July 2018 Issue

Using Simulation in Dietetics Education
By Christen Cupples Cooper, EdD, RDN
Today's Dietitian
Vol. 20, No. 7, P. 30

This mode of learning, which provides students hands-on, real-life clinical experiences, is trending among dietetics programs across the country.

A nutrition and dietetics student sits before a 45-year-old female patient who complains of chronic weakness. The student has reviewed the patient's chart and considered her self-reported body weight and ideal body weight. The student begins discussing the duration of the patient's weakness and appetite changes.

Sounds pretty routine, right? However, a closer look reveals it's actually taking place away from a typical examination room and the patient isn't a role-playing classmate.

The student and her patient, a volunteer from the local community, are performing a simulation, "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."1 Simulation isn't a technology, but rather a mode of learning meant to replicate clinical experiences as closely as possible.1

In this case, the student-patient team is working in an interprofessional simulation laboratory in which students, volunteers, actors, and other health care professionals in training work together to simulate realistic case scenarios. While they work, they're observed in real time by an instructor, observer, and simulation professional who sit behind Plexiglas and evaluate, support, and direct over a microphone.

The simulation sessions are recorded for later evaluation and feedback, including a sit-down debriefing session with the instructor. Students can access the sessions for the duration of the semester to review and refine their skills.

Benefits of Simulation
For more than a decade, physicians, nurses, and other health care professions have used simulation to provide students with a safe learning environment where they can learn patient care skills before interfacing with actual patients and other health care providers.2 In nutrition and dietetics, however, simulation largely has been an untapped resource. The literature on medical simulation suggests that because, like nursing, dietetics is competency based, it lends itself well to the use of simulation for training and education.3

According to SeAnne Safaii-Waite, PhD, RDN, LD, an associate professor of nutrition and dietetics at the University of Idaho and author of the textbook Medical Nutrition Therapy Simulations, "A new paradigm is required to meet the conflicting demands of the exponentially growing field of dietetics and the ever-decreasing contact time that interns get with individual patients. Dietetic interns who make a mistake in real patient care will never forget it—and likely never repeat it. However, this is helpful only for the next patient. Simulation promises to provide such instructive encounters in an artificial environment; yet, it is transferrable to the clinical setting, thereby accelerating the development of expertise while minimizing patient risk."

Jennifer Bean, MS, RDN, LD, an assistant teaching professor with the BS/MS Coordinated Program in Dietetics at the University of Missouri, which utilizes simulation in its curriculum, emphasizes the "soft skills" and debriefing elements of simulation: "It is a rare occasion for the student to get the perspective of the patient in the real world. So much of our ability to help people make changes to benefit their health depends upon soft skills—conversation skills, motivational interviewing, and interpersonal dynamics—not with the steps of the nutrition care process."

Marcia Nahikian-Nelms, PhD, RDN, LD, CNSC, FAND, director of academic affairs with the College of Medicine and Nursing at Ohio State University, believes simulation is the ultimate way to "bridge classroom learning to practice." The author of several nutrition textbooks and a published researcher on the use of simulation in dietetics education, Nahikian-Nelms says simulation can assist the nutrition and dietetics profession achieve its goal of becoming competency based.

Industry Views
The Academy of Nutrition and Dietetics (the Academy), the Academy of Nutrition and Dietetics Foundation, and the Accreditation Council for Nutrition and Dietetics (ACEND) encourage the use of simulation in nutrition and dietetics education. In 2012, the Academy of Nutrition and Dietetics Foundation offered grant funding of up to $200,000 for proposals on simulation.4 In addition, the Academy has created a task force to explore ways to advance the use of simulation across the country.

