Assessment of Healthcare Professionals’ Knowledge About Warfarin-Vitamin K Drug-Nutrient Interactions

Objective: Dietary vitamin K can interact with oral anticoagulant drugs and interfere with their therapeutic safety and efficacy. Therefore, knowledge about drug-nutrient interactions involving vitamin K possessed by physicians, pharmacists, dietitians and nurses practicing anticoagulant therapy was assessed.

Methods: Healthcare practitioners were surveyed using a 30-question, 98-item questionnaire on the most common and/or important food interactions with warfarin, drug interactions with warfarin and general drug-nutrient interactions involving vitamin K. The study sample included 160 randomly selected healthcare providers (40 physicians, pharmacists, dietitians and nurses) from 10 hospitals with 200 to 1000 beds from six Massachusetts regions. Random selection was conducted from a pool of selected healthcare providers practicing anticoagulant therapy who counsel patients receiving warfarin.

Results: All surveys were completed within three months of the start of the study, and all participants provided usable data for statistical analysis. The mean scores (±SD) on the overall test were 72.5±9.0 for pharmacists, 62.5±10.6 for physicians, 56.9±8.8 for dietitians and 50.2±9.3 for nurses, with 100 being a perfect score. Pharmacists scored significantly higher in the area of drug interactions (75.9±11.3, p<0.05). Dietitians scored higher in the area of food interactions (73.0±10.3). No significant differences between physicians and pharmacists were evident on general drug-nutrient interactions. While over 87% of the healthcare professionals correctly identified some common foods containing large amounts of vitamin K, such as broccoli and spinach, fewer than 25% were able to identify others such as pea soup, coleslaw and dill pickles.

Conclusions: Although the healthcare professionals surveyed in this study appear to have demonstrated some proficiency in their respective areas of expertise, they exhibited less knowledge in others. Therefore, additional training and integration of knowledge and expertise about drug-nutrient interactions among healthcare professionals are essential to provide appropriate patient counseling and optimal therapeutic outcomes.     

Assessment of healthcare professionals' knowledge about warfarin-vitamin K drug-nutrient interactions

OBJECTIVE: Dietary vitamin K can interact with oral anticoagulant drugs and interfere with their therapeutic safety and efficacy. Therefore, knowledge about drug-nutrient interactions involving vitamin K possessed by physicians, pharmacists, dietitians and nurses practicing anticoagulant therapy was assessed. METHODS: Healthcare practitioners were surveyed using a 30-question, 98-item questionnaire on the most common and/or important food interactions with warfarin, drug interactions with warfarin and general drug-nutrient interactions involving vitamin K. The study sample included 160 randomly selected healthcare providers (40 physicians, pharmacists, dietitians and nurses) from 10 hospitals with 200 to 1000 beds from six Massachusetts regions. Random selection was conducted from a pool of selected healthcare providers practicing anticoagulant therapy who counsel patients receiving warfarin. RESULTS: All surveys were completed within three months of the start of the study, and all participants provided usable data for statistical analysis. The mean scores (+/- SD) on the overall test were 72.5+/-9.0 for pharmacists, 62.51+/-10.6 for physicians, 56.9+/-8.8 for dietitians and 50.2+/-9.3 for nurses, with 100 being a perfect score. Pharmacists scored significantly higher in the area of drug interactions (75.9+/-11.3, p<0.05). Dietitians scored higher in the area of food interactions (73.0+/-10.3). No significant differences between physicians and pharmacists were evident on general drug-nutrient interactions. While over 87% of the healthcare professionals correctly identified some common foods containing large amounts of vitamin K, such as broccoli and spinach, fewer than 25% were able to identify others such as pea soup, coleslaw and dill pickles. CONCLUSIONS: Although the healthcare professionals surveyed in this study appear to have demonstrated some proficiency in their respective areas of expertise, they exhibited less knowledge in others. Therefore, additional training and integration of knowledge and expertise about drug-nutrient interactions among healthcare professionals are essential to provide appropriate patient counseling and optimal therapeutic outcomes.     

