Modeling the Problem-based Learning Preferences of McMaster University Undergraduate Medical Students Using a Discrete Choice Conjoint Experiment

Objectives: To use methods from the field of marketing research to involve students in the redesign of McMaster University’s small group, problem-based undergraduate medical education program. Methods: We used themes from a focus group conducted in an electronic decision support lab to compose 14 four-level educational attributes. Undergraduate medical students completed a discrete choice experiment composed of 15 web-administered, partial-profile, conjoint-choice tasks. Results: Latent class analysis revealed two segments with different preferences. Segment 1, (86% of students), preferred a problem-based approach with more small group tutorial sessions led by expert tutors who facilitated the tutorial process without teaching didactically. Segment 2, (14% of students), preferred more large group lectures, explicit learning objectives, expert tutors who taught didactically, and streaming options based on learning preferences. Although Segment 1 preferred smaller tutorial groups, simulations predicted these students would trade increases in tutorial group size for a conceptually integrated program that included tutorial problems based on core curriculum concepts, greater integration of the content of clinical skills training sessions and the tutorial curriculum, and a link between clerkship patient selection and the program’s curriculum. A majority of both segments would accept a more conceptually integrated program if the savings associated with increases in tutorial group size was reinvested in web-enhanced tutorial processes and computer-simulated health care problems. Conclusions: Most students preferred a small group, web-supported, problem-based learning approach led by content experts who facilitated group process. Students favored a program in which tutorial group problems, clinical skills training sessions and the patients selected for clerkship activities were more closely linked to core curriculum concepts.     

CAI in college-level nutrition education: a feasibility study

We developed a college-level computer-assisted instruction (CAI) lesson on vegetarianism and compared its effectiveness with the lecture/discussion method. Our independent CAI lesson consists of tutorial and drill-and-practice routines and a simple diet planning simulation. We collected pretest and posttest data on knowledge of and interest in vegetarianism from 44 students in an introductory foods and nutrition class. We randomly assigned three sections to receive either the CAI lesson, a comparable discussion lesson, or a lesson on another topic. There were no significant differences among these three groups either in pre- or posttest knowledge scores, or in interest in vegetarianism. CAI students' responses to learning by computer were positive. We discuss the potential savings in instructor and classroom time that may make CAI use advantageous as a substitute or supplement to classroom teaching.     

Computer-based simulations enhance clinical experience of dietetics interns

OBJECTIVE: To determine the impact of computer-based simulations on the performance of dietetics interns in initial clinical rotations. DESIGN: Interns used either a simulation program (Care Planning Simulation System CPSS[) or a computer-based tutorial (Nutrition Care Planning Tutorial NCPT[) during their orientation. Performance of these interns on nutrition care skills was evaluated during their initial clinical rotations. SUBJECTS/SETTING: Participants were 108 dietetics interns from 8 different programs. Each internship had at least 8 interns, and none of the internships awarded a graduate degree. INTERVENTION: Subjects in the experimental group completed nutrition assessment and care planning activities for 3 simulated patients. Subjects in the control group completed a tutorial on assessment and care planning. MAIN OUTCOME MEASURES: Likert scale ratings of 31 behaviors were recorded by clinical preceptors. Behavior statements were grouped into 8 categories and average ratings for each category were determined. STATISTICAL ANALYSIS: Repeated-measures analysis of variance and linear regression were used to compare performance ratings between groups. RESULTS: There were no differences in overall evaluations of the simulation and tutorial groups for the 8-week period. Interns who started clinical rotations immediately after orientation (CPSS-I and NCPT-I groups) were rated lower in all categories than those who began their clinical rotations later (CPSS-D and NCPT-D groups). Maturation and acquisition of general skills likely influenced ratings of interns with delayed clinical rotations. For most categories of behavior the rate of improvement in rating scores was greatest for interns who used CPSS. APPLICATIONS: Computer-based simulations are a promising supplement to current techniques in didactic instruction and may be useful in both didactic and practice settings. Computer-based simulations can provide more varied practice experiences to didactic students and interns in preparation for more skilled entry-level positions in dietetics.     