An article in the Journal of the Academy of Nutrition and Dietetics noted the following benefits of using simulation in dietetics education3:

• reduced patient risk;
• increased time for instructors to focus on student learning rather than patient care;
• optimization of increasingly scarce dietetics education resources;
• use of a systematic review and evaluation of student achievement;
• immediate feedback to students;
• accommodation of different types of learners, students of diverse backgrounds, and language abilities;
• accommodation of different teaching styles;
• ability to quickly repeat and refine student performance;
• ability to move from simple to more complex skills for progressive learning;
• opportunities for interprofessional interaction with professionals in a wide variety of roles before the student enters the hospital setting;
• ability to simulate rare cases and situations that students may not otherwise encounter in their traditional training;
• increased student confidence due to the ability to practice their skills before entering a real-life patient encounter;
• prompt debriefing and the opportunity to discuss opportunities for improvement; and
• development of targeted resources that can enhance important gaps in a program's curriculum or student experiences.

Simulation's Theoretical Foundation
On a basic level, simulation is based on the Transformative Learning Theory, which suggests that either real or simulated experiences serve as catalysts for learning.3 Students take the knowledge they already possess and put it into practice in realistic scenarios.

The use of simulation also is supported by the novice-to-expert model and experiential learning theory, both of which help explain the process by which simulation can bring students to higher levels of knowledge and skills through practice.5 Active reflection is key to incorporating new experiences into students' skillsets and to students' achievement of higher levels of expertise in their field.6 The theory of deliberative practice also is applicable to the use of simulation, since students use simulation to develop proficiency by repeatedly engaging the cognitive and psychomotor skills that lead to desired outcome goals.3

Researcher Pamela R. Jeffries, PhD, RN, FAAN, ANEF, a professor and dean of the George Washington University School of Nursing, developed a five-component framework for building nursing simulation experiences.7 The first step in the model is development of appropriate objectives based on students' current levels of knowledge and skills. The criteria for evaluation are important at this stage.

Second, simulations should be as realistic as possible, mirroring authentic cases. The review of scenarios by peers is a crucial component, since the students' combined experiences can help to refine scenarios.2 Third, the complexity of cases should move from simple to more complex in a carefully planned sequence so learning is steady and certain.

Fourth, the simulation should include effective cuing, such as verbalizations from those playing roles in the simulation, mock documentation, mistakes by food vendors or other health care professionals, or emergencies such as loss of utilities. Fifth, the debriefing process should be held during or as soon as possible after a simulation experience. This debriefing could be instructor feedback only, but also may include, for example, peer feedback and asking open-ended questions.2

Bean notes the critical importance of debriefing: "The standardized actor/patient provides valuable information on those skills that elicit behavior change that students, and even clinicians, may get only when the patient/client is extremely displeased or pleased. Providing such feedback creates more competent behavior change agents who can better help their clients to make healthier choices."

Hallmarks of Effective Simulation
From her textbook Medical Nutrition Therapy Simulations, Safaii-Waite shares some hallmarks of successful simulation.3

Self-Directed Students
Simulation works best when students are self-directed, motivated, and informed about the rules of the simulation. Whereas traditional classroom instruction is teacher centered, simulation is student centered. While students should feel safe to practice their skills, they should have a sense that there are high expectations regarding their performance. Self-efficacy is a major predictor of student success.

Well-Trained Instructors
Instructors must facilitate and support students during the learning process, from simulation to debriefing. Teachers must be well trained in simulation and possess a theoretical understanding of simulation and the skills to use it effectively. Instructors also must understand the skill level of each learner and be able to adapt case scenarios to students' skill levels. Effective instructors maintain high levels of expectations for their students, which encourages students to challenge themselves.

Sound Educational Practices
Effective simulation involves active learning and immediate feedback. The latter is something most traditional assignments can't offer. Collaborative learning, which increases the sense of interprofessional, intraprofessional, and student-instructor collegiality, is also key to simulation.

Quality Simulation and Debriefing
Achievement of learning outcomes seems to occur across multiple simulation methods. Because dietetics doesn't require "high-fidelity" mannequins to demonstrate most dietitian-patient interactions, dietetics students have a broader range of possibilities. (Unlike nursing, most interactions can be simulated using "low-fidelity," basic mannequins. Most dietetic simulations can be done with a low-fidelity mannequin or a "computerized" patient [an avatar]).