Leadership in clinical dietetics: meeting the challenge to roles in nutritional support

The success of efforts to improve nutrition training of other health professionals poses a threat to the position of clinical dietitians as authorities in nutrition. In situations in which no dietitians are present or dietitians' skills are not recognized, pharmacists and nurses are especially likely to take over nutritional support roles traditionally assigned to the clinical dietitian. At the University of California, San Francisco, where dietitians are included in nutrition education and patient care programs and where understanding of the role of the dietitian is a stated educational goal, a preliminary survey suggests that conflicts occur in roles that are shared by members of nutritional support teams. Factors contributing to role conflicts include not only inadequate education of other health professionals but also problems of job expectations, education, training, and self-image among dietitians. Improved training in clinical nutrition, acquisition of better team and patient care skills, documentation of the effectiveness of dietetic services, and efforts to improve status and visibility would help alleviate role conflicts and ensure clinical dietitians a more rewarding place in the health care system.     

A Position Paper on How Cost and Quality Reforms Are Changing Healthcare in America

Healthcare spending in the United States is the highest in the world, yet quality indicators such as life expectancy and infant mortality lag other countries. U.S. reforms are under way to lower costs and raise quality of care, notably the Patient Protection and Affordable Care Act (PPACA). Value‐based purchasing (VBP) and programs for reducing the incidence of hospital‐acquired conditions (HACs) and hospital readmissions represent initial changes. With these programs, overarching themes are to coordinate care during and beyond hospitalization and to ensure that physicians and hospitals are aligned in their treatment strategies. Hospital malnutrition represents a large, hidden, and costly component of medical care; hospital administrators and caregivers alike must harness the benefits of nutrition as a vital component of healthcare. Medical, nursing, and allied health training programs must find places in their curricula to increase awareness of nutrition and promote knowledge of best‐practice nutrition interventions. Hospitals use dietitians and nutrition support teams as critical members of the patient care team, but more work needs to be done to disseminate and enforce best nutrition practices. Such training, nutrition interventions, and practice changes can help prevent and treat malnutrition and thus help avert HACs, reduce hospital readmissions, lower infection and complication rates, and shorten hospital stays. Nutrition care is an effective way to reduce costs and improve patient outcomes. This article calls hospital executives and bedside clinicians to action: recognize the value of nutrition care before, during, and after hospitalization, as well as develop training programs and policies that promote nutrition care.     

Translation of nutritional sciences into medical education: the Nutrition Academic Award Program

For the past 40 y the scientific community has decried the inadequacy of the training of physicians and other health professionals in the subject of human nutrition. In 1997 the National Heart, Lung, and Blood Institute developed the Nutrition Academic Award (NAA) Program, an initiative to improve nutrition training across a network of US medical schools. The purpose of this funding, which began in 1998, is to support the development and enhancement of nutrition curricula for medical students, residents, and practicing physicians to learn principles and practice skills in nutrition. The NAA recipients developed the Nutrition Curricular Guide for Training Physicians, a plan to incorporate clinical guidelines into physician practice skills, create educational and assessment practice tools, and evaluate curricula, materials, and teaching tools. Dissemination of NAA activities and materials will be facilitated by a national website, presentations and publications, and consultants and advisors from the NAA nutrition education programs. The NAA Program constitutes a major new effort to enhance nutrition knowledge and skills among health care providers and to effectively apply the science of human nutrition to clinical medicine. This article describes the purpose and aims of the NAA Program, the organizational structure of the network of recipients, a profile of the recipients and individual programs at 21 medical schools, the various strategies to overcome barriers in training physicians in human nutrition, and collaborative and dissemination efforts.     

