Incorporating Simulations of the Nutrition-Focused Physical Exam into Graduate-Level Dietetics Curriculum

Abstract

Introduction: The nutrition-focused physical exam (NFPE) is an integral component of a nutrition assessment performed by registered dietitians, and is used to identify signs of malnutrition. However, many dietitians are not performing NFPE in clinical practice due barriers such as lack of training, lack of time, and discomfort touching patients. The Accreditation Council for Education in Nutrition and Dietetics (ACEND) has set a new 2017 competency of “Conduct nutrition-focused physical exams” for dietetic internships and coordinated programs in dietetics, indicating the need to incorporate NFPE training into dietetics education programs. Simulations have shown to be useful teaching tools for hands-on clinical skills, and may be a practical and effective method to train dietetics students in NFPE. Methods: Dietetics students (n=16) in a combined internship and Master’s program at the University of Kansas Medical Center participated in a simulation of the NFPE for a graduate-level medical nutrition therapy class. Observers evaluated participants using the NFPE Skills Assessment tool created by the Academy of Nutrition and Dietetics. Components of the NFPE were split into seven categories, each containing criteria used to evaluate participants. NFPE skill baseline was taken by having students perform an NFPE in pairs on each other while an observer checked off NFPE skills performed. Students received an NFPE training packet after baseline. Student learning from the training packet was self-directed. One month later, students performed a timed NFPE simulation on a standardized patient actor, with observers checking off NFPE skills performed. Constructive feedback was given to students on both the pre-test and post-test. The NFPE Skills Assessment tool measured objective measures of performance, and students took a pre-test and post-test survey to assess subjective measures of performance. Results: Significant improvements were seen in muscle assessment, subcutaneous fat assessment, and overall performance. When pre-test and post-test surveys were compared, student’s sense of NFPE importance significantly increased. Their perceived ability to assess subcutaneous fat, muscle, fluid accumulation, and micronutrient deficiencies increased. Student’s comfort touching patients significantly increased. 82% (n=13) of students felt they were adequately guided through the simulation process and 94% (n=15) felt the case study and training materials adequately prepared them for the simulation. 88% (n=14) of students felt the simulation increased their proficiency and confidence in performing an NFPE. From open-ended questions, students reported they enjoyed the realism of the standardized patient (n=11) and the opportunity to practice NFPE in a safe environment (n=6). Students felt the simulation could be improved by increasing simulation realism (n=4), additional materials for the training packet (n=3), and additional practice sessions before the live simulation (n=3). Conclusion: This study created an NFPE training program using role-play simulations for graduate dietetics students. The program demonstrated effectiveness at improving NFPE skills and perceived proficiency and confidence performing the exam. Students benefitted from constructive feedback and the opportunity to practice the exam in a safe setting. Student learning can further be improved by modifications to the training program. Overall, the study demonstrated an effective approach to incorporating NFPE training into a dietetic internship program, in efforts to meet the new dietetics education competency set by ACEND.