CLINICAL PRACTICE experience is essential in the training of health professionals. Fieldwork and supervised practice are the means by which registered dietitian nutritionists (RDNs) develop their clinical judgment and practice skills.1 However, placements in health care facilities are limited. This has been especially true during the COVID-19 pandemic. The need for simulated practice opportunities is particularly acute during a global pandemic, where physical distancing is required and in-person learning activities are not possible.2 Education and health care institutions had suspended many field placements, due to considerations about the safety of students, patients, staff, and others. This has compelled training programs to create alternative plans for this practical training.3

The intention of using a simulation is not always to replace the learning that takes place in supervised practice, but to provide similar opportunities to develop critical thinking, problem-solving skills, and self-efficacy. Previously, training via simulation was designed to bridge the gap between didactics and practice. By gaining basic skills through a simulation of practice, students and interns would begin fieldwork or internships at a higher level of functioning, with a more consistent level of preparation, and carry those understandings forward into professional practice roles.

It is known that when real-life experiences are not available, simulations can provide opportunities to develop practice skills. For example, Roberts et al4 found that replacing part of the required clinical practice hours of nursing students with simulation resulted in skills, knowledge, and confidence that was equivalent to those obtained via traditional clinical practice.

The present study describes the development and evaluation of a computer-based virtual hospital unit, designed to provide opportunities for dietetic interns (DI) and didactic program in dietetics (DPD) students to perform the nutrition care process (NCP). This form of experiential learning has applications during the COVID-19 pandemic and beyond, yet literature on development and evaluation of this type of simulation has been limited.

The field of nursing pioneered the movement toward development of simulations as a form of education as preparation for and during professional practice. This is well described in several recent reviews.5–9 Best practices for simulation in nursing were described by Bryant et al.10 The driving force behind the implementation of health care simulations is to provide students and continuing education professionals with the opportunity to develop clinical reasoning and problem-solving skills.3,4,6,10–14 Providing a hands-on approach to learning through simulations gives students opportunities to address diverse patients and conditions while minimizing risk in a safe environment.10,11,13–15

Thompson and Gutschall16 make a compelling case for the use of simulation in dietetics education. O'Shea et al17 have since provided a review of literature published between 1979 and 2018 on the application of simulations in diet and nutrition education programs. Detailed guidelines for the creation of educational simulations have been published by Forrest and McKimm.14 Simulations have also been used across many disciplines including political science,18 disaster studies,19 dental education,20 surgery,21 and counseling and communication in pharmacy training.22

Virtual patients include a variety of technologies to address a wide range of learning needs.9 These can be repeated as many times as necessary, to promote remediation and to allow students to learn at their own pace, until competence in achieved.

Computer-based simulations have the advantage of being available over wide geographic areas, as well as being less costly to produce and provide.14 Since they do not require a physical environment, virtual simulations can be applied for asynchronous teaching/learning and incorporation into e-learning, making these more accessible to a wide range of students, interns, and programs.

Successful simulations, no matter how they are executed, must provide a researched, compelling, and applicable narrative to provide participants with an ideal experience from which to learn.16,23 Similar to video games, there is also a degree of immersion in the health simulations. Wrapping the case in fiction and imagination or dramatization and exaggeration allows students to connect with the story and activate their thought processes to engage with the assigned tasks.23 These virtual scenarios can be created to be similar to face-to-face clinical experiences to promote authentic learning.11 Studies of video-based simulations in nursing have evaluated the development process and debriefing.24,25 This type of simulation has also compared favorably to standard practice experiences on measures of clinical competence.3

High-fidelity simulations recreate aspects of the real world encountered in practice, such as a realistic hospital room with realistic mannequins (such as SimMan) portraying the patients. This type of simulation has been widely utilized in dietetics education.26–29 Some have also included interprofessional education simulations involving representation of 2 or more disciplines, interacting to assess a simulated patient and develop an interdisciplinary care plan. These have been done both in person and virtually.30–33

Simulations have also been utilized in the training of dietetics students and in programs around the world from countries including Australia,32 Canada,34 China,27 Saudi Arabia,28 and the United States.26,29,31,35–37

It should be noted that this literature likely underrepresents the number and variety of simulations utilized in educational programs in nutrition and dietetics. Scoping the literature using the word “simulation,” between 2010 and 2019 there were 35 published abstracts from presentations at the Academy of Nutrition and Dietetics Food and Nutrition Conference and Expo (FNCE) that reported on simulations. This term has appeared in abstracts with increasing frequency during this time frame.

