Effectiveness of an enhanced peer assessment program: introducing education into regulatory assessment

INTRODUCTION: The College of Physicians and Surgeons of Ontario developed an enhanced peer assessment (EPA), the goal of which was to provide participating physicians educational value by helping them identify specific learning needs and aligning the assessment process with the principles of continuing education and professional development. In this article, we examine the educational value of the EPA and whether physicians will change their practice as a result of the recommendations received during the assessment. METHODS: A group of 41 randomly selected physicians (23 general or family practitioners, 7 obstetrician-gynecologists, and 11 general surgeons) agreed to participate in the EPA pilot. Nine experienced peer assessors were trained in the principles of knowledge translation and the use of practice resources (tool kits) and clinical practice guidelines. The EPA was evaluated through the use of a postassessment questionnaire and focus groups. RESULTS: The physicians felt that the EPA was fair and educationally valuable. Most focus group participants indicated that they implemented recommendations made by the assessor and made changes to some aspect of their practice. The physicians' suggestions for improvement included expanding the assessment beyond the current medical record review and interview format (eg, to include multisource feedback), having assessments occur at regular intervals (eg, every 5 to 10 years), and improving the administrative process by which physicians apply for educational credit for EPA activities. CONCLUSIONS: The EPA pilot study has demonstrated that providing detailed individualized feedback and optimizing the one-to-one interaction between assessors and physicians is a promising method for changing physician behavior. The college has started the process of aligning all its peer assessments with the principles of continuing professional development outlined in the EPA model.     

Planning for continuing education: goal setting and self-assessment

The American Dietetic Association placed the responsibility for professional growth and development on individual dietitians when the membership voluntarily accepted registration in 1969. One goal of registration was to improve individual competency of dietitians through their participation in continuing education activities. Such participation, to be effective, requires self-assessment of needs, formulation of goals, and the setting of priorities for learning. A recent study revealed, however, that only 20% of registered dietitians desire to assess their own learning needs and to plan their own continuing education experiences to meet those needs. This discrepancy between the goals of the professional association and the behavior of individual members may be a result of members not knowing about ways to plan effectively for their own professional growth. The "Well-Dones" method is presented as a tool for dietitians to use in planning their own learning by determining needs, setting goals, and assessing achievements. Professional concern over the improvement of competency through continuing education should be a matter of importance for each registered dietitian.     

Review of specialist dietitian services in patients with inherited metabolic disease in the United Kingdom

INTRODUCTION: Dietary management forms the mainstay of treatment for many inherited metabolic diseases (IMDs) and specialist dietitians play a crucial role in the multi-disciplinary core team for these patients. Professional concerns have been expressed that the current clinical workforce is inadequate for meeting current and future service demands. The aim of this work was to describe the provision of specialist dietetics to patients with IMD as part of a national needs assessment and review. MATERIALS AND METHODS: The 24 main specialist providers and 27 specialist dietitians were surveyed by a questionnaire. A focus group of three specialist dietitians was also held to explore the roles of specialist dietitians in greater depth. RESULTS: Responses were received from all 24 specialist service providers and 63% of 27 specialist dietitians. The majority of service providers (92%) have specialist dietitians, but only eight services had more than one whole time equivalent (33%). Key roles were management of complex dietary regimens, prevention and management of metabolic crises, education, co-ordination of care, clinical audit and research. Although highly qualified, there is currently no clear formal career structure or training pathway for dietitians in IMDs. CONCLUSION: Specialist dietitians have important clinical and leadership roles in managing IMD but specialist services are thinly spread. There is a need for access to formal education, training and support programmes. The clinical workforce needs expansion to provide more comprehensive and equitable services.     

Use and barriers to use of laboratory data by clinical dietitians

The results of this study reveal two general areas of concern for clinical dietitians in the use of laboratory data--their lack of confidence in their own interpretive skills and the perceived resistance of physicians. Although clinical dietitians receive theoretical and applied training on the use of laboratory values in their undergraduate education and dietetic internship, clinical managers should be aware that they need support and continuing education to use their laboratory assessment skills to the fullest. Also, dietitians should demonstrate more clearly to physicians their knowledge, skill, and needs in this area. They should initiate and continue dialogue about the importance of laboratory analysis to nutrition care and improved patient outcome. Evidence-based data and clear documentation of improved medical outcomes should help overcome barriers to use of laboratory data by clinical dietitians.     

