Shifting the narrative and practice of assessing professionalism in dietetics education: An Australasian qualitative study.

AIM: We aimed to explore current approaches to assessing professionalism in dietetics education in Australia and New Zealand, and asked the questions what is working well and what needs to improve? METHOD: We employed a qualitative interpretive approach and conducted interviews with academic and practitioner (workplace-based) educators (total sample n = 78) with a key stake in dietetics education across Australia and New Zealand. Data were analysed using team-based, framework analysis. RESULTS: Our findings suggest significant shifts in dietetics education in the area of professionalism assessment. Professionalism assessment is embedded in formal curricula of dietetics programs and is occurring in university and placement settings. In particular, advances have been demonstrated in those programs assessing professionalism as part of the programmatic assessment. Progress has been enabled by philosophical and curricula shifts; clearer articulation and shared understandings of professionalism standards; enhanced learner agency and reduced power distance; early identification and intervention of professionalism lapses; and increased confidence and capabilities of educators. CONCLUSIONS: These findings suggest there have been considerable advances in professionalism assessment in recent years with shifts in practice in approaching professionalism through a more interpretivist lens, holistically and more student-centred. Professionalism assessment in dietetics education is a shared responsibility and requires further development and transformation to more fully embed and strengthen curricula approaches across programs. Further work should investigate strategies to build safer learning cultures and capacity for professionalism conversations and in strengthening approaches to remediation.

Proposed Changes to Nutrition Curricula in Higher Education.

Although the field of nutrition has shifted to holistic approaches to dietary health, introductory nutrition courses have primarily focused on a reductionist approach. From my perspective, there is a need for radical changes in nutrition curricula to emphasize the importance of whole foods, complex dietary behavior, and food systems that align with the progress made within the field of nutrition. This holistic perspective of food and dietary patterns can help future dietitians and those not pursuing dietetics to understand the complex realities of nutrition while also learning transferable skills, such as systems-thinking, communication, and evaluation and critique of current research.

Dual RN-RDN program: Training for the future of health and nutrition.

PURPOSE: Explore the benefits and feasibility of a dual training program for dietetics and nursing to increase nutrition in clinical practice. METHODS: A professional interest survey on the perceived value of a dual program with 222 registered nurses (RN) and registered dietitian nutritionists (RDN) and an in-depth literature review were completed. RESULTS: A majority of RNs indicated the addition of the RDN would be beneficial for supporting patients with diet-related chronic diseases and performing nutritional assessments and interventions. The RDN respondents indicated a dual program approach would also improve the ability to serve a small community or place of employment that is limited in having both a full-time RDN and RN, and rated benefits for performing more medical and laboratory procedures. The RDNs also indicated the dual program could help increase their income potential. Both dual Master's and dual Bachelor's programs were rated as valuable. Of the 18 (8%) of respondents who had both RDN and RN credentials, half indicated personal growth and interest was the incentive for pursuing the dual training; whereas half indicated professional incentives (e.g., no RDN in the area, improving specialty care, job security, lack of opportunities), The literature review indicated no studies on the efficacy of a dual RDN-RN program on health outcomes; however, studies have shown that individualized counseling from RDNs is more beneficial than general nutritional counselling from other health care providers not specifically trained in dietary assessments. Noted barriers to pursuing dual training included time and cost, and some respondents in both specialties were not interested in a dual program. DISCUSSION: These results support providing students with dual program options, although further exploration of the specific approach is warranted, particularly decreasing time-to-degree while not affecting efficacy.

Evaluating the Implementation of Evidence-based Kidney Nutrition Practice Guidelines: The AUGmeNt Study Protocol.

Evidence-based nutrition practice guidelines (EBNPGs) inform registered dietitian nutritionist (RDN) care for patients with chronic kidney disease grade 5 treated by dialysis; however, there has been little evaluation of best practices for implementing EBNPGs. In this effectiveness-implementation hybrid study with a quasi-experimental design, United States RDNs in hemodialysis clinics will document initial and follow-up nutrition care for patients with chronic kidney disease grade 5 treated by dialysis using the Academy of Nutrition and Dietetics Health Informatics Infrastructure before and after being randomly assigned to a training model: (1) EBNPG knowledge training or (2) EBNPG knowledge training plus an implementation toolkit. The aims of the study include examining congruence of RDN documentation of nutrition care with the EBNPG; describing common RDN-reported EBNPG acceptability, adoption, and adaptation issues; and determining the feasibility of estimating the impact of RDN care on nutrition-related patient outcomes. The AUGmeNt study can inform effective development and implementation of future EBNPGs. Keywords: Chronic kidney diseases; medical nutrition therapy; implementation science; clinical practice guideline; nutrition care process terminology; dietitian.

