Identifying and Mapping Canadian Dietetic Students’ Interaction(s) with Simulation-Based Education: A Scoping Review
Publication: Canadian Journal of Dietetic Practice and Research
12 July 2023
Abstract
This scoping review mapped literature available on Canadian dietetics, nutrition, and foods students’ and graduates’ interaction(s) with simulation-based education (SBE) during undergraduate and/or practicum. One certified Librarian led the preliminary search (Summer, 2021), while three Joanna Briggs Institute-trained reviewers conducted the comprehensive search via MEDLINE (OVID), CINAHL (EBSCO), Academic Search Premier (EBSCO), Embase (Elsevier), Scopus (Elsevier), and Google (February 2022). A data extraction tool designed specifically for the study objectives and research inclusion criteria was used. We recorded 354 results and included 7. Seven types of SBE were recorded: (i) comprehensive care plan (n = 2); (ii) nutritional diagnosis/assessment (n = 2); (iii) body composition assessment (n = 1); (iv) introducing patient to dysphagia care (n = 1); (v) nutrition counselling session (n = 1); (vi) nutrition-focused physical examination (n = 1); and (vii) professional communications via social media (n = 1). Results indicate that Canadian dietitian-led SBE includes the use of simulated patients, nutritional diagnosis/assessment, and the creation of comprehensive care plans, among others. Students have been assessed for performance of trained tasks through exams, self-awareness surveys, and interviews, and SBE activities have been evaluated for effectiveness through questionnaires and interviews with users/students. Canadian literature is limited, and more can be learned by exploring the global context within and outside the profession.
Résumé
Cette étude de la portée a permis de faire le relevé de la littérature disponible sur les interactions des étudiants et diplômés canadiens en diététique, nutrition et alimentation avec l’enseignement par la simulation (ES) pendant leurs études de premier cycle et/ou stages. Un bibliothécaire certifiés ont réalisé la recherche préliminaire (été 2021), tandis que trois évaluateurs formés par le Joanna Briggs Institute ont effectué la recherche exhaustive via MEDLINE (Ovid), CINAHL (EBSCO), Academic Search Premier (EBSCO), Embase (Elsevier), Scopus (Elsevier) et Google (février 2022). Un outil d’extraction des données conçu précisément pour les objectifs de l’étude et les critères d’inclusion de la recherche a été utilisé. Nous avons consigné 354 résultats et en avons inclus 7. Sept types d’ES ont été consignés : (i) plan de soins complet (n = 2); (ii) diagnostic nutritionnel/évaluation nutritionnelle (n = 2); (iii) évaluation de la composition corporelle (n = 1); (iv) introduction du patient aux soins de la dysphagie (n = 1); (v) séance de counseling en nutrition (n = 1); (vi) examen physique axé sur la nutrition (n = 1); et (vii) communications professionnelles via les médias sociaux (n = 1). Les résultats indiquent que l’ES mené par des diététistes canadiens comprend, entre autres, l’utilisation de patients simulés, le diagnostic nutritionnel/l’évaluation nutritionnelle et la création de plans de soins complets. La capacité des étudiants à réaliser les tâches enseignées a été évaluée au moyen d’examens, de sondages sur la conscience de soi et d’entretiens, et l’efficacité des activités d’ES a été évaluée au moyen de questionnaires et d’entretiens avec les utilisateurs/étudiants. La littérature canadienne est limitée et on peut en apprendre davantage en explorant le contexte mondial à l’intérieur et à l’extérieur de la profession.
INTRODUCTION
Simulation-based education in dietetics: Is it “a thing” [1]?
Simulation-based education (SBE) provides realistic scenarios that allow students to develop hands-on skills in their field, including areas such as critical assessment, problem solving, communication, conflict resolution, evaluation, and management [2–4]. As a sub-category of experiential learning, it has been shown to decrease risk to participants. In fact, SBE has been shown to increase psychological safety for all involved, while increasing student understanding of course material in classroom and practical settings and decreasing physical risk to patients [5–9]. Moreover, SBE has been identified as an evidence-based approach to interprofessional education (IPE) [10, 11]. Commonly used by healthcare professionals (HCPs) including dietitians, nurses, physicians, dentists, physiotherapists, and occupational therapists during undergraduate, graduate, and practicum training, a wealth of literature and resources are available to those interested in SBE, including best practice guidelines and resources [12–15]. Notwithstanding, the contributions of dietitians do not appear to be mapped, described, or synthesized in the peer-reviewed literature [12–15]. This is despite SBE being an integral part of dietetics, nutrition, and foods (DNF) education since the 1980s.