Going rural but not staying long: Recruitment and retention issues for the rural dietetic workforce in Australia

Aim: To determine the recruitment and retention issues for rural based dietetic services. Methods: A sequential explanatory mixed methods approach was used to examine six case study sites of dietetic practice, in a geographical area covering 30 000 km² in rural New South Wales, Australia. Quantitative data were obtained from document searches of human resource records between 1991 and 2006. Data were tabulated and counts and proportions used. Qualitative data were obtained from in-depth semistructured individual interviews conducted with 40 key informants including past and present dietitians (n = 28), dietetic managers (n = 3), health service managers (n = 6) and other key influencers (n = 3). The interviews were thematically analysed using the NVivo 7 program. Themes were coded into common categories, using a constant comparison inductive approach. Results: Ninety individual dietitians (94% female) were employed across the six sites over 15 years. The majority were new graduates with less than 1 year of experience. Approximately one-third remained in their position for less than 6 months while 32% remained for 2 years or longer. Key themes emerged from the qualitative data around the characteristics of a rural role, line management of dietitians in a rural site and establishing and maintaining rural staff. Conclusion: Recruitment and retention in rural areas may be improved in the future through strategies to reduce perceived professional isolation, improve management support, access to continuing education and the development of career pathways.     

A computer application for dietary analysis in clinical nutrition.

The computerized dietary assessment system developed at Chedoke-McMaster Hospitals, to assist dietitians with routine calculation of nutrient intakes of patients, as a component of clinical nutrition assessment is described. The program was designed for dietary assessments of hospitalized patients and ambulatory patients, and to facilitate teaching students about dietary management of medical nutrition problems. To meet program objectives, efforts were directed toward software development, with flexibility to meet the needs of a wide variety of users, to accommodate rapidly changing nutrient composition data, to allow tailoring of the database to individual clinical settings, and for future expansion. The regionally accessible dietary assessment system is easy to use and is rapid, requiring 10 to 15 minutes to complete each one-day assessment. The program has been well accepted and utilized by hospital nutritionists in several clinical areas, for establishing dietary goals, monitoring progress, and in patient education.     

Assessment in postgraduate dental education: an evaluation of strengths and weaknesses

This paper describes a study designed to evaluate assessment in postgraduate dental education in England, identifying strengths and weaknesses and focusing specifically on its relevance, consistency and cost-effectiveness. METHODS: A four-phase qualitative method was used: a mapping of current career paths, assessment policy, and issues (phase 1); more detailed studies of the practice of assessment for a range of courses, and the systemic/management perspective of assessment (i.e. quality assurance) (phases 2 and 3), and analysis and reporting (phase 4). Data were analysed from documents, interviews, group consultations and observations. RESULTS AND DISCUSSION: Five key issues may be distilled from the findings: (i) lack of formal assessment of general professional training; (ii) trainer variation in assessment; (iii) the extent to which assessments are appropriate indicators of later success; (iv) the relationship between assessment and patient care, and (v) data to assess the costs of assessment. CONCLUSION: Current assessment procedures might be improved if consideration is given to: assessment which supports an integrated period of general professional training; training for trainers and inspection procedures to address variation; more authentic assessments, based directly on clinical work and grading cases and posts, and better data on allocation of resources, in particular clinicians' time given to assessment.     

Talk-back television: continuing education for the 1980s

Sixty-seven dietitians (N = 67) who participated in a talk-back television course in June 1981 were solicited for information to evaluate this method of continuing education. Responses (90%) supported data in the professional literature which specified that cost and distance deterred attendance at continuing education programs. Although problems such as technical difficulties and impersonal nature were identified with talk-back television, the majority of respondents (83%) gave it positive ratings and stated that they would participate in other such programs. Improvements need to be considered to enhance the attractiveness of this mode of learning for dietitians, but during the financial retrenchment of the 1980s, talk-back television appears to be supported as cost-effective and desirable.     

Treating malnutrition in AIDS: comparison of dietitians' practices and nutrition care guidelines

The acquired immunodeficiency syndrome (AIDS) is a complex disease; its manifestations include many opportunistic infections that lead to conditions causing severe malnutrition. Overcoming malnutrition can help AIDS patients increase their weight, improve their self-image, and enhance the quality of their lives. Thirty-eight dietitians who work with AIDS patients in New York City were surveyed to determine whether their facilities followed 40 suggested guidelines for the assessment and treatment of malnutrition in AIDS. Thirty dietitians (80%) reported that their facilities followed more than half of the suggested guidelines. Many guidelines were "always" followed by a majority of facilities. Those not followed might provide a focus for dialogue among practitioners with regard to nutrition care procedures. Thirty-two (84%) dietitians reported receiving AIDS education, including in-service programs (n = 18), professional meetings (n = 27), and formal education (n = 3). AIDS education in both undergraduate and graduate curriculums and additional continuing education programs are needed. Persons with AIDS are at high risk for nutrition-related disorders. Practitioners need to know and apply nutrition care guidelines suggested in the literature to improve the quality of care for this growing population.     

Assessing continuing education needs of five allied health professions in rural California.

