Pilot study of an innovative model for clinical education in dietetics

Aim: To pilot and evaluate a new model of clinical dietetics education to address the sustainability of dietetic placements in the clinical setting.

Methods: Final-year dietetics students (n = 14) completed all nine weeks of clinical placement in the pilot program at two large tertiary referral and teaching health services in metropolitan Melbourne. Staff and students completed surveys about their experience within a week of completing placement. Data collected included paid and unpaid staff working hours, hours in clinical and teaching activity, hours of student attendance and student clinical work hours. Data for the last month of the placement programs in the preceding three years were used for comparison with the pilot program.

Results: Combined data for the two providers showed that the model reduced the amount of supervision hours per student hour on placement by 16% while maintaining quality indicators during the pilot compared with previous years. Students in the pilot program were more positive about their experience compared with students in the existing program. The overall trend of responses in the staff surveys was positive for the pilot program, but the trend was not as marked as that of student responses.

Conclusion: The new model of clinical dietetics education was successfully piloted and demonstrated the potential to increase student training capacity without a negative impact on student achievement or major resource demands. Refinements to the model and opportunities to enhance integration into the dietetics degree program were identified during the project. The learning needs of non-English-speaking background students require further scrutiny.

Development and validation of an expedited 10g protein counter (EP-10) for dietary protein intake quantification

Precise protein quantification is essential in clinical dietetics, particularly in the management of renal, burn and malnourished patients. The EP-10 was developed to expedite the estimation of dietary protein for nutritional assessment and recommendation. The main objective of this study was to compare the validity and efficacy of the EP-10 with the American Dietetic Association’s “Exchange List for Meal Planning” (ADA-7g) in quantifying dietary protein intake, against computerised nutrient analysis (CNA). Protein intake of 197 food records kept by healthy adult subjects in Singapore was determined thrice using three different methods – (1) EP-10, (2) ADA-7g and (3) CNA using SERVE program (Version 4.0). Assessments using the EP-10 and ADA-7g were performed by two assessors in a blind crossover manner while a third assessor performed the CNA. All assessors were blind to each other’s results. Time taken to assess a subsample (n=165) using the EP-10 and ADA-7g was also recorded. Mean difference in protein intake quantification when compared to the CNA was statistically non-significant for the EP-10 (1.4 ± 16.3 g, P = .239) and statistically significant for the ADA-7g (-2.2 ± 15.6 g, P = .046). Both the EP-10 and ADA-7g had clinically acceptable agreement with the CNA as determined via Bland-Altman plots, although it was found that EP-10 had a tendency to overestimate with protein intakes above 150 g. The EP-10 required significantly less time for protein intake quantification than the ADA-7g (mean time of 65 ± 36 seconds vs. 111 ± 40 seconds, P < .001). The EP-10 and ADA-7g are valid clinical tools for protein intake quantification in an Asian context, with EP-10 being more time efficient. However, a dietician’s discretion is needed when the EP-10 is used on protein intakes above 150g.

Using expedited 10g protein counter (EP-10) for meal planning

Precise protein quantification and recommendation is essential in clinical dietetics, particularly in the management of individuals with chronic kidney disease, malnutrition, burns, wounds, pressure ulcers, and those in active sports. The Expedited 10g Protein Counter (EP-10) was developed to simplify the quantification of dietary protein for assessment and recommendation of protein intake.1 Instead of using separate protein exchanges for different food groups to quantify the dietary protein intake of an individual, every exchange in the EP-10 accounts for an exchange each of 3g non-protein-rich food and 7g protein-rich food (Table 1). The EP-10 was recently validated and published in the Journal of Renal Nutrition recently.1 This study demonstrated that using the EP-10 for dietary protein intake quantification had clinically acceptable validity and reliability when compared with the conventional 7g protein exchange while requiring less time.2 In clinical practice, the use of efficient, accurate and practical methods to facilitate assessment and treatment plans is important. The EP-10 can be easily implemented in the nutrition assessment and recommendation for a patient in the clinical setting. This patient education tool was adapted from materials printed in the Journal of Renal Nutrition.1 The tool may be used as presented or adapted to assist patients to achieve their recommended daily protein intake.