Current SBE guidelines encourage educators to begin with conceptualizing how a simulation-based activity will meet the course teaching and learning objectives [3, 5, 16]. Learning objectives should shape the simulation or redirect educators to other approaches [3, 17]. Dietetic educators commonly use case studies (as complexity increases, time commitment increases) and role play (reasonable for shorter classes, single sessions) in courses and laboratories, but this work is not accurately represented in the peer-reviewed literature, which is abundant with examples from other HCPs [16, 18].
The SBE literature is diverse in terms of primary outcomes, aims, methods, definitions, and discipline, making the literature difficult to interpret, despite being generally supportive of SBE [16, 19]. Dietitian-led research on SBE appears to concentrate on assessment of student learning outcomes (e.g., knowledge uptake, students’ perceived learning) and experience (e.g., satisfaction, lived experience), arguably offering a catalyst or invitation for mapping and knowledge synthesis [20–22]. For instance, dietetic educators in the United Kingdom found that interaction with simulated or standardized patients improved students’ communication skills (e.g., attitudes towards learning, understanding importance of, and confidence in communication skills) [21]. To evaluate this, dietetic educators administered a pre/post standardized patient session questionnaire to DNF students [21]. Similarly, when American educators surveyed dietetic students on skill performance and asked them to rate their change in confidence, they found that SBE improved student confidence in their application of the Nutrition Care Process and associated communication skills [23].
Australian and New Zealand dietetic educators have also contributed to SBE literature. For instance, two Australian studies, exploring interprofessional collaboration, found that with the use of SBE, DNF students could better express needs assessments within the context of patient consult and displayed improved teamwork and communication [18, 24]. These studies, led by dietetic clinical educators, included focus groups and a questionnaire to collect data on DNF student learnings [18], as well as directed content analysis of transcripts generated from interviews with students before and after SBE sessions [24]. A New Zealand-based study captured students’ experiences and perceptions of SBE as a means of teaching dysphagia assessment and related diagnosis, intervention, and monitoring through the administration of workshop evaluation forms and surveys. Students reported improved confidence and readiness in this study led by three speech-language pathologists and two dietetic clinical educators [25].
Cultivating solutions by “growing forward”: What are we doing/not doing [26]?
A preliminary literature search, conducted in Summer 2021, led by two certified librarians, and a research intern trained in JBI (formerly known as the Joanna Briggs Institute) methodologies for scoping reviews [27], highlighted that several search terms, including “experiential learning” and “simulation”, differ in definition between countries. For instance, some countries and professions use the terms interchangeably, while others do not [16, 21, 28]. As a place to start, the work of Thompson and Gutschall [16] was used to develop the preliminary search, study introduction/rationale, and the final search strategy.
While there is evidence that dietetic educators engage in and recognize the benefits of SBE, there appears to be limited Canadian literature available on the topic [12, 13, 29]. There is a need to better understand the dietetic professions engagement with this approach to teaching and learning. It is generally recognized that teaching and learning can be enhanced by understanding and considering students [18, 24, 25]. Before synthesis can be conducted, a scoping review is recommended [30, 31]. Synthesis is the contextualization of research studies within the current literature and larger body of knowledge on the topic (e.g., systemic review and meta-analysis) [30]. Knowledge synthesis and scoping reviews are useful for examining emerging evidence, when it is still unclear what other, more specific questions can be posed and valuably addressed, and when there is a need to determine the scope of coverage of a body of literature [30, 31]. A common purpose for conducing such reviews (our purpose) is to identify and map available evidence [30, 31]. Therefore, this scoping review identifies and maps the literature available on Canadian dietetic students’ interaction(s) with SBE [27]. The research question is: What evidence is currently available on Canadian dietetic students’ interaction(s) with simulation-based education? For the purposes of this review, interaction with SBE is defined as participation in and/or exposure to any step(s) of the simulation life cycle [32], as per Dalhousie University, Simulation-based Education and Interprofessional Education Program. The SBE life cycle includes: (i) conceptualizing simulation; (ii) creating an immersive environment; (iii) integrating technology; (iv) simulation assessment; (v) debrief; and (vi) evaluating learning outcomes [32].