Health care providers' attitudes toward nutrition

A survey questionnaire, assessing general attitudes toward the importance of nutrition in the prevention of disease and the maintenance of good health, was administered to physicians, nurses, dentists, and technicians at five U.S. Army medical centers. The various groups of health care specialists differed significantly on many items concerning the importance of good nutrition and eating habits for maintenance of good health and for recovery from illness, as well as on items concerning the importance of nutrition knowledge and training in their health care professions. More agreement was found among the groups on items concerned with the relationship between disease states and dietary factors and the effectiveness of health education programs in the prevention of various diseases. Self-reports of personal health habits did not correlate with scores on survey items concerned with the importance of good nutrition, suggesting that personal attitudes toward nutrition may be unrelated to other health practices.     

Peer Reviewed: Therapeutic Lifestyle Strategies Taught in U.S. Pharmacy Schools

Introduction

Several organizations representing pharmacy and other health professions stress the importance of teaching public health topics as part of training future practitioners. The objective of our study was to assess the number of U.S. pharmacy schools that incorporate lifestyle modification topics into their curricula.

Methods

We developed an electronic survey on lifestyle modification topics and sent it to each of the 89 pharmacy schools in the United States. The survey defined lifestyle modification topics as topics that address nutrition, exercise, weight loss, smoking cessation, and alcohol use.

Results

Of 89 pharmacy schools contacted, 50 (56%) responded to the survey. Of the 50, four offer at least one required course in a lifestyle modification topic, seven offer at least one elective course, and one offers a required course that incorporates more than one lifestyle modification topic. Five required and nine elective courses were identified from the responses. Nutrition was the most commonly offered required course topic, followed by smoking cessation, exercise, weight loss, and alcohol use.

Conclusion

Few pharmacy schools are addressing recommendations to promote public health education through formalized didactic courses. More courses on lifestyle modification topics should be offered to pharmacy students, who will be highly accessible to the public as pharmacists and will be able to offer education to enhance public health focused on the prevention of chronic diseases.     

Consensus Recommendations for Optimizing Electronic Health Records for Nutrition Care

Provision of nutrition care is vital to the health and well-being of any patient who enters the health care system, whether in the ambulatory, inpatient, or long-term care setting. Interdisciplinary professionals—nurses, physicians, advanced practice providers, pharmacists, and dietitians—identify and treat nutrition problems or clinical conditions in each of these health care settings. The documentation of nutrition care in a structured format from screening and assessment to discharge allows communication of the nutrition treatment plans. The goal of this document is to provide recommendations to clinicians for working with an organization’s Information Systems department to create tools for documentation of nutrition care in the electronic health record. These recommendations can also serve as guidance for health care organizations choosing and implementing health care software.     

The role of the clinical dietitian: I. Present professional image and recent image changes

This study was designed to assess the image of dietitians in the hospital setting. Fifty persons in each of six health professions responded to a telephone questionnaire. The six health professions were nutrition support dietitians, general clinical dietitians, directors of nursing, hospital administrators, chief dietitians, and physicians. Respondents were selected from relatively large hospitals (greater than 200 beds) that were distributed geographically across the United States. Results indicated that nutrition support dietitians had a more positive view of how their profession was viewed by others than did general clinical dietitians. A larger proportion of nutrition support dietitians than of general clinical dietitians believed that they were viewed as working with specialized patients (14% vs. 9%), as an important part of the hospital team (20% vs. 6%), and as acting as a resource person for the medical staff (30% vs. 13%). Physicians and chief dietitians held the strongest opinions concerning the image of the nutrition support and general clinical dietitians; both held a more positive view of the nutrition support dietitian. A greater number of physicians expressed the view that nutrition support dietitians were more competent and knowledgeable than were general clinical dietitians (24% vs. 9%) and were an important part of the hospital team (36% vs. 15%). A greater percentage of chief dietitians said that nutrition support dietitians, in comparison with general clinical dietitians, were competent and knowledgeable (40% vs. 19%) and professional, well respected, expert, and more specialized (65% vs. 44%). In comparison with 5 years ago, 76% and 69% of nutrition support and general clinical dietitians, respectively, thought that they are now viewed as more professional and as having abilities that are recognized.     