Undergraduate dietetics programs do not support training students in smoking cessation

Although tobacco use is the leading contributor to death and disability in the United States, allied health professionals often lack knowledge of smoking cessation techniques. The objective of this study was to identify the extent to which undergraduate dietetics programs (referred to as didactic programs in dietetics [DPD]) teach about tobacco and smoking cessation interventions and also DPD directors' opinions regarding tobacco and smoking cessation in dietetics education. All DPD directors in the United States (n=231) were sent a questionnaire to assess programs' and directors' demographics, courses that included tobacco and smoking cessation education, and directors' opinions pertaining to tobacco and smoking cessation education. The response rate was 49% (n=113). On average, DPD directors did not agree that tobacco and smoking cessation education should be a formal part of undergraduate dietetics programs and that it is not as important as other content areas required of dietetics students. Just 37% of directors believed that a dietitian's job responsibility included educating patients on smoking cessation. Only 7% of DPD directors had formal education on smoking cessation and tobacco use, but 53% had formal education on behavior modification. More than half of DPD programs (56%) did not offer any courses that provided tobacco and smoking cessation education. These results indicate that most undergraduate dietetics programs do not incorporate tobacco and smoking cessation education in their curricula. Dietetics and other allied health educators could consider including smoking cessation education in their curricula to ensure that future health professionals can contribute to Healthy People 2010 objectives related to smoking cessation.     

Providing access to blacks and Hispanics in dietetics education

To increase the number of blacks and Hispanics in dietetics and three other health professions, the Health Sciences Recruitment and Retention Program was developed and implemented in 1985 by the College of Health at Florida International University in Miami. The coordinated undergraduate program assisted in a federal grant to accomplish the objectives of recruiting and retaining minority students. High school and community college students were recruited using a slide/tape presentation featuring black and Hispanic professionals. In addition, the college offered a summer course entitled "Perspectives of the Health Sciences Professions" to students entering their senior year in high school. In this course, students learned how dietitians, medical laboratory scientists, and physical and occupational therapists treat various disease states. Field trips and site visits provided additional exposure to the professions. A summer orientation and tutorial program was established to retain minority students enrolled in the coordinated undergraduate program. We recommend that this program be considered as a model for dietetics educators to use in developing other programs to increase the number of minorities in the profession.     

Comparison of methods for teaching clinical skills in assessing and managing drug-seeking patients

AIMS: New medical graduates lack clinical skills in assessing and managing patients seeking drugs of dependence. This study compares the effectiveness of three different clinical skills training methods, with similar content, which were developed to teach these skills to senior medical students. METHODS: A preliminary survey indicated that common problems seen by primary care practitioners included both new and previously known patients seeking either benzodiazepines or opiates. The common content of the teaching was determined from this survey. A didactic small group tutorial (DT), a video-based tutorial (VBT) using professional actors, and a computer-aided instruction package using digitized video (CAI) were developed with this common content, and trialled with undergraduate medical students over 2 years in a parallel-group design. Outcome was assessed by student feedback, performance on a case-based written examination and by a structured evaluation of interviews with simulated patients requesting drugs. Comparison was also made between methods on the basis of knowledge tests. RESULTS: No difference was seen in written examination and simulated patient outcomes between the three groups. However, the VBT was thought by the students to be preferable to other methods. The estimated development costs of CAI were higher, but total costs over a 6-year period were lower than for the DT and VBT. The results suggest that clinical skills can be taught equally effectively through several different methods. Collaboration between institutions in the development of widely applicable CAI tools should be an efficient and economical mode of teaching with a wide range of applications.     

