Tuesday, June 8, 2010

Using Simulation and Video Feedback to Enhance Dietetic Interns’ Counselling Skills and Confidence



The transition from dietetic intern to registered dietitian involves a tremendous amount of adaptation over a relatively short time. Interns must acquire the knowledge, practical skills, and critical thinking processes that underpin dietetic practice. In addition, interns must move through a socialization process where they internalize the values, attitudes and behaviours that define how dietitians conduct themselves in the workplace.

Evidence suggests that student nurses, medical interns and other trainees (including dietetic interns) experience ’Transition Shock’ (Duchscher, 2008) and struggle with feelings of anxiety, insecurity, inadequacy and instability as they move from the known role of student to the less familiar role of health care practitioner (Kramer, 1974; Duchscher, 2008). Simulations have been identified as a strategy to combat Transition Shock, and can be used to provide a skills-based clinical experience in a safe and secure environment (Fowler-Durham and Alden, 2007). Exposing students to activities that mimic those occurring during practicum training is thought to decrease anxiety and promote skill development.

Role the tape!

In September 2008, simulation suites based at the University of Alberta (UA) Health Sciences Education and Research Commons (HSERC) began operations. The suites, constructed to resemble clinical interview or examination rooms, allow students to be discreetly videotaped while engaged in practice-based activities with mock patients. The process used to tape simulated patient care activities at the HSERC is novel. While both the student and the mock patient consent to being videotaped, they have limited awareness of a camera in the room as cameras are disguised as light fixtures and controlled by a teaching assistant from a hidden monitoring room. Video footage of the simulation is saved to a secure website that students can access. Students can only access their own footage. They can do this from home if they wish and can view the footage repeatedly to identify strengths and areas for skill development.

The first cohort of dietetic interns participated in simulated patient interviews in the Winter of 2009. The simulations were structured to expand on a basic nutrition assessment and interviewing framework taught in NUTR 466: Introduction to Professional Practice. NUTR 466 is a classroom-based course designed to transition interns into professional life. The interns were asked to interview a mock patient diagnosed with either uncomplicated type 2 diabetes or hyperlipidemia. They were to assess the patient’s nutritional requirements, develop a simple care plan, and provide basic nutrition education. In addition, interns were asked to demonstrate their ability to manage the interview by taking time to develop rapport, set one to three simple goals, and to respond to questions. Intern feedback was extremely positive. They commented that they appreciated being able to ‘see’ how they did while engaged in the interview; many indicated that they had a clearer idea of skills to develop.

The simulated interviews are now a dedicated part of the NUTR 466 curriculum. Each intern completes at least two videotaped interviews and additional sessions can be arranged for those who are struggling or who want extra practice. Feedback from interns continues to be positive. Informal feedback from preceptors and interns (once interns are in placements) suggests that simulation use along with the other practical teaching methods used in NUTR 466 have increased intern confidence and readiness to engage in patient interviews.

Cut the tech

No simulation suite – no problem! It is possible to reap the benefits of videotaped simulation in ways that are relatively simple to organize:

  • Ask interns to invite a friend, family member or colleague to act as their mock patient.

  • Set up a mock interview room by arranging a table and two chairs in front of a clean wall. Place a video camera on a tripod in front of your set.

  • Position the intern and the mock patient in the chairs in front of the camera and begin recording.

  • After the interview, download the footage and share it by email or save to a disk or data stick.

All interns experience some degree of “Transition Shock” as they enter the health workforce. However, novel teaching strategies like simulation and video feedback may help to lessen this effect and make the experience enjoyable for both interns and preceptors.

REFERENCES

Duchscher JB. (2009). Transition shock: the initial stage of role adaptation for newly graduated registered nurses. Journal of Advanced Nursing, 65(5): 1103-1113.

Fowler-Durham C, and Alden KR. (2008). Enhancing patient safety in nursing education through patient simulation. In Patient Safety and Quality: An evidence-based handbook for nurses: Vol. 3. Available at www.ahrq.gov/qual/nurseshdbk/.