Nutritional education in public health services

The purpose of this study was to discuss the implementation of nutritional education in public health services from the perspective of health professionals (physicians and nurses) working in them. The study was conducted in the Municipality of Campinas, S?o Paulo State, Brazil, from October 1993 to July 1995, using action-based research methodology. The results describe the construction of nutritional knowledge in training and professional institutions; behavior towards food-related problems in daily professional experience as compared to personal life; the contradiction between the apparently trivial act of eating and the complexity of dietary problems; the interface between the acceptance of this work and the incorporation of nutritional education activities and their actual institutionalization; and health professionals' opinions concerning situations permeating the implementation of activities. The paper concludes by referring to the need to implement nutritional education activities, difficulties experienced by physicians and nurses in approaching nutritional problems, and the importance of including nutrition in the curricula of health courses.     

Knowledge translation in interprofessional education: what difference does interprofessional education make to practice?

Cancer Care Nova Scotia developed an Interprofessional Core Curriculum for Nova Scotia health professionals, using a provincial educational needs assessment of health professionals caring for patients with cancer. This paper reports on the educational outcomes of the Interprofessional Core Curriculum programme, particularly the translation of learning into changes in practice and interprofessional interaction, and factors influencing change. The evaluation was guided by Kirkpatrick's model for assessing educational outcomes and Green and Kreuter's PRECEDE model of factors promoting and impeding change. In total, 411 participants attended the sessions, including nurses (54%), pharmacists (23%), and physicians (11%). We used self-report questionnaires to assess the transfer of learning into changes in practice and interprofessional interactions. High percentages of participants reported changes in both clinical practice and interprofessional interactions 3 months after the sessions. Frequently reported changes to interprofessional interactions were improved communication, increased confidence and assertiveness in interactions with other health professionals and being more respectful of other professions. Participants identified time and work-load as major barriers to change as well as lack of micro- and macro-system level support. The most common reported enabler of change was having attended the educational session. Overall, participants were highly supportive of interprofessional education, although when compared to nurses and pharmacists, physicians were less supportive and had proportionately lower attendance.     

Longitudinal and horizontal integration of nutrition science into medical school curricula

The overall goal of our Nutrition Academic Award (NAA) medical nutrition program at Mercer University School of Medicine is to develop, implement and evaluate a medical education curriculum in nutrition and other aspects of cardiovascular disease (CVD) prevention and patient management with emphasis on the training of primary care physicians for medically underserved populations. The curriculum is 1) vertically integrated throughout all 4 y of undergraduate medical education, including basic science, clinical skills, community science and clinical clerkships as well as residency training; 2) horizontally integrated to include allied healthcare training in dietetics, nursing, exercise physiology and public health; and 3) designed as transportable modules adaptable to the curricula of other medical schools. The specific aims of our program are 1) to enhance our existing basic science problem-based Biomedical Problems Program with respect to CVD prevention through development of additional curriculum in nutrition/diet/exercise and at-risk subpopulations; 2) to integrate into our Clinical Skills Program objectives for medical history taking, conducting patient exams, diet/lifestyle counseling and referrals to appropriate allied healthcare professionals that are specific to CVD prevention; 3) to enhance CVD components in the Community Science population-based medicine curriculum, stressing the health-field concept model, community needs assessment, evidence-based medicine and primary care issues in rural and medically underserved populations; 4) to enhance the CVD prevention and patient management component in existing 3rd- and 4th-y clinical clerkships with respect to nutrition/diet/exercise and socioeconomic issues, behavior modification and networking with allied health professionals; and 5) to integrate a nutrition/behavior change component into Graduate Residency Training in CVD prevention.     

A Global Survey of Occupational Health Competencies and Curriculum

Abstract

The World Health Organization has identified a world-wide shortage of occupational health professionals, but evidence suggests that the work and education of these professionals vary across countries. This survey examined the professionaldeveloprnent of occupational physicians, occupational nurses, industriaL hygienists, and ergonomists in terms of practice competencies and academic curriculum. Of 89 countries that received the survey, 48 (54%) responded. Important differences in competencies and curricula were identified for all groups. More competencies were identified more frequently in deyeloped countries. Academic programs existed more often in developed countries, but curriculum contentsvaried. The study provides a concrete reference point for discussion and developtnentof competencies and curriculum.     