Predictors of nutrition care process knowledge and use among dietitians internationally.

BACKGROUND: The nutrition care process (NCP) and its associated standardised terminology (NCPT, referred to collectively as NCP/T) forms a problem-solving framework fundamental to dietetic practice. Global implementation would assist in confirming outcomes from dietetic care, but implementation rates have varied between countries. We investigated which factors predict NCP/T knowledge and use among dietetic professionals in an international cohort, aiming to understand how implementation can be strengthened. METHODS: The validated International NCP Implementation Survey was disseminated to dietitians in 10 countries via professional networks. Implementation, attitudes and knowledge of the NCP/T along with workplace and educational data were assessed. Independent predictive factors associated with higher NCP/T knowledge and use were identified using backward stepwise logistic regression. RESULTS: Data from 6149 respondents was used for this analysis. Enablers that were independent predictors of both high knowledge and frequent use of NCP/T were peer support, recommendation from national dietetic association and workplace requirements (all p < 0.001). Country of residence and working in clinical settings (p < 0.001) were demographic characteristics that were independent predictors of high knowledge and frequent use of NCP/T. A high knowledge score was an independent predictor of frequent NCP/T use (p = 0.002). CONCLUSIONS: Important modifiable enablers for NCP knowledge and use rely on organisational management. National dietetic organisations and key stakeholders such as employers are encouraged to integrate active NCP/T support in their leadership initiatives. This could take the form of policies, formalised and structured training strategies, and informatics initiatives for the integration in electronic health records.

The Value of Programmatic Assessment in Supporting Educators and Students to Succeed: A Qualitative Evaluation.

BACKGROUND: Programmatic assessment has been proposed as the way forward for competency-based assessment, yet there is a dearth of literature describing the implementation and evaluation of programmatic assessment approaches. OBJECTIVE: To evaluate the implementation of a programmatic assessment and explore its ability to support students and assessors. DESIGN: A qualitative evaluation of programmatic assessment was employed. PARTICIPANTS/SETTING: Interviews with graduates (n = 8) and preceptors (n = 12) together with focus groups with faculty assessors (n = 9) from the one Australian university explored experiences of the programmatic approach, role of assessment in learning, and defensibility of assessment decisions in determining competence. ANALYSIS PERFORMED: Data were analyzed into key themes using framework analysis. RESULTS: The programmatic assessment increased confidence in defensibility of assessment decisions, reduced emotional burden of assessment, increased value of assessment, and identified and remediated at-risk students earlier when philosophical and practice shifts in approaches to assessment were embraced. CONCLUSIONS: Programmatic assessment supports a holistic approach to competency development and assessment and has multiple benefits for learners and assessors.

Simulation in Learning and Using the Nutrition Care Process/Terminology: Experiences and Perceptions of Dietitians in Canada.

Purpose: To investigate experiences with, and perceptions of, simulation in learning and using the Nutrition Care Process/Terminology (NCP/T) of dietitians in Canada. Methods: In February-March 2017, a convenience sample of 382 dietitians in Canada (71.8% in clinical practice) completed an online survey regarding the type(s), setting(s), and perceptions of the simulations in which they engaged in learning and using the NCP/T. Results: A majority (76.7%) of respondents had engaged in NCP/T-related simulation, most commonly case studies (85.3%) and role-play (42.0%), as part of workplace/volunteer training (51.4%) and undergraduate internship/stage/practicum (34.2%). Nearly half (49.5%) of respondents learned all 4 NCP components via simulation, with Nutrition Diagnosis being the most common individual component (57%). Over three-quarters of respondents agreed/strongly agreed that simulation helped them better understand/use the NCP/T and that NCP/T-related knowledge/skills gained through simulation are transferable to the clinical setting/dietetic practice. Conclusions: Dietitians in Canada perceive simulation to have helped them learn and use the NCP/T. Resources should be directed at further developing simulation for teaching the NCP/T in dietetics education and training. Research investigating characteristics, barriers, and facilitators of effective NCP/T-simulation, using objective (vs. perceived) learning outcome measures is needed.

Social Justice and Dietetic Education: Are We Preparing Practitioners to Lead?