Meeting the needs of rural health care professionals for continuing education remains a challenge for health planners. An assessment of these needs is the focus of this survey of rural practitioners. A continuing education needs survey of five allied health professions in an agricultural region of California was conducted. Variables selected related to professional education and retention and included paramedics, physical therapists, pharmacists, clinical psychologists, and medical technologists. Results indicated a strong need for high quality, moderate cost, locally offered continuing education seminars. Access to professional literature searches was also regarded as important. Several of the selected health profession groups were concerned about maintaining licensure; most intended to remain in their professions for at least six to ten years. These survey findings clearly suggest a need for centrally coordinated continuing education opportunities for allied health personnel in rural service delivery areas.     

Melbourne dietitians' experience of Medicare policy on allied health services (strengthening Medicare; Enhanced Primary Care) in the first 12 months

Objective: To describe Victorian private practitioner dietitians’ experience of the Enhanced Primary Care (EPC) program funded under national heath insurance. Design: Dietitians’ experience of the EPC program was investigated between August 2004 and July 2005. A purposive sample of 10% (n = 15) of Victorian dietitians in private practice was interviewed via semi‐structured interviews or focus groups. Focus group/interview data were audio‐taped, transcribed verbatim and thematically analysed using NVIVO software to manage data. Subjects: Victorian dietitians. Setting: Dietetic private practice. Main outcome measures: Issues identified from narrative themes. Results: Thirteen (86%) participants were registered with the Medicare Australia and managed EPC‐referred patients. Two chose not to. All those using the program supported it but voiced frustrations experienced in the first year. Five themes emerged from narrative analysis involving difficulties with implementation in the following areas: referral issues, client preparedness, annual number of consultations limit, impact of financial cost on client and non‐reimbursed administration costs. Conclusion: For clients with chronic illness, access to dietitians in private practice under Medicare EPC is an important service. As increasing numbers of dietitians nationally work with EPC patients with chronic illness or complex care needs, there is a need for information sharing between professional groups about billing procedures and chronic care management. More dietitians need to structure practice to initiate bulk‐billing. Rigorous evaluation is needed to understand which diagnosis types can benefit from the program and to implement an evidence‐based model of chronic care improvement for dietetics consultations.     

Perceived needs of Canadian dietitians for continuing education in management.

The purpose of this research was to assess the perceived needs of Canadian dietitians for continuing education in management both currently and as they plan for advancement, career change and development. A self-assessment questionnaire was mailed in January 1985 to 1000 members of the Canadian Dietetic Association (CDA) selected by a systematic randomized technique. Analysis of 450 anonymous questionnaires from employed CDA members showed that 77% were employed full-time and 23% part time. The analysis indicated a profession with a young membership of an eight-year mean and a six-year median in full time practice. A ranked ordering of the types of positions to which dietitians aspired was chief administrative dietitian, consultant, positions in other administration, and then private practice. Personnel and financial management were very important areas for current positions and were expected to be even more so in future. Respondents cited salient factors regarding continuing education programs and prioritized their need for several management topics. These topics were further analyzed according to the present positions of the respondents. This research supports the need for high quality continuing education programs in management for practising dietitians.     

Registered dietitians' use of physical assessment parameters in professional practice

OBJECTIVE: To examine how registered dietitians who have completed one of two physical assessment programs use the knowledge and skills learned in practice and whether method of instruction had an affect on use of skills in practice. SUBJECTS/SETTING: Surveys were mailed to 891 persons, all of whom completed a Dietitians in Nutrition Support dietetic practice group or University of Medicine and Dentistry of New Jersey continuing education program. Four hundred seventeen surveys were returned and 407 were usable. STATISTICAL ANALYSIS: chi(2) analysis and stepwise logistic regression was used to analyze the data. Statistical significance was P=.05. RESULTS: Sixty percent of respondents worked in a clinic setting. Four of the five most-used competencies were similar between the two programs. More registered dietitians are using physical assessment competency information in clinical assessment, but not performing the competencies independently. Respondents with the Certified Diabetic Educator credential (P=.007) and Certified Nutrition Support Dietitians credential (P=.215) were more likely to use select physical assessment competencies. Confidence was reported as enhancing use of physical assessment competencies (n=153, 45%) and time was a barrier to using physical assessment competencies (n=159, 52%). APPLICATIONS/CONCLUSIONS: There were no significant differences in use of physical assessment competencies between the University of Medicine and Dentistry of New Jersey program and the Dietitians in Nutrition Support program. Although not statistically significant, there appeared to be more use of physical assessment competencies by those who received additional training and those who completed the University of Medicine and Dentistry of New Jersey program. This study reveals that registered dietitians are using the values in clinical assessment, however they must move to actually performing physical assessment competencies in practice.     