Financing nutrition services in a competitive market

Budget deficits and inflationary medical care costs threaten nutrition services, which until recently have been funded largely by federal, state, and local revenues. Nutritionists and dietitians responding to demands in the marketplace should develop innovative programs and pursue new sources for financing through the private sector, third-party payers, business/industry health promotion, and consumer fees for their services, as well as targeted federal, state, and locally funded food assistance, nutrition education, and health care programs. Trail-blazing dietitians are successfully offering their services in health maintenance organizations (HMOs), hospital or industry fitness programs, private practice, voluntary health agencies, and official agency programs. With the new federalism, nutritionists must articulate their role in comprehensive health care and market their services at the state and local levels in addition to the federal level. Nutrition services are defined to include assessment, planning, counseling, education, and referral to supportive agencies. Data management, managerial, and marketing skills must be developed for dietitians to compete effectively. Basic educational preparation and continuing education for practicing professionals must develop these competencies.     

20th Lenna Frances Cooper Memorial Lecture: Nutrition: an integral aspect of medical education

Meaningful and effective clinical nutrition must be solidly rooted in the concept that nutrition is an essential component of health, health care, and life itself. During the past decade a variety of factors have contributed to a definite movement toward greater emphasis on nutrition in medical education. More and more registered dietitians are involved in professional collaboration with physicians in nutrition education. In accepting the challenges of the 1980s, we have come to realize the positive and dynamic role that is ours to play in the movement of increased emphasis on nutrition education for physicians and other health care professionals.     

Prevalence of dietitian burnout

Background: Burnout is the result of unmanaged stress that has been shown to affect those working in the healthcare professions. Although much research has been conducted on burnout among nurses, physicians and other health professionals, there is limited documentation on the phenomenon among dietitians. The purpose of this study was to establish the prevalence of burnout among dietitians in Ontario, Canada, determine the demographic variables associated with burnout, and compare these results with burnout data for other healthcare professionals. Methods: The Maslach Burnout Inventory–Human Services Survey and a demographic questionnaire were emailed to registered dietitians. Results: The dietitians surveyed experienced a moderate amount of emotional exhaustion (mean = 19.96), a low level of depersonalisation (mean = 4.31) and a moderate sense of personal accomplishment (mean = 38.61). Statistically significant relationships were found between years as a dietitian and personal accomplishment (r = 0.16; P = 0.05), age and personal accomplishment (r = 0.15; P = 0.01), hours worked per week and emotional exhaustion (r = 0.17; P = 0.01) and hours worked per week and depersonalisation (r = 0.14; P = 0.01). There were no significant differences in mean burnout scores across the five areas of practice. Over 57% of dietitians had scores indicative of moderate to high levels of burnout overall. Conclusions: Although dietitians have lower levels of burnout compared to other healthcare professionals, moderate levels of emotional exhaustion and only moderate levels of personal accomplishment remain workplace issues for this professional group.     

Enteral nutrition: beliefs and practices of physicians and dietitians in one hospital

Establishing an enteral nutrition formulary for a hospital requires critical evaluation of all nutrition products and examination of the population to be served. A careful determination of the needs of each patient should precede selection and administration of any product. Monitoring nutrition therapy should be a combined effort of physicians and dietitians, emphasizing both nutrition and metabolic indexes. Finally, education must be provided to physicians and other health care professionals so that the skills and clinical expertise of the registered dietitian in nutrition and enteral nutrition support are recognized and utilized.     