Higher-level simulations can use an actor as the patient. When an actor is used, it's important to standardize the student experience, exposing each student to the same scenario presented in the same way. Debriefing is a critical step that ties together all of the learning and should be a rich, informative experience for students.

Successful Simulations in Dietetics
Few studies have been conducted on the use of simulation in nutrition and dietetics. However, the existing studies point to its acceptability to students and its usefulness for teaching skills and building confidence in the clinical setting.

In 1999, Hampl and colleagues reported that students who performed simulations with standardized patients were highly satisfied with the learning experience.8 A study on dietetic interns who interacted with standardized patients whom they counseled on nutrition improved student confidence levels and competence.9

A study of interns using either computer-based simulations or computer-based tutorials found no difference between the groups, but found higher rates of skill improvement among those using the simulations.10 Another study examined the use of actors as standardized patients, with students reporting that the experience was "effective" and "realistic."11              

Many nutrition and dietetics programs are using simulation effectively. "Innovations in Education: Utilizing Dietetic Simulation for Clinical Experience," a preconference workshop at the 2017 Food & Nutrition Conference & Expo™ (FNCE®), featured scholars from the University of Idaho and Dominican University and invited others from various schools that are using and growing their simulation efforts.

University of Missouri-Columbia
Le Greta Hudson, MS, RDN, LD, CDE, of the University of Missouri-Columbia's Coordinated Program in Dietetics explains, "My colleagues and I were invited to participate in the 2017 FNCE® preconference workshop because of how far we've come in integrating simulation into our curriculum. After participating in the workshop, our program took off. We partnered with a simulation facility connected to our medical school and obtained valuable case study scenarios from Marcia Nahikian-Nelms and SeAnne Safaii-Waite."

The University of Missouri uses simulation for dietetics students in several ways: to provide a clinical experience for students while testing their knowledge of MNT, to teach students how to perform the nutrition-focused physical exam, to engage in motivational interviewing, and to learn how to use the nutrition care process while charting in an EMR.

"Our programs are in a unique position in that we work with a 'pay to play' standalone simulation center, and we have our own satellite facility in our building to run low-fidelity simulations whenever we wish," Hudson says.

Such a facility has the potential to create a revenue stream from the needs of the various health programs within the university and from independent groups such as hospitals wishing to conduct professional development or training on specific procedures or disease states.

University of Idaho
The University of Idaho is a pioneer in simulation, with its model being successfully implemented in other medical and dietetics programs. Safaii-Waite and her colleagues conducted a national focus group with dietetics instructors and professors to determine the top 10 disease conditions that might effectively be taught through simulation. Those conditions cited—celiac disease, congestive heart failure, COPD, type 1 and type 2 diabetes, liver disease, lung cancer, pancreatitis, renal failure, and wound care—were incorporated into the university's MNT simulations.

Upon the completion of 150 hours of simulation, University of Idaho dietetics students spend eight weeks in a hospital for supervised practice. "Our preceptors love this model because the students have practiced so much on 'sim man' robots that they are [eager] to have real patients, and they are ready for them," Safaii-Waite says. "Unlike some students who are like deer in the headlights when they walk into a patient's room for the first time, our students have been through the drill 10 times with instructors watching them and critiquing them, so they are well prepared."

Safaii-Waite's textbook provides an overview of simulation and nutrition assessment, followed by 10 chapters of patient scenarios, patient scripts, and evaluation criteria for dietetics instructors. There's also a digital decision tree, a tool for mapping out the possible steps in deciding what to recommend for patients, including the benefits, costs, and outcome probabilities for each simulation, which students can use for practice.

Ohio State University
Ohio State University uses simulation for both interprofessional and dietetics-only training, with about 600 students per semester from various disciplines working together in the simulation lab.