Connecting dietetic students to suitable clinical experiences is crucial in developing their skills to assess and provide medical nutrition therapy. If clinical opportunities for students to adequately learn these skills are limited, it ultimately poses risk to their future patients. Development of diagnosis-specific skill sets via simulation has been demonstrated in the literature. This has included management of type 2 diabetes,38 insertion of small-bowel feeding tubes,39 and preparation of parenteral nutrition.40

Following any simulation experience, debriefing is essential as a means of developing clinical judgment. Postsimulation debriefing should be planned and structured to encourage reflection and integration of what has been learned.25 Through the debriefing process participants integrate what was learned from the experience. The instructor can then relate the insights gained to other situations that they may encounter in practice. All of these elements were considered in development of a computer-based clinical nutrition simulation, which has been described next.

The purpose of this study was to evaluate the usability and efficacy of a virtual clinical simulation for practice of the NCP by students in a DPD and 2 dietetic internships. This may help to guide development of other similar educational tools.

DEVELOPMENT OF THE SIMULATION

The City University of New York (CUNY) Simulated Hospital Unit (CSHU) was developed as an online virtual general medicine hospital unit for simulation of the NCP. Disorders to be simulated were selected based upon the 2017 Accreditation Council for Education in Nutrition and Dietetics Accreditation (ACEND) Standards for Dietetic Internships to include a variety of patients with a range of disease states.41

Prepilot case study

An initial simulation was developed featuring a single patient. This case was built around a narrative of a middle-aged man who is admitted to the hospital after breaking his leg in a motor vehicle accident. His admission laboratory tests reveal that he also has type 2 diabetes. This then determines the basis of his encounters with a resident physician (MD) and a registered dietitian (RD). The enthusiasm generated by this single case simulation led to a desire to further develop the simulation into a simulated hospital unit, and funding was sought for this purpose. The expansion of this single case simulation into a 10-patient unit is described next.

Patients and staff

All patients and staff in the CSHU are fictitious but are based on an author's nearly 20 years of experience in clinical nutrition practice. This process is summarized in Figure 1. To make each patient and member of staff as realistic as possible, their basic characteristics were determined by rolling multisided dice typically used in fantasy gaming. These included such factors as “intelligence,” “charisma,” and “constitution.” Other factors such as ethnicity, sexual orientation, marital status, education, profession, number of progeny (if any), and their characteristics were also determined by rolls of gaming dice. These characteristics then formed the basis for each simulated patient's back story. That information was then displayed through their conversations with the simulated MD and RD staff, as well as detailed in the social work notes in the simulated electronic medical record (EMR). Names were derived from an online random name generator (http://random-name-generator.info/random) with some adjustments made for family groups.

Figure 1.:

Simulation development process.

Each character was then placed into a situation where they found themselves admitted to the hospital with a particular medical diagnosis, as well as one or more randomly selected comorbidities. The decision to add comorbidities to the cases was based on a desire to make the simulation more true-to-life. It is unusual for a practicing RD to encounter patients in an acute care setting who have only one medical issue. Learning to prioritize various issues and needs is an important part of skill development for RDs in training.

Staff were developed using similar methods to those employed to create the patient characters. Each patient was then randomly assigned to meet with 2 of the simulated staff, 1 MD and 1 RD. The simulated staff are introduced to simulation users during a video orientation session. Being familiarized with who these virtual staff are as people can enhance observed interaction with simulated patients.