METHODS
This scoping review was conducted in accordance with the JBI methodology for scoping reviews, including Peters et al.’s updated guidance on scoping reviews [27, 33], adapted from Arksey and O’Malley framework [34]. No current or in-progress scoping reviews or systematic reviews exist on this topic.
Inclusion criteria: population, concept, context
This scoping review included literature that demonstrates DNF students’ interaction with SBE life cycle in dietetic internship and practicum settings [32]. No restrictions were set for year of students’ studies. Graduates were included if the literature reflected interaction with SBE during their time as a student. Dietitians and faculty/staff were considered as graduates; therefore, results investigating dietitians were also included. This review considered results that discussed SBE that provided students with realistic scenarios in classroom and practicum settings. Results were included regardless of the types of simulation used. For instance, studies specific to one or more of full-scale simulation, standardized patients, computer-based simulation, peer-to-peer, and unfolding case studies were included. Both uni-professional and interprofessional simulation were included. This review considered results that took place in Canadian university or dietetic practicum settings.
Types of sources
Both peer-reviewed and gray literature were considered for this review, including, but not limited to, quantitative and qualitative primary research studies, systematic reviews, meta-analyses, text and opinion papers, university websites, healthcare clinic websites, and publicly available reports/disseminations.
Search strategy
To develop the search strategy, an initial limited search of PROSPERO, MEDLINE, the Cochrane Database of Systematic Reviews, and JBI Evidence Synthesis was conducted to locate relevant results (YZ, SG, JM). In collaboration with a JBI-certified research librarian (MR), the text words contained in the titles and abstracts of relevant articles, and the index terms used to describe the articles were used to develop a full search strategy with a set of keywords for CINAHL (MR; see Table 1) [35]. The search strategy, including all identified keywords and index terms, was adapted for each database and/or information source. Results published or translated in English were included. No date of publication restriction was set, as not to exclude resources that may be long-standing.
Table 1.
The databases that were searched included: MEDLINE (OVID), CINAHL (EBSCO), Academic Search Premier (EBSCO), Embase (Elsevier), and Scopus (Elsevier). Google was used to conduct gray literature searches (JM; see Table 2).
Table 2.
Data and evidence selection
Following the database searches conducted on 25th February 2022 (MR), all identified peer-reviewed results were collated and uploaded into Covidence Systematic Review Software (Veritas Health Innovation, Melbourne, Australia. Available at www.covidence.org) and duplicates were removed. Gray literature results were uploaded into Zotero (Corporation for Digital Scholarship, available at www.zotero.org) on 25th February 2022 and duplicates were removed (JM). Following a calibration exercise with the review of 10 articles, titles and abstracts were screened by two independent reviewers (JM, MC) for assessment against the inclusion criteria and potentially relevant peer-reviewed papers were retrieved in full. Peer-reviewed results that did not meet the inclusion criteria at full-text review stage were excluded (see Supplemental Table 11 for exclusions). Any disagreements that arose between the reviewers (which were minimal) were resolved through discussion and consensus achieved (JM, MC).
Data and evidence extraction
Data and evidence were extracted from the peer-reviewed papers by two independent reviewers (JM, MC) using a data extraction tool in Covidence (see Supplemental Table 21). Evidence from gray literature was extracted using the extraction tool in MS Word (Microsoft Corporation, Redmond WA USA, 2021). The data extracted included specific details about the population, concept, context, and key findings relevant to the review question.
RESULTS
Literature
Results of the search strategy and paper selection process are presented in a PRISMA-ScR (Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews) diagrammatic flow chart (Figure 1) [36]. Database searches yielded 280 results, identified from five databases. Gray literature searches yielded another 74 results (see Table 2). A total of 354 results were recorded. After duplicates were removed (including four results for which the weblink was broken), 273 results remained for title and abstract screening. Of those, 234 were irrelevant to the research question. The remaining 53 results (19 peer-reviewed and 34 gray literature) were screened against the inclusion criteria, yielding seven results (six peer reviewed and one gray literature) for full-text review (Table 3). The three reasons for exclusion at the full-text review stage were recorded as: (i) not Canadian (n = 10); (ii) simulation was not used/named (n = 21 total; 10 of these were Universities who named SBE on their website as part of DNF curriculum, but did not list or describe types of simulation); and (iii) not DNF students or graduates (n = 15).
Table 3.
Figure 1.
Figure 1. Search results and study selection and inclusion process [36].
*Acronyms: Simulation-based education (SBE); dietetics, nutrition and foods (DNF).