Productivity and time use during occupational therapy and nutrition/dietetics clinical education : a cohort study

Background: Currently in the Australian higher education sector higher productivity from allied health clinical education placements are a contested issue. This paper will report results of a study that investigated output changes associated with occupational therapy and nutrition/dietetics clinical education placements in Queensland, Australia. Supervisors’ and students’ time use during placements and how this changes for supervisors compared to when students are not present in the workplace is also presented. Methodology/Principal Findings: A cohort design was used with students from four Queensland universities, and their supervisors employed by Queensland Health. There was an increasing trend in the number of occasions of service delivered when the students were present, and a statistically significant increase in the daily mean length of occasions of service delivered during the placement compared to pre-placement levels. For project-based placements that were not directly involved in patient care, supervisors’ project activity time decreased during placements, with students undertaking considerably more time in project activities. Conclusions/Significance: A novel method for estimating productivity and time use changes during clinical education programs for allied health disciplines has been applied. During clinical education placements there was a net increase in outputs, suggesting supervisors engage in longer consultations with patients for the purpose of training students, while maintaining patient numbers. Other activities are reduced. This paper is the first time these data have been shown and form a good basis for future assessments of the economic impact of student placements for allied health disciplines.

A problem-based approach to clinical education in dietetics

Developing the clinical skills and knowledge of dietetic students provides a challenge for both universities and health care agencies. Deakin University has recently adopted a group learning model using problem-based learning to deliver the clinical component of the Master of Nutrition and Dietetics course. This approach was designed to enhance integration of clinical theory and practice, develop closer links between on-campus and off-campus learning environments and provide students with more active learning experiences. The impact of the new approach was evaluated using student questionnaires, academic and competency outcomes, and a focus group convened with hospital supervisors. The evaluation indicated that students generally thought that this method of learning had helped to integrate their basic knowledge with dietetic case management. There was no difference in academic scores from the previous year and an apparent reduction in the number of students requiring additional placement time to mee t competency standards. Hospital supervisors were supportive of the changes, although they had some reservations regarding the time and structure of clinical placements. As a result of this evaluation, recommendations for future development of the program include introducing problem-based learning to students earlier in their course, providing additional placement days during the block and increasing the amount of time dedicated to more complex topics. Based on the evaluation results obtained, this collaborative learning using a problem-based approach will continue to be used in the clinical education program at Deakin University.

Innovative model for clinical education in dietetics

Aim: Professional practice placement programs in dietetics face a number of challenges in respect of quantity, quality and sustainability. The aim of the present study is to report on the development of an innovative placement model based on a variety of training and supervision approaches to address these aforementioned challenges.

Methods: The model was developed following an investigation of existing practice and the literature with approaches that were identified as important to the requirements and constraints of dietetics clinical training incorporated into the model.

Results: Although one-on-one supervision is the predominant approach in Australian dietetic education, the educational literature and the authors' experience showed that a variety of approaches are represented in some form. The model developed involves the pairing of two students with one supervisor with students changing peer partners and supervisors every three weeks during the nine-week placement to diversify exposure to working and learning styles. The model integrates four customised approaches: incremental exposure to tasks; use of a clinical reasoning framework to help structure student understanding of the methods and judgements involved in patient care; structured enquiry in group discussions; and peer observation and feedback.

Conclusions: The model has potential to achieve efficiencies in supervisors' involvement by coordinating the skill development activities of students as a group and promoting peer-assisted learning.