Dietetics Students' Ability to Choose Appropriate Communication and Counseling Methods Is Improved by Teaching Behavior-Change Strategies in Computer-Assisted Instruction

Several models and theories have been proposed to help registered dietitians (RD) counsel and communicate nutrition information to patients. However, there is little time for students or interns to observe and/or participate in counseling sessions. Computer-assisted instruction (CAI) can be used to give students more opportunity to observe the various methods and theories of counseling. This study used CAI simulations of RD−client communications to examine whether students who worked through the CAI modules would choose more appropriate counseling methods. Modules were created based on information from experienced RD. They contained videos of RD-patient interactions and demonstrated helpful and less helpful methods of communication. Students in didactic programs in dietetics accessed the modules via the Internet. The intervention group of students received a pretest module, two tutorial modules, and a posttest module. The control group only received the pretest and posttest modules. Data were collected during three semesters in 2006 and 2007. Two sample t tests were used to compare pretest and posttest scores. The influence of other factors was measured using factorial analysis of variance. Statistical significance was set at P<0.05. Eleven didactic programs participated. A total of 350 students were in the intervention group and 102 students were in the control group. Pretest scores were not different (6.30±0.26 vs 6.21±0.15, control and intervention, respectively). The intervention group's posttest score was higher than its pretest score (6.21±0.15 vs 6.65±0.16, pretest and posttest, respectively). Change in score from pretest to posttest was higher for the intervention group (−0.02±0.20 vs 0.44±0.11, control and intervention, respectively). For the 21 questions in the tutorials, those who answered 19 to 21 correctly had a greater increase from pretest to posttest than those who answered <13 correctly (−0.44±0.37 vs 0.84±0.17, <13 and 19 to 21 correct, respectively). There was no effect of instructor, grade point average, school year, or prior counseling on the results. The study provides evidence that the use of CAI can improve communication and counseling methods for dietetics students.     

Simulations for Teaching and Evaluating Nutrition-Focused Physical Exam Skills

ObjectiveTo develop, implement, and evaluate a patient simulation to assess Nutrition-Focused Physical Exam (NFPE) skills among dietetics students.MethodsThree student cohorts (n = 47) in a combined internship and master's program participated. Curricula included: (1) formal instruction with practice resources, (2) baseline NFPE evaluation performed on a classmate, and (3) final NFPE evaluation performed on a standardized patient. Trained observers evaluated students using the NFPE Skills Assessment tool. Self-rated performance was assessed by the 8-item survey completed at baseline and after the final evaluation. Paired t tests analyzed differences in observed NFPE skill, and 1-tailed Wilcoxon signed-rank test analyzed differences in survey responses.ResultsNutrition-Focused Physical Exam skill improvements were observed for each cohort (P < .05). Surveys demonstrated increased comfort touching patients (P < .001), and improved self-rated abilities to assess subcutaneous fat, muscle stores, fluid accumulation, and micronutrient deficiency (P < .001).Conclusions and ImplicationsSimulations were an effective method for increasing observed and perceived NFPE skills among dietetics students. These findings justify the investigation of these methods within a larger sample of students from multiple programs with rigorous study design.     

Participants’ Evaluation of a Weight-loss Program

Objective The purpose of this study was to evaluate participants’ perceptions of the weight-loss intervention used in a hypertension prevention clinical trial.Design A total of 308 overweight and moderately obese subjects participated in the weight-management intervention. After the 18-month program, 281 participants completed a questionnaire designed to evaluate their perceptions of the program's effectiveness.Subjects/setting Adult participants (224 men and 84 women) in the weight-loss modality of the Trials of Hypertension Prevention Phase I, surveyed in 1991.Statistical analyses performed χ² Analyses were used to test for statistical significance of group differences. Results Intervention components that were most useful are presented. Older participants (older than 50 years) were most likely to attend sessions and women were most likely to identify stress and frustration because of disappointing results. Successful participants were more likely to incorporate exercise into their daily activities, exercise regularly, and use self-monitoring strategies. Few participants found group exercise to be useful.Conclusion These findings suggest that interventionists in weight-loss programs need to find flexible and creative ways to maintain contact with participants, continue to develop better methods of self-monitoring, obtain the skills needed to recognize frustration and provide timely support, continue to couple the message of diet and exercise, and emphasize helping participants develop their problem-solving skills. This may require training outside the traditional field of dietetics. J Am Diet Assoc. 1999;99:66-71.     