Continuing education needs of registered dietitians regarding nutrigenomics

The purpose of this study was to assess continuing education needs for registered dietitians regarding application of the science of nutritional genomics in clinical settings. A cross-sectional survey was mailed to a random national sample of 2,500 registered dietitians with a 40% response rate (n=995). The survey assessed knowledge; attitudes related to benefits and barriers to application; perceptions of consumer motivators and barriers; attitudes regarding ethical, legal, and social issues; and preferences for continuing education. Differences were determined according to year of registration using nonparametric Kruskal-Wallis tests. Survey respondents had little previous exposure to nutrigenomics, had not applied nutrigenomics in their practice in the past year, and were not confident in their ability to apply nutrigenomics in a clinical setting, but were interested in learning more about its application. Few differences existed in attitudes about benefits and barriers to application of nutrigenomics by year of registration. The most favored learning activity for continuing education was seminars/workshops. The most important content areas for continuing education were foundational knowledge, application, and communication to the lay public. Continuing education should focus on these content areas to allow application based on the supporting science and ways to effectively communicate the information to consumers.     

Clinical education in private practice: an interdisciplinary project

Education of rehabilitation professionals traditionally has occurred in acute care hospitals, rehabilitation centres, and other publicly funded institutions, but increasing numbers of rehabilitation professionals are now working in the community in private agencies and clinics. These privately owned clinics and community agencies represent underutilized resources for the clinical training of students. Historically, private practitioners have been less likely to participate in clinical education because of concerns over patient satisfaction and quality of care, workload, costs, and liability. Through a program funded by the Ministry of Health of Ontario, we conducted a series of interviews and focus groups with private practitioners, which identified that several incentives could potentially increase the numbers of clinical placements in private practices, including participation in the development of student learning objectives related to private practice, professional recognition, and improved relationships with the university departments. Placement in private practices can afford students skills in administration, business management, marketing and promotion, resource development, research, consulting, networking, and medical-legal assessments and processes. This paper presents a discussion of clinical education issues from the perspective of private practitioners, based on the findings of a clinical education project undertaken at Queen's University, Kingston, Ontario, and previous literature.     

Dietetics professionals have a positive perception of professional development

This study summarizes the perceptions towards the Professional Development Portfolio method of recertification and attitude towards professional development of dietetic professionals as measured in the national pilot study of the Portfolio. Portfolio compared to control respondents had greater awareness, and better understanding and knowledge of the Portfolio process after using the Portfolio guide. The perception that the Portfolio process will aid in maintaining competence did not differ between groups. The perception that self-reflection aided in determining career goals and confidence to conduct a learning needs assessment differed slightly between groups. Both groups had a positive attitude towards professional development and that continuing professional education (CPE) improved competence. All perceptions and attitudes were positive. The focus of CPE in foods, business, management, education, and research did affect the ability of dietetics professionals to find appropriate CPE. Rural and unemployed respondents had more difficulty finding appropriate CPE. The findings indicate that the Portfolio guide aides the dietetics professional using the Portfolio process and that the perception towards the Portfolio process is positive. Some dietetics professionals with different CPE focus had difficulty finding appropriate CPE, and this did not differ by control and Portfolio group. More innovative methods of CPE delivery may need to be considered for these practitioners.     

Self-completed online dietary recalls as an alternative method of dietary assessment for dietetic outpatient appointments: A feasibility study

Background

Integrating digital dietary assessment within dietetic care could save time and reduce costs, at the same time as increasing patient engagement. The present study explores the feasibility of implementing a web-based dietary assessment tool, myfood24 ( https://www.myfood24.org ), into routine healthcare.

Methods

This mixed methods feasibility study recruited dietitians and patients from a National Health Service (NHS) hospital outpatient setting. Patients completed and shared three online 24-h dietary recalls in advance, which were used as a dietary assessment by dietitians. Recruitment data were collected and questionnaires on technology, usability, and acceptability were completed. Patient interviews and focus groups with dietitians were conducted.

Results

Eleven dietitians working in allergy, bariatrics, diabetes, oncology, general, renal, infectious diseases, and coeliac services took part with 39 patients. Recruitment rates were highest in bariatrics and lowest in renal and oncology. Compared to other studies, completion rates were good, with 29 (74.4%) completing three recalls despite lower technology readiness and software usability scores than in similar studies. Illness and difficulty with technology were reasons for non-completion. Opportunity to receive nutritional feedback from the tool and share this with a dietitian motivated patients to complete the record accurately. Consultation times were shortened in approximately one-third of appointments and a higher proportion of time was spent on nutritional education compared to usual practice. However, mean preparation time increased by 13 min per appointment because dietitians found nutritional analysis reports difficult to interpret.

Conclusions

It is feasible to introduce a digital dietary assessment tool into NHS dietetic practice. However, further development is needed to ensure that the tool is suitable for healthcare.