Characteristics of Included Results
The included results in this review were published between 2007 and 2022. Three perspectives in practice (two published 2016, and one 2020), two original research articles (published in 2007 and 2019), and one report (published in 2020) were included from the peer-reviewed literature. The gray literature search yielded one practice blog (published in 2022; 688 words in length). Below we have organized the findings based on the objectives of this scoping review.
Population
Six of the seven results included were focused on DNF undergraduate and master’s students (n = 311 cumulative). One peer-reviewed result included Canadian dietitians (n = 382). One of the original research articles included interprofessional teams (n = 25 nutrition students; n = 128 students total).
Concept
A range of types of SBE were covered in the included literature including standardized patient, role-play, case studies, and debriefing. Seven different SBE activities completed by students were recorded: creating a comprehensive care plan (n = 2); nutritional diagnosis/assessment (n = 2); body composition assessment (n = 1); introducing patient to dysphagia care (n = 1); nutrition counselling session (n = 1); nutrition-focused physical examination (n = 1); and professional communications via social media (n = 1).
Outcomes measured through these types of SBE included communication skills (n = 2), nutritional care competencies (n = 2), quality of patient-care plans (n = 2), collaboration (n = 1), and engagement (n = 1). Outcomes of the included results were assessed by dietetic educators, and the settings were most often in course-based classrooms (n = 6), with one taking place in an assessment lab (n = 1). Methods of student assessment for performance in trained tasks included questionnaires/surveys (n = 3), standardized evaluations based on Integrated Competencies for Dietetic Education and Practice (n = 2) [37], course exams/mid-terms (n = 1), pre/post student interviews (n = 1), and student self-assessment (n = 1).
Context
The distribution of included university and practicum settings across provinces and territories was Ontario (n = 4); Saskatchewan (n = 2); and Canada-wide (n = 1).
DISCUSSION
Through mapping student interactions with SBE in Canada, we confirmed that additional research is warranted. Exploring research and methods employed in settings outside of Canada [18, 24, 25] may provide insights on teaching, surveying, evaluation, and assessment practices that may be adapted to the Canadian context. This said, international similarities and differences between dietetics, dietetic education, and practice must be considered in the development of future research questions. Moreover, teacher and learner interactions with SBE have and continue to be an area of research of great interest for other health professions (e.g., nursing) [3, 9, 12, 13]. Drawing from this body of work can provide insights into research and practice approaches, standards and “best practice”, that can also be adapted to the dietetic context, although profession-specific competency must be considered.
Before they can apply to write the Canadian Dietetic Registration Examination, DNF students must demonstrate competencies from seven domains of practice during their education and practicum [38]. The pandemic limited the number of practical placements or internships available to dietetic students and interns, highlighting the need for flexible, creative, and person-centred pedagogy in training tomorrow’s dietitians [10]. Through using realistic scenarios, SBE allows students to develop hands-on skills in their field, including areas such as critical assessment, problem solving, communication, conflict resolution, evaluation, and management [2–4] and has been shown to decrease risk to all participants (e.g., patients, learners, teachers).
SBE has been an integral part of DNF education since the 1980s and provides some timely solutions for program barriers (e.g., placement access, IPE), but Canadian profession-led research is lacking. Our profession has a unique opportunity to revisit our learning objectives, activities, assessments, and evaluations, as we integrate the 2020 competencies [38]; to co-create a symbiotic relationship between research and teaching and learning, so one informs the other, and together they (and we) are stronger. Examples of questions that could be asked include:
1.
Is SBE considered psychologically safe by dietetic educators and students engaging in an anthropometric assessment laboratory?
2.
Does a swallowing assessment simulation transfer knowledge and skills to students as effectively as practical experience with a patient in a clinical setting?
3.
What is the effect of an interprofessional conflict resolution simulation on learners’ satisfaction, knowledge, and behaviour pre- and post-simulation?
4.
Which professional and communication competencies are achieved through a simulated counselling session with a trained simulated patient and debrief?