How dietetics students like to learn: Implications for curriculum planners

Aim:  To investigate the learning styles of nutrition and dietetics students to assist in informing nutrition and dietetics curriculum methods, design and review.
Methods:  A total of 129 students from years one to four of a nutrition and dietetics undergraduate curriculum completed the Index of Learning Styles and the Kolb Learning Style Inventory to reveal their learning style preferences.
Results:  The Index of Learning Styles identified the students as learners who were intuitive (innovative), verbal (preferring spoken/written explanations) and global (preferring holistic approaches) while the Kolb Learning Style Inventory found that the students had an inclination towards converging (practical) and assimilating (reasoning) learning styles.
Conclusions:  Analysis of learning styles can assist curriculum change towards teaching strategies that suit students. Teaching and learning activities for dietetics students should be developed to strengthen reflective and emotional learning and to develop students' ability to appreciate different points of view. The finding that learning styles changed with year level requires confirmation via cohort studies.     

Influences on the Selection of Dietetics as a Career

Objective To gather information on the factors that influence students’ decisions to choose dietetics as a career.Design Self-administered questionnaires regarding the point at which career decisions were made were completed by 1,695 students in Plan IV/V dietetics programs throughout the United States.Subjects All Plan IV/V dietetics programs that reported greater than five graduates in the academic year 1989 to 1990 were selected from the 1990-1991 Directory of Dietetic Programs for the sample population. Of the 156 schools that were mailed questionnaires, responses were received from 84 schools (54%). Almost 90% of the students were women, 10.6% were men.Statistical analyses Data were analyzed using the Statistical Package for the Social Sciences. A χ² analysis was used to examine the relationship between point of decision and factors that influenced career choice, including people who influence career choice.Results The majority of students (55%) questioned reported making their career decision in college. Students rated interest in nutrition (96.3%) and job enjoyment (93.8%) as factors that were important in their decision to pursue a career in dietetics. College catalogs were rated by 48.3% of the students as being either useful or very useful in helping them make their career selection. With respect to gender differences, women rated a diverse work environment as being very important to their career decision more frequently than men (χ²=15.44, P<.01). Women were more likely than men to rate part-time work opportunities as being very important (χ²=26.75, P<.001); and selected working with people as being very important to their career decision (χ²=17.59, P<.01).Conclusions Findings identified that recruitment strategies need to be audience specific. Because career decision making appears to occur during one of three time frames (high school, college, or work experience), recruitment activities should be developed to specifically target students at these times. One way to increase the exposure of students to the profession of dietetics is for registered dietitians to give guest lectures in introductory college courses and high school upper-class courses in health, home economics, and biology. The use of university/college catalogs as effective marketing tools should also not be underestimated.Data suggest that gender differences exist in factors that influence persons to choose dietetics as a career. To increase the number of men who pursue careers in dietetics, future research should be designed to more fully explore gender differences, so that strategies to recruit more men into the profession can be developed. J Am Diet Assoc. 1997: 97;254–257.     

Introducing a problem-based unit into a lifespan nutrition class using a randomized design produces equivocal outcomes

Problem-based learning (PBL) is a tutorial, student-centered, problem-driven educational strategy adopted by medical and allied health educators to positively influence self-directed learning, critical thinking, and learning behavior. PBL was examined in dietetics education through random assignment of 32 undergraduate dietetics students for two weeks to either a problem-based or a lecture-based case format for the infant and elderly units of a 16-week lifespan nutrition course. Random assignment followed stratification for gender and earlier course examination performance. Expert validation of PBL curricular components and noted differences in discussion structure and information resources verified curriculum distinctiveness. Main outcome measures were pre- and post-Cognitive Behavior Survey scores for memorization, reflection, and positive learning experience scales, unit and course evaluations and unit examination scores. Students in problem-based modules demonstrated greater gains in reflective thinking with stable memorization, suggesting improved critical thinking skills. Tenets that problem-based learning promotes knowledge retention and provides a more positive learning experience were not upheld. Knowledge acquisition was not hindered by a problem-based approach. We conclude that gains in reflective thinking and evidence of increased self-directed learning argue for inclusion of PBL in dietetics curricula and that a problem-based education will help dietitians successfully respond to professional development needs.     