Students tackle a series of simulations that build upon each other in complexity. For example, Nahikian-Nelms and her colleagues pioneered a three-part simulation that teaches the nutrition-focused physical exam. The simulation process begins with an introductory lecture on the exam, followed by students performing functional assessments on micronutrient status, muscle/fat stores, and sit-to-stand tests. Finally, students read a medical record, assess for malnutrition, perform the nutrition-focused physical exam in the simulation lab, and receive feedback from the instructor. Students do the simulation three times each, progressing to patients of higher complexity.

Nahikian-Nelms also uses the simulation lab to teach mentoring and precepting skills in paired-peer teaching. New students are paired with more experienced students who provide feedback and mentoring. Once the students gain experience, they're paired with newer students. The most experienced students perform the simulations by themselves. Practicing precepting helps meet an important ACEND dietetics education competency and turns students into confident future preceptors.

Future of Simulation
Simulation appears to have a bright future in dietetics. It allows students the time to develop their skills in a safe environment at their own speed and ability level while perfecting and building confidence in their clinical and interpersonal skills.

"As an educator, I love using simulation techniques because they reproduce real-world settings where students can practice in a guided experience," Safaii-Waite says. "Students have knowledge from their classes, but simulation helps them practice skills of inquiry, communication, critical thinking, and problem solving."

Simulation also may be used for professional development for medical professionals teaching at a university or practicing in the community, as well as a benefit for preceptors for a dietetics program. It also may serve as a revenue stream for a college of health professions.

Moreover, the simulation lab is an appropriate setting for interprofessional exercises. The College of Health Professions at Pace University in New York City and Pleasantville, New York, has been using its state-of-the-art simulation labs for decades as a way to train nurses and nurse practitioners. The college has expanded its health care programs to a Coordinated MS in Nutrition and Dietetics, as well as Communication and Speech Disorders, Physician Assistant, and Occupational Therapy with students working interprofessionally in the simulation lab on complex scenarios.

"This is one more tool to ensure quality clinicians," Bean says. "It can never replace the hours of internship/supervised practice and the mentorship that a preceptor brings. The hope is that the student will be more confident and competent when they arrive on day one with their preceptor. With the number of supervised practice sites dwindling and/or competition for sites, simulation is a viable companion to enhanced learning outcomes."

— Christen Cupples Cooper, EdD, RDN, is founding director of programs in nutrition and dietetics at Pace University in Pleasantville, New York.

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

2. Thompson KL, Gutschall MD. The time is now: a blueprint for simulation in dietetics education. J Acad Nutr Diet. 2015;115(2):183-194.

3. Safaii-Waite S. Medical Nutrition Therapy Simulations. Burlington, MA: Jones & Bartlett Learning; 2017.

4. Academy of Nutrition and Dietetics, Commission on Dietetic Registration. Commission on Dietetic Registration Report to Dietetics Educators of Practitioners Dietetic Practice Group. www.eatright.org/Foundation/content.aspx?id=6442468762. Published Spring 2012.

5. Waldner MH, Olson JK. Taking the patient to the classroom: applying theoretical frameworks to simulation in nursing education. Int J Nurs Educ Scholarsh. 2007;4:Article18.

6. Kolb D. Experiential Learning: Experience as the Source of Learning and Development. Upper Saddle River, NJ: Prentice Hall; 1984.

7. Jeffries PR. A framework for designing, implementing and evaluating simulations used as teaching strategies in nursing. Nurs Educ Perspect. 2005;26(2):96-103.

8. Hampl JS, Herbold NH, Schneider MA, Sheeley AE. Using standardized patients to train and evaluate dietetics students. J Am Diet Assoc. 1999;99(9):1094-1097.

9. Henry BW, Duellman MC, Smith TJ. Nutrition-based standardized patient sessions increased counseling awareness and confidence among dietetic interns. Top Clin Nutr. 2009;24(1):25-34.

10. Turner RE, Evers WD, Wood OB, Lehman JD, Peck LW. Computer-based simulations enhance clinical experience of dietetics interns. J Am Diet Assoc. 2000;100(2):183-190.

11. Beshgetoor D, Wade D. Use of actors as simulated patients in nutritional counseling. J Nutr Educ Behav. 2007;39(2):101-102.