We began the paper outlining that there are differences in naming SBE and experiential learning [16, 21]. During this review, we also discussed nuances between the outcomes reported in the literature and the methods applied to measure them. For instance, perspectives, experiences, and knowledge inform point of view or perception, but perspective, experiences, and perception are not one outcome [20, 39, 40]. Words, labels, and definitions matter and vary within and between disciplines, professions, countries, and individuals [19]. In the case of this scoping review, for example, of the six peer-reviewed articles included, the journals in which they were published had categorized them as: (i) perspectives in practice (n = 3), (ii) research article (n = 2), and (iii) report (n = 1). Those categorized as “perspectives and practice” and “report” were published in the Canadian Journal of Dietetic Research and Practice (CJDPR). Upon review, the authors found this work and the work that makes it up met the requirements to qualify as original research as defined by the Government of Canada, Cochrane, and JBI [41–43]. As CJDPR is committed to publishing research to help in identifying student needs towards dietetic education and professional development [44], we ask dietetic educators to consider the language used in categorizing research, as it can impact knowledge exchange, synthesis, translation, and ultimately dietetic education.
Limitations
Two noteworthy limitations of this research, include (i) Only results available in English were included, excluding other languages (e.g., French) and potentially resulting in selection bias. Practical challenges such as time and funding constraints made the use of translation services infeasible for this project. (ii) The evidence from gray literature searches was based on publicly available websites; thus, it is possible that there is more evidence available than we were able to access.
IMPLICATIONS FOR RESEARCH AND RELEVANCE TO DIETETIC PRACTICE
Through sharing this work, we aim to contribute to and stimulate discussion and research, and to support those applying for funding for future research. By better understanding DNF students’ interaction with SBE and other teaching methods, dietetic educators can better assess whether students’ perceived and actual learning objectives are being met. Current research focuses significantly on student experience, confidence, and satisfaction, while there are limited data on evaluation of simulation as an educational activity (meeting teaching and learning outcomes) and in meeting competencies. Additional surveying of students, interns, educators, and dietitians is warranted, and subsequent mapping and synthesis.
Acknowledgements
We acknowledge the intellectual contributions of the University-Based Nutrition Programs Experiential Learning Working Group, including Sarah O’Brien, and dietetic educators at St. Francis Xavier University, Mount Saint Vincent University (MC, AM YZ AH, JFA, DL, SG), and Acadia University. Contributions to the grant applications that made this work possible were made by several dietetic educators at Mount Saint Vincent University, St. Francis Xavier University and Acadia University, all members of University-Based Nutrition Programs Experiential Learning Working Group. Also, relevant to acknowledge, are the contributions of Dalhousie University’s Centre for Collaborative Clinical Learning and Research (C3LR), current director Noel Pendergast, and co-authors (KH, KL).
Guided by the principal(s) co-conceptualized by Dr. Elder Albert Marshall including knowledge gardening (growing forward), co-learning, and the gift of multiple perspectives, dietetic educators, in Nova Scotia, established the University-Based Nutrition Programs Experiential Learning Working Group in 2020, a community of practice (CoP), with the goal of exchanging knowledge, skills, and strategies related to experiential learning, including simulation-based education.
Finally, we would also like to extend special thanks to YYZ’s MSc Supervisor, Dr. Anna Kate Shoveller, Department of Animal Biosciences (ABSc), University of Guelph, for allowing her to complete work on this manuscript post-graduation (BSc), Department of Applied Human Nutrition, Mount Saint Vincent University.
Footnote
1
Supplementary data are available with the article at Supplementary Material.
Sources of financial support: Funding to conduct in this review was provided by Mount Saint Vincent University Committee on Research and Publications’ (CRP) and Nova Scotia Department of Labour and Advanced Education.
Conflicts of interest: The authors declare no conflict of interest.
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Published In
Canadian Journal of Dietetic Practice and Research
Volume 84 • Number 4 • December 2023
Pages: 233 - 241
Editor: Naomi Cahill
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Version of record online: 12 July 2023
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© 2023.
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YingyingZhangBSc, MeganChurchillBSc, JessicaMannetteMA, MelissaRothfusPhD, MLIS, AmyMireaultPDt, AntoniaHarveyPDt, MScAHN, KellyLackieRN, PhD, CCSNE, KathrynHaywardMN, JudyFraser ArsenaultPDt, MAHE, DaphneLordlyPDt, DEd., MAHE, and ShannanGrantPDt, MSc, PhD. 2023. Identifying and Mapping Canadian Dietetic Students’ Interaction(s) with Simulation-Based Education: A Scoping Review. Canadian Journal of Dietetic Practice and Research.
84(4): 233-241. https://doi.org/10.3148/cjdpr-2023-016
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1. Designing Dietetics Education Programs to Enhance Graduates’ Preparedness for Practice
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