Kramer M. (1974), Reality Shock - Why Nurses Leave Nursing. St. Louis: Mosby.


Contact

Heidi Bates, MSc, RD
Director, University of Alberta Integrated Dietetic Internship
Edmonton AB
E: hbates@ualberta.ca




Friday, June 4, 2010

The H1N1 Pandemic: A Shot at an Extraordinary Learning Opportunity

Interning with Public Health Services in the Capital District Health Authority, Nova Scotia during the H1N1 pandemic was a whirlwind experience. Public Health was my first rotation as an intern. I was privileged to witness both its health promotion and health protection roles during my community rotation. In the late summer, my preceptor alerted me that I would be starting my rotation with Public Health earlier than anticipated in hopes that I would miss an H1N1 pandemic that was forecasted to begin in January. This change did not go as planned as cases of H1N1 arrived earlier than predicted.

In the last week of October I could sense that the Public Health team was feeling the heat; it was ‘crunch time’ to prepare for mass immunization clinics as the vaccine had finally arrived. I was fortunate to experience two immunization clinics; once when the vaccine eligibility criteria was restricted to high risk groups and once when the vaccine was available to all. However, I was not involved with clinics every day as I had to complete other competencies unrelated to this unique experience.

While the nutritionists were at the clinics, I provided day care directors with verbal and written feedback on their menus, integrated dialogue from several meetings into notes, kept a journal, inputted an online survey, and worked on my research project. Because everyone was occupied with H1N1 related activities in the community, I was working in a ‘ghost town’ office complete with empty cubicles and lunches eaten in solitude. This contrasted my earlier experiences when I had had lunch with at least 10 others and would always hear someone typing at their computer. I began to feel a sense of isolation.

Before my internship, I anticipated that I would receive ample amounts of direction as an intern. My expectations became apparent during the pandemic as my contact with the team was limited. I was nervous that the work I was completing was not sufficient and I had few opportunities to ask for guidance. This unavoidable situation forced me to become more self-directed in my work. I knew I had to finish the projects and that it was time for me to trust my instincts and myself. This was the only way for me to accomplish the projects. Reflecting on this, I realized that I was afraid to believe in myself and that sometimes I have to be bold and take risks, even if it is uncomfortable. I had to trust my capacity and knowledge. I tended to forget that I am in a learning environment where I will make mistakes but will also celebrate successes. I realize that being pushed outside of my comfort zone in this supportive learning environment was integral to preparing me for the future as I continue to encounter experiences with unknown outcomes. My advice to future interns is to embrace learning opportunities and to engage in these experiences as much as possible - even if you feel thrown into the dangerous ‘deep end of the pool’ instead of what feels to be the ‘safe shallow end’.

In December when the immunization clinics came to an end, I was invited to participate in a closing discussion that involved Public Health employees who acted as clinic leaders. This discussion group of about 40 employees amazed me. I realized the honesty and mindfulness that this group of public health professionals possessed. I learned from the many stories told, and was touched and motivated by their enthusiasm and dedication. That evening I participated in a mass immunization clinic and confirmed my perceptions of this working group. I got to see the clinic staff (including volunteers, students, and public health employees) in action.

My participation in this experience was extraordinary! I believe that fate led me to Public Health during a time when I could experience first-hand health protection and health promotion, two of the core functions of Public Health. I did not learn about the functions of the health care system during times of crisis while at university. Owing to my immersion I feel better prepared for the possibility of involvement in a pandemic in my career.

I encourage future interns to seek rotation opportunities in public health, and suggest that internship programs provide and promote opportunities encouraging interns to experience community rotations in public health.

My sincere thanks to the staff members at Capital District Health Authority’s Public Health Services that made this an invaluable learning experience possible. A special thank you to my supportive preceptor, Rita MacAulay.

