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Simulation learning in dietetics education: What options are available?

As a dietetics educator, I am keenly aware that securing clinical nutrition rotations for dietetics interns is the most difficult aspect of scheduling supervised practice experiences. A few reasons why securing clinical nutrition rotations can prove to be difficult include local competition with other programs, a limited number of preceptors available, lack of facilities in proximity to program sites, and a limited number of overall placement opportunities due to the amount of experiential learning time required. 

Clinical nutrition rotations can be scheduled with a variety of healthcare organizations, including hospitals, clinics, renal dialysis centers, eating disorder clinics, and long-term care centers. Of utmost importance, however, is providing opportunities for dietetic interns to fulfill the requisite learning competencies as mandated by the Accreditation Council for Education in Nutrition and Dietetics (ACEND). Dietetic internship programs must offer learning experiences that allow interns to meet a variety of clinical nutrition competencies. Some examples of clinical nutrition competencies are as follows: 

  • CRDN 1.6: Incorporate critical thinking skills in overall practice. 
  • CRDN 2.4: Function as a member of inter-professional teams.
  • CRDN 3.1: Perform the Nutrition Care Process and use standardized nutrition language for individuals, groups and populations of differing ages and health status, in a variety of settings. 
  • CRDN 3.6: Use effective education and counseling skills to facilitate behavior change. 
  • CRDN 4.9: Explain the process for coding and billing for nutrition and dietetics services to obtain reimbursement from public or private payers, fee for service and value-based payment systems (ACEND).  

An additional layer of complexity in securing clinical nutrition rotations this past academic year was the onset of the COVID-19 pandemic. While some hospitals and clinics chose to continue taking our interns in person, others requested partial or fully virtual rotations, while others decided to opt out due to difficulties transitioning to online learning. Several of our hybrid and fully online sites provided opportunities for interns to observe and engage in telehealth sessions with clients. 

Currently, we are a few weeks away from our first cohort of dietetic interns completing our inaugural program year. Though I am quite satisfied with the quality and variety of learning experiences our interns have had this year, I want to investigate how clinical nutrition education can be provided to dietetic interns through use of simulation learning. 

Specifically, my question for this module is: How can dietetics educators incorporate innovative clinical nutrition simulation learning experiences into their dietetic internship curriculum to improve student outcomes while advancing their technological skills? 

My question aligns with the International Society for Technology in Education’s (ISTE) Standard 1 Learner: “Educators continually improve their practice by learning from and with others and exploring proven and promising practices that leverage technology to improve student learning. Educators (ISTE). 

In this blog post, I will be focusing on ISTE Standard 1a: 

“Set professional learning goals to explore and apply pedagogical approaches made possible by technology and reflect on their effectiveness” (ISTE). 

Simulation learning: an advanced educational approach in dietetics education

According to Levett-Jones and Lapkin (2014), simulation learning is: “A technique used to replace or amplify real experiences with guided experiences that evoke or replace substantial aspects of the real world in a fully interactive manner. Simulation isn’t a technology, but rather a mode of learning meant to replicate clinical experiences as closely as possible.” Further, Davis (2015) states that “simulation education serves as a bridge between classroom learning and real-life clinical experience.” 

Simulation learning and corresponding curriculum theory 

According to Cooper (2018), simulation learning stems from Transformative Learning Theory, “which suggests that either real or simulated experiences serve as catalysts for learning. Students take the knowledge they already possess and put it into practice in realistic scenarios.” 

Simulation learning is also rooted in Experiential Learning Theory, which focuses on learning by engaging in direct experiences rather than rote memorization (Ellis, 2020). The phases of experiential learning are as follows: concrete experience (i.e. the actual experience), reflection and observation (i.e. reflecting on the experience), forming abstract concepts (i.e. developing concepts based on the experience), and testing these concepts in new situations (Lindsey & Berger, 2009; Miettinen, 2010).  

Clinical simulation learning is available to dietetics educators using a variety of models and tools. Some of the options include the following: 

Laboratory simulation using robots, which depict human patients, are used to gain professional practice in a simulated clinical environment. According to Cooper (2018), The University of Idaho’s dietetics education program is the pioneer academic site to incorporate the SimMan robot to provide experiential learning to their students. After students complete 150 hours of simulation learning with a focus on 10 disease states, such as type 2 diabetes and celiac disease, students then advance to a real clinical environment where they are mentored by preceptors. This link provides a description of how this type of simulation learning is utilized at The University of Idaho (www.uidaho.edu). An important learning experience for dietetics students using SimMan would be to perform Nutrition-Focused Physical Exams. 