Purpose: To explore dietetic practitioners' perceptions of their education and training in the knowledge, skills, and confidence to understand social justice issues and to engage in socially just dietetic practice and social justice advocacy. Methods: An online semi-qualitative survey sent to Canadian dietitians. Results: Most respondents (n = 264; 81.5%) felt that knowledge- and skill-based learning about social justice and social justice advocacy should be a part of dietetic education and training. Reasons given by respondents for the importance of social justice learning include: client-centred care and reflexive practice, effecting change to the social and structural determinants of health, preventing dietitian burnout, and relevance of the profession. Yet, over half of respondents either strongly disagreed or disagreed that they were adequately prepared with the knowledge (n = 186; 57.4%), skills (n = 195; 60.2%), or confidence (n = 196; 60.5%) to engage in advocacy related to social justice concerns. Some questioned the practicality of adding social justice learning via additional courses to already full programs, while others proposed infusing a social justice lens across dietetic education and practice areas. Conclusions: Dietetic education and training must do more to prepare dietitians to answer calls for dietitians to engage in social justice issues through practice and advocacy.

[Apprentissage par simulation : activité novatrice de formation interprofessionnelle sur la gestion de la dysphagie].

Interprofessional patient simulations are an emerging pedagogical approach that is increasingly being used in the education of health professionals. Although the benefits of patient simulations have been widely documented in the fields of medicine and nursing, few studies have explored the potential of this approach in educating future dietitians. This article describes 4 patient simulations, including 2 interprofessional simulations, focused on the management of dysphagia, which were carried out as part of an Honours Bachelor in Nutrition Sciences program and discusses the potential merits of this teaching method in educating future dietitians.

Les simulations interprofessionnelles sont une approche pédagogique émergente de plus en plus utilisée dans la formation des professionnels de la santé. Bien que les avantages des simulations soient documentés exhaustivement dans le domaine de la médecine et des sciences infirmières, peu d'études ont exploré le potentiel de cette approche dans la formation des futurs diététistes. Cet article décrit quatre simulations, dont deux interprofessionnelles, axées sur la gestion des soins de la dysphagie qui ont été réalisées dans le cadre d'un programme de baccalauréat spécialisé en sciences de la nutrition et discute les mérites potentiels de cette approche pédagogique dans la formation des futurs diététistes.

Investigation of empathy amongst dietetic interns at selected primary and tertiary health-care facilities.

AIM: Empathy is an essential aspect in the delivery of quality nutrition care and promoting better outcomes in patients. With an increased emphasis of patient-centred care in dietetic practice, empathy should underpin the construct of the curriculum in dietetic education. The present study investigated the empathy level of dietetic interns through self-reporting measures and patients' perception. METHODS: This cross-sectional study was conducted on a total of 57 dietetic interns and 99 patients from primary and tertiary health care settings. The dietetic interns completed the Toronto Empathy Questionnaire (TEQ) while the Consultation and Relational Empathy (CARE) measure was self-administered by patients. Socio-demographic information of participants was collected. RESULTS: The dietetic interns' mean (standard deviation [SD]) TEQ scores were 46.90 ± 5.28 and 47.78 ± 5.34 in primary and tertiary care, respectively. CARE measure scores rated by patients in the primary care were 38.61 ± 8.38 and for tertiary setting, the scores were slightly higher (39.47 ± 7.65). The settings, gender, ethnicity and period of internship did not affect dietetic interns' empathy level. In primary care, CARE scores were significantly different between patients' age grouping (P = 0.007). CONCLUSIONS: Findings from the present study showed that patients' age significantly affected their perception of dietetic interns' empathy in primary health care. These preliminary findings could facilitate an understanding of the level of empathy amongst interns for consideration in the future design of dietetic training.

Extending the Reach of Hospital-Based Nutrition: A Registered Dietitian Nutritionist's Perspective on the Malnutrition Quality Improvement Initiative and Improving Patient Recovery.

Registered dietitian nutritionists (RDNs) at Legacy Salmon Creek Medical Center (Washington) recognized a need to use nutrition to help patients recover faster and stay independent longer. With the goal of decreasing 30-day hospital readmission rates, the RDNs at Legacy Salmon Creek developed a program for posthospital nutrition care. The intervention was a pilot program designed to provide palatable and nutritious meals to patients at home during a 4-week, postdischarge interval. The RDNs obtained approval from hospital administrators and received buy-in from nursing staff who participated in RDN-led training on malnutrition awareness and risk screening. Results of the pilot program indicated a high level of patient satisfaction and a decrease in the rate of readmissions. FUNDING/SUPPORT: Publication of this supplement was supported by Abbott. The Academy of Nutrition and Dietetics does not receive funding for the MQii. Avalere Health's work to support the MQii was funded by Abbott.