Nutrition education in health professions programs: a survey of dental, physician assistant, nurse practitioner, and nurse midwifery programs

OBJECTIVE: This study determined the perceived needs and curriculum recommendations for nutrition education, and expected competencies in nutrition of graduates, of predoctoral dental, physician assistant, nurse practitioner, and midwifery programs. SUBJECTS: Surveys were mailed to all dental schools (n = 54) and physician assistant (n = 95), nurse practitioner (n = 150), and certified nurse midwifery programs (n = 42) in the United States. Surveys were addressed to the program directors of physician assistant, nurse practitioner, and certified nurse midwifery programs and the associate or assistant dean of academic affairs of dental schools. DESIGN: A 4-page survey was designed and pilot-tested. The survey included questions on respondents perceptions of and recommendations for their programs in nutrition education and expected nutrition competence level of their graduates. A reminder postcard was mailed 2 weeks after the initial mailing to nonrespondents; a second survey was mailed to nonrespondents 1 month after the postcard mailing. STATISTICAL ANALYSES: Data were analyzed using JMP-IN software. Frequencies, and chi 2 analyses, Wilcoxon rank sum test, Pearson chi 2 test. RESULTS: The overall response rate was 80.7% (n = 276). Perceived needs for competence in nutrition varied by respondents. Most of the physician assistant nurse midwifery, and nurse practitioner program directors had similar perceptions of graduates' competence in nutrition. Dental school academic administrators differed significantly from the program directors about the perceived need for knowing how to counsel on a modified diet and how and when to refer to a registered dietitian. Time was the most important factor that would enhance provision of nutrition education in the programs. Computer-based programs were the most frequently requested education tool to enhance nutrition education. APPLICATIONS/CONCLUSIONS: The disciplines agreed that graduates of dental schools and physician assistant, nurse practitioner, and nurse midwifery programs need some level of competence in nutrition relative to their discipline. Registered dietitians involved in health professions education can play an active role in developing practice-based, time-sensitive, and flexible strategies for nutrition education of these health professions groups.     

Developing a tool for health professionals involved in producing and evaluating nutrition education leaflets

Introduction Nutrition education leaflets are widely used by dietitians and many dietitians are also involved in their production. However, there does not appear to be a suitable tool to assist health professionals to produce or evaluate nutrition education leaflets. There are Guidelines available that are either specifically concerned with nutrition but for all educational materials or specifically for use with leaflets, but not necessarily to do with nutrition. The aim of this study was to develop a tool suitable to assist health professionals when producing and evaluating nutrition education leaflets.
Methods Patients and dietitians were surveyed by self-completion questionnaire to determine their opinions of the importance of various criteria which might be applied to nutrition education leaflets were.
Results The research revealed significant differences in the opinions of dietitians and patients for seven of 11 criteria.
Conclusion The evaluation tool developed was based on the patients' ranking of all the criteria. Its reliability was assessed amongst a group of dietitians in Dorset but its wider use and acceptability should be looked at. The tool is likely to be appropriate as a checklist for health professionals producing new nutrition education leaflets or as a framework for evaluating existing nutrition education leaflets.     

Sustainable eating: Opportunities for nutrition professionals

Increasing demand for food from a growing human population is leading to adverse environmental and health consequences. The emerging topical issue of sustainable eating and diets might offer new opportunities for the training of nutrition professionals. Ongoing research is uncovering synergies between how dietary patterns can meet both health and environmental goals. Yet this area is a challenge for the nutrition professions, as relevant education often involves politically driven, systems leadership‐style thinking, which is drawn from a less familiar evidence base than traditional nutritional sciences. As pressures mount to achieve sustainability agenda goals, new evidence appraisal and educational input are essential to support the potential role of nutrition professionals. This article appraises sustainable eating and diets, as well as considering the value of better education to be embedded more consistently within nutrition curricula and Continued Professional Development (CPD), to achieve sustainability literacy for nutrition professionals. The importance of stronger advocacy skills and collaborative leadership is also highlighted, as well as the need for more effective high‐level policy involvement. Recommendations for how nutrition professionals can be more effectively equipped for this emerging and dynamic area of professional practice are provided.