Factors influencing the self-efficacy of registered dietitian nutritionists working with clients with eating disorders: A mixed methods study

Eating disorders (EDs) are a multifaceted and very serious mental illness that requires treatment from mental health professionals, physicians, and registered dietitian nutritionists (RDNs). Prior research indicates difficulty treating this population due to apprehension, limited resources, and lack of knowledge related to mental health concerns. Specifically with RDNs, research indicates frustration, poor knowledge of counseling techniques, role limitations, and feeling unprepared to treat a client with ED. Limited research is available regarding the self-efficacy of RDNs when working with a client with an eating disorder. The purpose of this study was to explore factors that may influence self-efficacy when treating a client with an eating disorder to determine targeting training for this area of practice.

A mixed methods approach utilizing Social Cognitive Theory (SCT) was used to drive discussions for focus groups to inform the development of a national survey. A sample of 16 RDNs were recruited across the nation to participate in one of three focus group discussions conducted at the Academy of Nutrition and Dietetics (AND) Food and Nutrition Conference and Expo. A semi-structured discussion guide was used to evoke conversation regarding RDN experiences working with clients with ED. The audio recordings were transcribed and analyzed using line by line coding. Four themes emerged including: professional/behavioral capability, barriers to treatment, resources, and treatment and evaluation outcomes. Eight subthemes were present under these themes including: challenges related to client mental health issues, apprehension, blurred boundaries of practice, poor awareness of ED by other health professionals, mentor/colleague collaboration, minimal formal education, expectations of protocols, and holistic expectations. The results were used to inform the quantitative national survey.

A sample of 225 RDNs were recruited across the nation via email to participate in the online national survey to assess the same topic area using structural equation modeling (SEM). The questions used in the final SEM were grouped into the following constructs: ED education exposure, knowledge of factors influencing ED development, personal protocols (AND Standards of Professional Performance), self-efficacy with ED treatment, self-efficacy with professional roles in ED treatment, and general self-efficacy. The data were imported into SEM software for analysis in the hypothesized model. The model supported the association of personal protocols to constructs of self-efficacy and also of knowledge of factors that influence ED development to the construct of self-efficacy with professional roles in ED treatment, through mediation by general self-efficacy. General self-efficacy was also significantly associated to self-efficacy with professional roles in treatment. ED education exposure (limited to undergraduate and supervised practice/graduate level education) was not associated with either self-efficacy construct.

This study found that formal education did not impact self-efficacy in ED treatment or with professional roles in treatment. Knowledge and use of the AND Standards of Professional Performance were the greatest influential factor for self-efficacy in these two areas indicating that providing more access and awareness of guidelines by AND or other ED professional organizations may be an important target area of further research and training.