety; and positional power (e.g., the teacher/student relationship) (Wartenberg 1991).

Post-oppositional perspective:

Ways of working and engaging that move beyond being in opposition, that is, working collaboratively rather than counter to whomever or whatever one considers as the antagonist. Working from a post-oppositional perspective, one embraces interconnectivity and creates conditions for fruitful dialogues toward transformational possibilities. One considers political, ethical, social, spiritual, intellectual, and pedagogical dimensions of issues. Keating (2013) declared that post-oppositionality “calls for and enacts innovative, radically inclusionary ways of reading, teaching, and communicating”.

To be powered over:

To be subject to the forms of power that another person or organization holds and wields.

To have power over:

To exercise one’s power over another or a group in a social relationship.

How This Chapter Addresses the Critical Dietetic Framework

The Critical Dietetics Framework is addressed in this chapter through the naming and discussion of forms of power that are inherent in all human communications and social situations including those occurring in clinical nutrition practice. Integrating the concepts of power over and being powered over, in addition to inviting consideration of a post-oppositional perspective, disrupts the view that clinical nutrition practice involved only a simple, clear-cut identification of a client’s nutritional needs, the provision of meals and snacks consistent with these needs, and the making of nutrition information available so that people are able to feed themselves according to their diet prescriptions once in their own homes. Instead, the chapter was prepared to enhance awareness of the complex social environments and relationships extant in clinical practice settings, and that forms of power, a dietitian’s own and those of others, influence all that happens in that work environment. Developing an understanding of what these relationships are and how they benefit some and not others may help clinical dietitians to recognize and explain the challenges they have encountered in learning how to contribute effectively to client care and the provision of clinical services.

The values grounding the chapter were client-centeredness, post-oppositionality, and the importance of relationship-building among clients, families, and health services personnel to recognize and address power differentials in the interest of client-identified optimal outcomes. To be relevant and appropriate, nutrition care planning is the coalescing of the experiences, preferences, and declared needs of clients and families with nutrition and medical standards of care. Socially just clinical nutrition practice is enhanced when the voices of all participants in clinical practice settings are heard, valued, and respected. The collective can collaborate to ensure that clinical nutrition services unquestionably benefit those for whom the services are intended. This requires some people to have a voice or a stronger voice and for others to recognize that for socially just needs to be met, the power they have held will redistribute.