Clinical Reasoning and Reflective Practice: Implications of Fieldwork Activities

Objectives. Theories and research suggest that learning clinical reasoning skills requires students to be reflective in their practice. To explain this proposition, five research questions were developed to examine the effect of: (a) the fieldwork experience on clinical reasoning skills, (b) degree of participation in different clinical reasoning activities on clinical reasoning skills, and (c) the total number of clinical reasoning activities in which students participated related to clinical reasoning.

Method. Data (n = 70) were collected using a researcher-developed case analysis test, the Adaptive Style Inventory, and a questionnaire. Paired t tests, ANCOVA, and multiple regressions were used to analyze the data from the research questions.

Results. Fieldwork does improve clinical reasoning skills (large effect size). Participation in activities thought to develop clinical reasoning skills was mixed.

Conclusion. The results support the improvement of fieldwork as a mode of developing clinical reasoning skills in occupational therapy students.     

Nutrition Intervention Group Program based on Preaction-stage–oriented Change Processes of the Transtheoretical Model Promotes Long-term Reduction in Dietary Fat Intake

Objective To develop and evaluate the long-term effectiveness of an intervention program, based on preaction-stage–oriented change processes of the Transtheoretical Model of Behavior Change, that could be delivered in a group setting to help participants lower dietary fat intake.Design An enhanced version of the nonequivalent control group experimental design was used. Entire sections of an undergraduate introductory nutrition science course were assigned to an experimental, pretest/posttest control, or posttest-only control group. Daily fat intake and stage of change of the experimental and pretest/posttest control groups were determined at the pretest and posttest and 1-year later at a follow-up test. Every 1 to 2 weeks during the study, stage of change of the experimental group was assessed. Daily fat intake of the experimental group was assessed at study midpoint. Daily fat intake and stage of change of the posttest-only control group was determined at the posttest. Pretest results were used to place participants of the experimental and pretest/posttest control groups in either the preaction stage (ie, precontemplation, contemplation, or preparation) or the action/maintenance stage.Subjects/setting The sample consisted of 38, 30, and 42 undergraduate students who were assigned to the experimental, pretest/posttest control, and posttest-only control groups, respectively.Intervention The experimental group participated in a group-based, dietary fat intake intervention that included a series of 11 lessons taught over a 14-week period. Each lesson was based on 1 or 2 of the preaction-stage–oriented change processes of the Transtheoretical Model.Main outcome measures Data were evaluated to determine the effects of the intervention program on long-term dietary fat reduction and stage of change progression.Statistical analysis performed Analysis of variance, repeated-measures analysis of variance, and paired t tests.Results For pretest and posttest dietary fat intake scores, stage and time were significant, and there was a significant time-by-stage interaction. Time was significant for pretest and posttest stage scores. Subjects in the preaction-stage experimental group significantly increased their mean stage of change and reduced their fat intake between the pretest and posttest; these changes persisted for 1 year. Pretest/posttest control group participants who began in a preaction stage also significantly increased their mean stage and reduced fat intake by the posttest, but these changes did not endure until the follow-up test.Applications/conclusions This intervention program produced an enduring, significant reduction in mean dietary fat consumption and a significant progression in mean stage of change of subjects in the experimental group who were in the preaction stage. It may be appropriate to design group interventions to use preaction stage processes rather than the more traditionally used action and maintenance stages change processes. J Am Diet Assoc. 2000;100:335-342.