Pushing cultural competence boundaries in nutrition and dietetics training

A health workforce ready for safe practice is a government priority, and particularly critical to support indigenous communities closing ‘the gap’. Increased pressure exists on dietetic training programs for quality placements, with fewer opportunities for immersion in Aboriginal and Torres Strait Islander communities to demonstrate cultural competence. In 2012, Queensland University of Technology established a partnership with Apunipima Cape York Health Council with 56 weeks of dietetic placement for 8 students provided to achieve these aims. Clinical practice in Community Public Health Nutrition (CPHN) was structured in a standard 6 week placement, with Individual Case Management (ICM) and Foodservice Management (FSM) integrated across 8 weeks (4 each), with an additional 2 weeks ICM prior in a metropolitan indigenous health service. Students transitioned from urban to rural then remote sites, with new web-based technologies used for support. Strong learning opportunities were provided, with CPHN projects in antenatal and child health, FSM on standardisation of procedures in a 22 bed health facility, and ICM exposing students to a variety of cases via hospital in/outpatients, general clinics and remote community outreach. Supervisor focus group evaluation was positive, with CPHN and FSM enhancing capacity of service. Student focus group evaluation revealed placements exceeded expectations, with rating high, and strong confidence in cultural competence described. Students debriefed final and third year cohorts on their experiences, with increased awareness and enthusiasm for work with indigenous communities indicated by groups. With the success of this partnership, placements are continuing 2013, and new boundaries in dietetic training established.

Chemotherapy-induced nausea and vomiting: A narrative review to inform dietetics practice

Chemotherapy-induced nausea and vomiting (CINV) are common nutrition-impact symptoms experienced by cancer patients. They exert a detrimental effect on dietary intake, risk of malnutrition and quality of life. While CINV are primarily managed with medication, dietitians play an important role in the management of CINV-related complications such as reduced dietary intake. This review discusses the burden of nausea and vomiting which cancer patients can experience, including its effect on quality of life, nutrition status, and treatment outcomes. Implications for dietetic practice include the need to explore the nature of reported symptoms, identify predisposing risk factors, and to consider the use of a variety of interventions that are individualised to the patient’s symptoms. There are little clinical data regarding effective dietetic interventions for nausea and vomiting. In summary, this review discusses dietetic-related issues surrounding CINV including the pathophysiology, risk factors, prevalence, and both pharmacological and dietetic treatment options.

Nutrition during noninvasive ventilation: clinical determinants and key practical recommendations

Malnutrition and poor nutritional intake have been identified as key issues associated with poorer clinical outcomes in chronic obstructive pulmonary disease (COPD) patients. There is strong evidence showing nutritional support is effective in treating malnutrition in stable COPD, but there is only limited research regarding nutritional status in patients treated with noninvasive ventilation (NIV). The impact of NIV during acute exacerbations of respiratory disease on nutritional status requires further investigation.

Complementarity of Subjective Global Assessment (SGA) and Nutritional Risk Screening 2002 (NRS 2002) for predicting poor clinical outcomes in hospitalized patients

Background & aims: We evaluated the ability of Nutritional Risk Screening 2002 (NRS 2002) and Subjective Global Assessment (SGA) to predict malnutrition related to poor clinical outcomes. Methods: We assessed 705 patients at a public university hospital within 48 h of admission. Logistic regression and number needed to screen (NNS) were calculated to test the complementarity between the tools and their ability to predict very long length of hospital stay (VLLOS), complications, and death. Results: Of the patients screened, 27.9% were at nutritional risk (NRS+) and 38.9% were malnourished (SGA B or C). Compared to those patients not at nutritional risk, NRS+, SGA B or C patients were at increased risk for complications (p = 0.03, 0.02, and 0.003, respectively). NRS+ patients had an increased risk of death (p = 0.03), and SGA B and C patients had an increased likelihood of VLLOS (p = 0.008 and p < 0.0001, respectively). Patients who were both NRS+ and SGA C had lower estimates of NNS than patients who were NRS+ or SGA C only, though their confidence intervals did overlap. Conclusions: The concurrent application of SGA in NRS+ patients might enhance the ability to predict poor clinical outcomes in hospitalized patients in Brazil. (C) 2010 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.