Once these basic scenarios were set up, all encounters were scripted, and then sent to the animator to be rendered as animated short videos. Character voices were created utilizing text-to-voice software, primarily due to cost constraints. The videos were also closed captioned to be compliant with the Americans with Disabilities Act (ADA) accommodations in educational programs.

Simulation design

Design elements like detailed backgrounds and character props, diversity of the characters, and filming techniques like zooming and fading also work to better appeal to present-day students and specifically target visual and auditory senses to maintain undivided interest in the video patient encounters, which run for an average of 7 minutes. Similarly, this imagery maximizes student learning on how to navigate a dietetic consultation versus verbally telling them how to do it.

Table 1. - Study Participants Didactic Program in Dietetics Students Dietetic
Internship Group 1
Students Dietetic
Internship Group 2
Students n = 147 n = 25 n = 25 Asian 14 3 8 Black 42 2 6 Hispanic 65 2 2 White 26 18 9 Male 18 2 3 Female 129 23 22
Narrative technique

The simulation provides a virtual aesthetic that helps to make the health scenarios less daunting. The animated conversations were designed to provide a sense of relatability to the patients. Throughout the simulation, life stories and personal experiences cross in potentially surprising ways since they all live in the same (fictitious) town. While the simulation creates for dietetic students the specifics of completing nutritional assessments, it also shows them appropriate and sympathetic bedside manner and the importance of reinforcing to patients how to incorporate what they learn into their daily lives. There is an emphasis on teamwork between the staff to achieve this.

Creation of simulated medical records

Each simulated patient has a written medical record containing laboratory and diagnostic testing results, as well as chart notes from various disciplines. These include MD admission notes, nutrition screening, and notes from other disciplines including social work and nursing, with the exception of the nutrition assessment note. A blank form, in Assessment, Diagnosis, Intervention, Monitoring and Evaluation (ADIME) format, was included for the students/interns to complete, based upon the information available via patient video and other EMR notes. All documents in the EMR were optimized for use with e-readers, again to be compliant with ADA accommodations in educational programs.

METHODS

Assessment of the simulation was carried out using a mixed-methods approach. This included a participant questionnaire with both closed- and open-ended questions, data usage “hits” from tracking software in the course pages, and post hoc key informant interviews with participating faculty, using a list of scripted, open-ended questions.

The protocol was reviewed by the CUNY Human Research Protection Program prior to data collection and met the criteria for exemption from institutional review board review. Students and interns were informed in advance that completion of the survey was optional and would have no bearing on their grades.

Study groups included 1 DPD program and 2 dietetic internship programs. Demographic data for the 3 groups are shown in Table 1. DPD students engaged with the simulation during their clinical 1 and clinical 2 courses. DI group 1 engaged with the simulation at the beginning of their program. DI group 2 entered the simulation later in the year, with both programs using it as a supplement to their clinical rotation placements.

The survey was posted to the course Blackboard pages for all groups. A message appeared when they logged into the page, describing the purpose of the survey and inviting them to participate. They were asked to complete it after they had finished the simulation exercises. Answers were submitted anonymously through the course page. Answers to closed-ended questions were tabulated by percentage giving each answer. Answers to open-ended questions were grouped by similar comments to generate overall themes in these responses.

Utilizing the course tools function of Blackboard, the percentage of time spent in each area of the simulation was evaluated. This captured objective usage information from all participants to evaluate how much of their time was spent engaged with each feature of the simulation.

Lastly, following the semesters in which the simulation was implemented, the principal investigator conducted key informant interviews via Zoom with the faculty (3 White females) who had utilized the simulation in their classes. All were asked the same questions from a semistructured interview protocol, to obtain consistent data. Notes from these meetings were analyzed to identify themes in their observations as instructors.