Implementing a Clinical Practice Change: Adopting the Nutrition Care Process.

The Nutrition Care Process (NCP), created by the Academy of Nutrition and Dietetics, provides a framework that encourages critical thinking and promotes uniform documentation by Registered Dietitians (RD). Additionally, it creates a link between the nutrition assessment, nutrition intervention, and the predicted or actual nutrition outcome. NCP has been integrated into a number of institutions in Canada and internationally. A committee of nonmanagement RDs at the Hospital for Sick Children led the Department of Clinical Dietetics in adopting the NCP. The committee developed and consecutively delivered a tailored education plan to 5 groups of RDs within the department. Additional resources were developed to complement the learning plan. The committee administered informal pre- and post-education surveys to measure outcomes. RDs reported receiving adequate training and felt confident implementing NCP into their practice. Adopting the NCP was well-received and RDs within the department continue to integrate it into their current practice.

The Impact of Fellowship in Dietetics on Clinical Practice.

Medical nutrition therapy (MNT) in pediatric cancer treatment is essential. The Nutrition Department and the International Outreach Program at St. Jude Children's Research Hospital in Memphis, TN have worked together from 2005 to 2013 to develop and implement a training program for international dietitians working with pediatric oncology patients. During that time, St. Jude hosted 15 dietitians from various countries for this 3-week-long program. The curriculum provided experience in nutrition risk screening, nutrition care process, nutrition for cancer prevention, palliative care, and exposure to nutrition support. Monthly online meetings were established through the Cure4Kids website to continue collaboration and training. Learning outcomes were developed, and the impact of the program was evaluated based on changes made by former fellows in clinical practice, research, management, and food service upon return to their country. In addition, the program was evaluated based on recognition by the medical team, professional growth/networking, and personal growth. The survey return rate was 100%: responses revealed that 80% of participants continued working in pediatric oncology, 67% participated in monthly meetings, 47% collaborated on research, 100% advanced their competency in clinical practice, 93% broadened their competency in research, 67% became increasingly competent in management, 60% implemented changes in food service, 100% were recognized for participating in the program, and 100 and 93% noted that participation in the fellowship program helped their professional and personal growth, respectively. The psychological impact of the training on healthcare providers was as important as the impact of the program on patient care.

Determination of Renal Nutrition Training and Education Need for Pediatric-Focused and Adult-Focused Clinicians: The North American Pediatric Renal Nutrition Education Survey (NAPRNES).

OBJECTIVE: The purpose of the study was to ascertain pediatric-focused and adult-focused renal dietitians' perspectives on need for pediatric specific training and education materials. DESIGN: This study has a descriptive, survey research design using a cross-sectional electronic survey. Subjects included North American dietitians of all ages and experience levels in either pediatric or adult-focused renal nutrition care per self-report. Inclusion criteria were access to renal listservs and/or membership within a Council on Renal Nutrition (CRN) group. METHODS: Individuals were recruited to participate in the survey via email correspondence disseminated through the pediatric renal listserv hosted by the University of Alberta, Canada, and through the NKF online list of CRN contacts. Surveys were conducted between April 14 and May 2, 2016, and between December 5, 2016 and January 9, 2017. A quantitative and qualitative survey/questionnaire was used to gather information. The main outcome measure of this study was to determine the need for pediatric specific renal nutrition training and education. RESULTS: The majority of both pediatric-focused and adult-focused renal dietitians indicated that more pediatric renal nutrition training and education materials (100% and 87.8%, respectively) than what is currently available would be at least somewhat beneficial. In addition, the survey results showed that 22.1% of adult-focused practitioners work with pediatric individuals (≤21 years) at least monthly. Those practitioners also indicated a need for pediatric training resources and education materials. CONCLUSION: More pediatric training and education resources need to be made available to meet the needs of both adult-focused and pediatric-focused dietitians to ensure optimal care of children with renal disease.

Dietetics workforce preparation and preparedness in Australia: A systematic mapping review to inform future dietetics education research.