Direct patient contacts of dietetic students during their final clinical placement

Direct student-patient contacts, during the professional clinical placement of a Master of Nutrition and Dietetics course, were collected and analysed for the first time using a computerised method. In the final eight-week hospital placement, 26 dietetic students submitted data on direct patient contacts which included: dietetic activities (e.g. assessing, counselling and reviewing); the primary nutritional condition of the patient (e.g. type 2 diabetes and liver disease); and the time spent in contact with patients. The most common dietetic activities were reviews, followed by collection of dietary information and counselling. The most common nutritional condition encountered by students was an inadequate nutrient intake, followed by patients receiving enteral nutrition. Contact time with patients increased over the placement, with proportionately more time spent by students seeing patients independently than when being observed by supervising dietitians. The data collected provided valuable informa tion on the amount of time spent by students in direct patient contacts, the range of dietetic activities undertaken and the amount of time student activities were directly observed. This information will be useful in the development of benchmarks for clinical skill development, hospital and university staff planning and the assessment of the impact of any changes to the format of student placement experience in the clinical setting.

Barriers and enablers to clinical fieldwork education in rural public and private allied health practice

There is a need to maximise rural clinical fieldwork placement to build health workforce capacity. This study investigated allied health professionals' (AHPs) experience of supervising students as part of work-integrated learning in public and private rural health settings. An anonymous postal questionnaire with 30 questions was used to collect quantitative and qualitative data about the barriers and enablers that AHPs encounter when supervising students in their clinical setting. A total of 113 public and private AHPs from Southwest Victoria, Australia, returned the questionnaire. The AHPs were trained in the disciplines of occupational therapy, physiotherapy, speech pathology, dietetics, podiatry or psychology. The majority of respondents (75%) had previously supervised students. Most respondents had only provided fieldwork education in the public sector. Allied health professionals working in public and private sectors had positive experiences with clinical fieldwork education and often had increased job satisfaction while supervising students. They experienced similar enablers to involvement in clinical fieldwork education programs, however the barriers they encountered were different. The findings highlight the differing issues between rural public and private settings that need to be addressed for successful clinical fieldwork education and work-integrated learning. Strategies to address the identified barriers need to be specific to the work conditions of each setting.

Microbiota benefits after inulin and partially hydrolized guar gum supplementation - a randomized clinical trial in constipated women

Introduction: Prebiotics positively affect gut microbiota composition, thus improving gut function. These properties may be useful for the treatment of constipation. Objectives: This study assessed the tolerance and effectiveness of a prebiotic inulin/partially hydrolyzed guar gum mixture (I-PHGG) for the treatment of constipation in females, as well as its influence on the composition of intestinal microbiota and production of short chain fatty acids. Methods: Our study enrolled 60 constipated female health worker volunteers. Participants reported less than 3 bowel movements per week. Volunteers were randomized to treatment with prebiotic or placebo. Treatment consisted of 3 weeks supplementation with 15 g/d I-PHGG (fiber group) or maltodextrin (placebo group). Abdominal discomfort, flatulence, stool consistency, and bowel movements were evaluated by a recorded daily questionnaire and a weekly interview. Changes in fecal bacterial population and short chain fatty acids were assessed by real-time PCR and gas chromatography, respectively. Results: There was an increased frequency of weekly bowel movements and patient satisfaction in both the fiber and placebo groups with no significant differences. Total Clostridium sp significantly decreased in the fiber group (p = 0.046) and increased in the placebo group (p = 0.047). There were no changes in fecal short chain fatty acid profile. Conclusions: Consumption of I-PHGG produced clinical results comparable to placebo in constipated females, but had additional protective effects on gut rnicrobiota by decreasing the amount of pathological bacteria of the Clostridium genera.