RESULTS

Data from the closed-ended questions (Figure 2) indicated that in both DPD and DI programs the majority of participants found navigation of the simulation pages easy. Eighty-five percent of DPD students, 67% of DI group 1 and 100% of DI group 2, rated these as either “somewhat easy” or “very easy.” Majorities across programs also rated the experience as valuable to their education, 85%, 55%, and 100%, respectively. It was also seen as helpful in better understanding the NCP by 100% of DPD students, 56% of DI group 1, and 100% of DI group 2. There was however a significant discrepancy between DPD and DI programs as to the rating of the simulation as enjoyable. A large majority of the DPD students (85%) rated the experience as either very or somewhat enjoyable, whereas only 50% of DIs in both programs surveyed did so.

Figure 2.:

Closed-ended questions by group. Question 1: How was it for you to access and find things within the unit? Percentage of each group responding “very easy” or “somewhat easy.” Question 2: As compared to other educational activities, how would you rate the CUNY Simulated Hospital Unit in terms of educational value? Percentage of each group responding “very valuable” or “somewhat valuable.” Question 3: As compared to other educational activities, how would you rate the CUNY Simulated Hospital Unit in terms of enjoyment of the activity? Percentage of each group responding “very enjoyable” or “somewhat enjoyable.” Question 4: Did your use of the CUNY Simulated Hospital Unit help you to better understand the nutrition care process? Percentage of each groups responding “very much” or “somewhat.”

Themes generated through the open-ended questions were largely consistent with the closed-ended question results. However open-ended comments reflected the participants' experiences engaging with the simulation in a more detailed way. Overall comments were generally positive, with participants stating understanding of the purpose and benefits of the simulation. Some examples are given in Table 2.

Table 2. - Examples of Open-Ended Comments I'm finding the postassessment list of questions to be helpful in aiding me to use my clinical judgment for why I chose specific nutritional recommendations for the patients. This is an educational tool to get the feel of what it could be like in a hospital setting, different scenarios, and real-life patient interaction. I love connecting with people and I personally do not enjoy a simulation lab; however, I appreciate having the opportunity as needed, which I did for oncology and nutrition support. I think this is a great alternative to have on hand if there are not enough cases to assess in person that fit the needed chronic disease [experiences required]. It was awesome, love the humor in each unit.
Assessing the simulated patients

The majority of participants in both DPD and DI classes understood the purpose of the simulation and perceived learning benefits from working with it. Some examples of these positive statements were: “Practicing MNT (medical nutrition therapy) for the simulated patients was very educational as it reinforced me to go back to my clinical notes to read up on various diseases and the required nutritional therapies. In addition, I got to brush up on writing PES (problem, etiology, signs and symptoms) statements.” “It helped me with searching for the patient's medical history and try to understand what they are going through, by watching the virtual nutrition interviews. I have to think of the different types of dietary interventions that would be appropriate for each patient, based on their level of compliance and health condition.” “I like all the info that we are able to see the patient's chart. Having access to their charts can give us a better idea of who the patient is and also gives us a chance to practice determining what information is pertinent and what info we shouldn't worry about.” However, some participants seemed not to perceive that value, saying for example: “The only part that was useful was the formulation of PES statements. The rest was copy and pasting because what else was there to do?” Or, “I found completing this assignment incredibly overwhelming.”

The segments of the simulation were separated to more closely mimic an actual acute care setting, with medical records in one segment and patient rooms in another. While some participants had no difficulty with this arrangement, saying “I found the experience pretty intuitive and easy to access,” a majority expressed that they would have preferred to have each “case” all together on a single page, saying “things may have been too compartmentalized” and “grouping the videos and the charts together so that they aren't in two different places.”

Assessment form in ADIME format

The included nutrition assessment form was structured to look like an ADIME note in an EMR, with sections for the RD to fill in. While some found this beneficial, saying “It was helpful to get a preview of how a nutrition assessment document might look, and to examine the different sections that are required for a dietitian to know after seeing a patient before I started my clinical rotation.” “I can say this was as useful if not more useful than the charting I did at [rotation site].” The majority of participants were unsure of how to complete the nutrition assessment in this format, saying things like: “Providing a sample of an assessment would be helpful.” “[Provide] ADIME examples and tutorials.” “Give examples of the assessment forms so that students understand how to fill them out.”