AIM: The present study aimed to systematically map and summarise existing research regarding dietetics workforce preparation and preparedness that has been conducted in Australia. The secondary aim was to then identify gaps in the literature to inform future priority areas in Australian dietetics education research. METHODS: The databases MEDLINE, CINAHL, Embase, ERIC, Informit and PsycINFO were systematically searched from inception until July 2017 using key search terms to identify eligible studies. Extracted data were independently reviewed, and study quality was appraised by multiple researchers. Results were categorised by setting and primary focus/foci and then narratively summarised. RESULTS: Sixty-eight studies were included from 3779 records identified. Dietetics education research in Australia has spanned almost 30 years with more than half of studies (51%; 35/68) published in the last five years. The greatest proportion of research was conducted in the university setting (43%; 29/68), with students as participants (48%; 43/90) and was focused on the medical nutrition therapy area of dietetics practice (43%; 29/68). Published studies involving graduates (14%; 13/90); conducted in the workplace (12%; 8/68); and regarding emerging areas of dietetics practice (0%; 0/90) are lacking. Employment outcomes of dietetics graduates across Australia were last published over 25 years ago. CONCLUSIONS: This review provides a map for dietetics educators and researchers in Australia to guide future research regarding the preparation and preparedness of dietitians. Advancing the Australian dietetics workforce of the future will require a strategic, coordinated and collaborative approach to address the research gaps identified in this review.

Are Dietitians Documenting Malnutrition Based on Subjective Global Assessment Category?

Purpose: This study reports on dietitian use of the Nutrition Care Process Terminology (NCPT) diagnosis of malnutrition based on Subjective Global Assessment (SGA). Methods: Nutrition assessment reports for adults in medical, surgical, and cardiac units in 13 Canadian hospitals were retrospectively examined for a 6-week period in 2014. Reports with a SGA and NCPT diagnosis were included regardless of why the patient was seen by the dietitian. Results: Of the 932 nutrition assessment reports, 857 (92%) included an SGA. Based on SGA, the prevalence of mild to moderate malnutrition (SGA B) and severe malnutrition (SGA C) was 53.4% (n = 458) and 10.0% (n = 86), respectively. When categorized as severely malnourished, the most common NCPT diagnoses were "malnutrition" (n = 55, 72.4%), "inadequate oral intake" (n = 11, 14.5%), and "inadequate protein-energy intake" (n = 10,13.1%). Among those with SGA B and C, the assignment of the NCPT malnutrition diagnosis was 19.8% (n = 95). Conclusions: Dietitians play a key role in the prevention, identification, and treatment of malnutrition in the hospitalized patient and are well positioned to take a leadership role in improving its documentation. Ongoing audits, staff support, and training regarding NCPT use may improve the application of the malnutrition diagnosis. Future research examining dietitian barriers to using the malnutrition diagnosis would be valuable.

Towards Providing Culturally Aware Nutritional Care for Transgender People: Key Issues and Considerations.

Transgender people are an important group for whom access to healthcare is often problematic. Dietitians need to be aware of key issues in transgender health to provide culturally competent clinical nutritional care. This article serves as a primer, clarifying key terms and concepts, exploring the impact of stigma and discrimination on health and nutrition for people from transgender communities, and offering practical advice for nutritional and other related issues. Education for dietitians both pre- and postqualification is an important part of improving care and building skills and awareness of cultural humility. Transgender people may be at increased nutritional risk due to increased risk of cardiovascular disease, HIV, body image issues, and food insecurity. This risk profile, along with the history of trauma both outside and related to the medical community means that there is an urgent need for dietitians to develop practice tools for assessment, care, and referral to improve the nutritional status and well-being of this client group.

A Consensus Model: Shifting assessment practices in dietetics tertiary education.

AIM: The aim of this research was to evaluate a Consensus Model for competency-based assessment. METHODS: An evaluative case study was used to allow a holistic examination of a constructivist-interpretivist programmatic model of assessment. Using a modified Delphi process, the competence of all 29 students enrolled in their final year of a Master of Nutrition and Dietetics course was assessed by a panel (with expertise in competency-based assessment; industry and academic representation) from a course e-portfolio (that included the judgements of student performance made by worksite educators) and a panel interview. Data were triangulated with assessments from a capstone internship. Qualitative descriptive studies with worksite educators (focus groups n = 4, n = 5, n = 8) and students (personal interviews n = 29) explored stakeholder experiences analysed using thematic analysis. RESULTS: Panel consensus was achieved for all cases by the third-round and corroborated by internship outcomes. For 34% of students this differed to the 'interpretations' of their performance made by their worksite educator/s. Emerging qualitative themes from stakeholder data found the model: (i) supported sustainable assessment practices; (ii) shifted the power relationship between students and worksite educators and (iii) provided a fair method to assess competence. To maximise benefits, more refinement, resources and training are required. CONCLUSIONS: This research questions competency-based assessment practices based on discrete placement units and supports a constructivist-interpretivist programmatic approach where evidence across a whole course of study is considered by a panel of assessors.