SimMan in action
  • Laboratory simulation using human actors to replicate patient interactions. An instructor observes interactions from a nearby booth and provides instant feedback on student performance via a microphone. Additional human actors are present in the simulated environment to mimic an interdisciplinary healthcare team (Cooper, 2018). 
  • Computer software programs designed with 3D virtual simulation learning environments and avatars, which allow interns to interact with patients of varying backgrounds and interdisciplinary healthcare providers (Davis, 2015). Students can practice providing medical nutrition therapy (MNT) services to patients in acute and out-patient settings while increasing their skills in utilizing the Nutrition Care Process, performing coding and billing tasks, and using the Academy of Nutrition and Dietetics’ Evidence Analysis Library (Academy of Nutrition and Dietetics Foundation). An example of this type of simulation learning is described on New Mexico State University’s website: https://dieteticinternship.nmsu.edu/virtual-realitysimulatio.html

Source: www.laerdal.com

Computer software programs using a case study approach in a virtual learning environment to provide opportunities for students to enhance their critical thinking and problem solving skills by engaging in the Nutrition Care Process, completing coding and billing exercises, and pre-recorded video interviews with patients to review. One example is Nutrition Care Professionals (NCPRO) Virtual Learning Environment (https://www.nutritioncarepro.com/). 

Source: Davis, A. (2015). Virtual reality simulation. An innovative teaching tool for dietetics experiential education. The Open Nutrition Journal. 9, (suppl. 1-M8),65-75.

  • Virtual reality training using a headset and hand controls, such as Oculus Rift, was not seen in my research on dietetics-specific virtual reality simulation training. However, I did locate software that is currently being used in nursing education. 

How can simulation learning improve student outcomes? 

Numerous benefits of simulation learning in dietetics education have been shared with the dietetics community. A few examples are listed below (Cooper, 2018): 

  • “ability to simulate rare cases and situations that students may not otherwise encounter in their traditional training”
  •  “increased time for instructors to focus on student learning rather than patient care”
  • “ability to quickly repeat and refine student performance”
  • ability to move from simple to more complex skills for progressive learning”
  • “immediate feedback to students”
  • “opportunities for interprofessional interaction with professionals in a wide variety of roles before the student enters the hospital setting.” 

What expertise do dietetics educators need to oversee simulation learning? 

To administer a successful simulation learning curriculum, dietetics educators must: 

  • Understand simulation learning pedagogy 
  • Possess expertise in clinical nutrition to develop curriculum, provide real time feedback to students, and debrief on student performance. 
  • Possess a variety of technological skills required to oversee the various types of simulation learning system adapted. 

The chart below depicts the expertise needed by dietetics educators administering virtual simulation learning in their curriculum: 

Source: Davis, A. (2015). Virtual reality simulation. An innovative teaching tool for dietetics experiential education. The Open Nutrition Journal. 9, (suppl. 1-M8),65-75. 

Evaluation of clinical simulation learning resources

There are several variations of clinical simulation learning resources available for dietetics education. All have merits, but some are more realistic to consider implementing due to the resources required. Laboratory simulations, whether using robots or human actors, require a designated laboratory space and in-person participation. Though this may be something to consider in the future, due to the COVID-19 pandemic, I am currently interested in focusing on simulation software that can be accessed from any remote location and can be utilized asynchronously (vs. in real time). These features would allow our interns to either enhance their in person clinical nutrition experiences with supplemental simulation learning, or would enable interns to complete clinical nutrition competencies in a remote learning environment. I have decided to narrow my focus to simulation software, such as NCPRO since it does not require instructors to create the curriculum as opposed to the virtual reality software options. However, now that I have learned so much about options available that simulate the clinical environment, I will definitely consider virtual reality and robot simulations in the future. 

References

Academy of Nutrition and Dietetics Foundation. EatrightPro Practice simulation series.  https://www.eatrightfoundation.org/why-it-matters/public-education/simulation/

2017 Standards and Templates. Accreditation Council for Education in Nutrition and Dietetics. https://www.eatrightpro.org/acend/accreditation-standards-fees-and-policies/2017-standards

Cooper, C.C.(2018). Using simulation in dietetics education. Today’s Dietitian. 20,7,30.  

Davis, A. (2015). Virtual reality simulation. An innovative teaching tool for dietetics experiential education. The Open Nutrition Journal. 9, (suppl. 1-M8),65-75. 

Ellis, A. (2020). Podcast on instructional theory. Seattle Pacific University. 

Levett-Jones T, Lapkin S. (2014). A systematic review of the effectiveness of simulation debriefing in health professional education. Nurse Educ Today. 34,6, 58-63.

Lindsey, L., & Berger, N. (2009). Experiential approach to instruction. In Reigeluth, C., & CarrChellman, A. (2009). Instructional-design theories and models, volume III: Building a common knowledge base (pp. 118-40). Taylor & Francis Group. 

New Mexico State University. Virtual reality and dietetics simulation lab. https://dieteticinternship.nmsu.edu/virtual-realitysimulatio.html

Nutrition Care Pro Virtual Learning Environment. https://www.nutritioncarepro.com/

University of Idaho.(2021). Dietetics simulation.  https://www.uidaho.edu/cals/family-and-consumer-sciences/teaching-labs/dietetics-simulation