Contact

Melissa Koch, Dietetic Intern
Capital Health
Halifax, NS
E: melissa.koch@cdha.nshealth.ca


Rita MacAulay
Keely Fraser

Public Health Nutritionists
Capital Health
Halifax, NS



Northern Reflections – My Experiences During An Allied Health Placement

In the summer of 2009, a program offering placements to nursing in northern communities was extended to allied health practitioners at University Health Network. This program, funded by the Ontario Ministry of Health, allowed clinicians to travel north for approximately four weeks to engage in education networking as well as clinical care delivery opportunities. The purpose of this program is to foster collaboration, to exchange knowledge, and to provide an enriched experience among health care practitioners. The opportunity appealed to my adventurous side and on August 24, 2009, I began my northern experience.

The bulk of my five-week placement was on Moose Factory Island located on the Moose River just south of James Bay. The island has a population of approximately 2700 individuals who are predominantly of Cree First Nation descent. The nearest town is Moosonee that is so remote that it has no road access. Travel to Moose Factory Island involves a flight or train to Moosonee followed by a boat, helicopter or car ride across the Moose River depending on the season and the stability of the ice road in winter.

My placement was based out of Weeneebayko General Hospital – a hospital that had been without an inpatient dietitian for two years. Part of the challenge with this placement was etching out how to best utilize my time and resources while I was there. Some of the responsibilities I undertook included assessing and implementing nutrition care plans with inpatient and outpatient consults, preparing community presentations on a variety of nutrition topics, and assisting in various clinics. I also had the opportunity to fly to the coastal community of Kashechewan to assess the nutritional status of women at the prenatal clinic.

The challenges were numerous and overwhelming, and my brain was stretched with the magnitude of nutritional issues that this community faced. Food insecurity, substance abuse, isolation, poverty, and the prevalence of nutritionally relevant illnesses seemed to be more the norm than the exception. In addition to these challenges, there was the education level of the clientele (many could not read English or Cree), the lack of other allied health professionals to which I had become so accustomed (e.g., speech language pathologists), my unfamiliarity with some of the foods (e.g., bannock bread), and the research into nutritional issues that I would not typically see on my general internal medicine unit in Toronto.

It was sometimes hard to know what to say to the 20 year old mother of three who told me that she could not afford to eat healthy food when four litres of milk was $13.59 and a five pound bag of potatoes was $10.69. It was difficult to remain unmoved by the elderly gentleman on hemodialysis who was too tired to cook, had no family, and for whom there were neither home care services nor home meal delivery services to provide assistance. There was also the challenge of trying to advise young mothers against feeding their babies evaporated milk and convincing them that it was nutritionally incomplete (even though it was what their mothers had done for them). Food availability did not make it any easier. If you were well accustomed to the grocery store delivery schedule, you could get the pick of the best and freshest groceries available. In-between deliveries, you would be lucky to find half-decent fresh fruits and vegetables, if available at all. One evening when I went to pick up milk, I found that the entire island was sold out until the next delivery.

Provision of dietetic services up north is unique in both the needs of the clientele and the retention of professional services. However, despite all of the challenges – maybe even because of them – I found dietitian work in the north to be truly satisfying. Overcoming the seemingly insurmountable hurdles produced a sense of achievement. Dietetics in the north is rewarding and fulfilling; I would encourage you to consider the many opportunities that abound in northern Ontario. I also encourage you to embrace every opportunity you get to immerse yourself in other cultures! Cultural competence is an ongoing process that is developed through familiarization of oneself with and in diverse cultural backgrounds. By better understanding cultural norms and mores, nutrition professionals can tailor nutrition counselling to best meet client needs. For the vast majority of my placement, I was working outside my ‘comfort zone’, and it was a great way to grow, both personally and professionally. I was grateful to be part of such a collaborative initiative that exposes health care staff to unique educational opportunities.


Contact

Tiffany Krahn, RD
University Health Network
Toronto Western Hospital
Toronto, ON
E: tiffany.krahn@uhn.on.ca