Medical terminology/abbreviations

Chart notes from all disciplines included in the EMR used standard medical terminology and abbreviations. Many participants noted that these were unfamiliar to them. Some took this as an opportunity to take initiative for their own learning, saying: “There were a LOT of medical abbreviations that I needed to Google but I guess that's a good way to learn.” Others felt that the simulation should have provided “[explanation of] medical terminology or provide a resource” or simply “reduce the amount of abbreviation.”

Patient observation videos

Patient observations were presented as animated videos, voiced by text-to-speech software. Some participants expressed a strong dislike of the “robotic voices” and stated that they would have preferred live voice actors. Others felt that the “cartoons” were not sufficiently realistic. Some were able to look past these limitations, saying: “I enjoyed watching the videos on every patient. It was helpful on getting a better picture on the disease state for every patient” and “This is a great tool to look for values and indicators for the NCP in order to help with critical thinking. I think it's important to hear different types of people, how to ask questions to patients, and how to assess a plan properly. This helped me a lot to feel as if I was shadowing the healthcare professionals in the patient's room.”

Internal tracking of usage

Internal tracking (through Blackboard/ACE metrics) of time spent in each area is shown in Figure 3. These data indicated that the most time was spent viewing the patient EMRs, with the second most spent viewing patient interaction videos. Other materials included the orientation and debriefing videos, and directions for assignments, which were viewed less frequently. These frequencies were what would be expected for the simulation being used as intended and provide objective data consistent with the survey results.

Figure 3.:

Percentage of total usage time spent in each area.

Key informant interviews with faculty

All pilot test faculty expressed overall satisfaction with the simulation, and desire to continue using it in their respective classes. Their insights as to what worked well, and areas for further improvement differed from those of the students and interns. Examples of open-ended comments are shown in Table 3.

Table 3. - Examples of Faculty Comments From Key Informant Interviews This tool was applicable to both DPD and DI assignments. The virtual cases provided a richer learning experience than printed case studies. The simulation provides a bridge from classroom learning to practice. Additional patients would be desirable, including weight loss, upper GI, Alzheimer's disease, respiratory, hemodialysis, and a range of pediatric patients. Including further video dialogs with patients to include more detailed diet histories and counseling would be helpful, as well as discussions between staff for IDE. Ranking the cases from least difficult to most difficult would be beneficial, in order for assignments to progress from low to high complexity. Examples of completed assessments and PES statements would be helpful to provide as feedback to students/interns, along with estimated times to complete each assessment.
DISCUSSION

Creating a nutrition assessment simulation for dietetics students who are unable to secure clinical training is a much-needed endeavor, especially when clinical placements for dietetics students are few and highly competitive. A simulation such as this one makes an important contribution to professional education in dietetics. Not only will it allow students the ability to learn remotely but it will also help to make dietetics practice experiences more accessible.

The primary strengths of this simulation identified were the diverse and true-to-life stories portrayed, the convenience of the web-based and asynchronous format, and the opportunity it provided to practice the NCP in writing ADIME notes for patients.

Limitations

One limitation of the study was the use of convenience samples of DPD students and interns within the same university. Simulation users in other programs may not have responded to this experiential learning in the same way.

There was possible influence of timing of survey administration on the obtained results. DI group 1 was assigned the simulation assessments at the beginning of their program, while DI group 2 did so closer to the end of the program year. The DPD students had utilized different patients and elements of the simulation over 2 courses in 2 semesters. The timing of exposure was possibly a factor in shaping responses to the experience.

Cost of production constraints resulted in production values that were less than satisfactory to some participants. It also limited the amount of dialogue available. Charting by members of the interdisciplinary team was similarly limited. Since the medical records were static, details such as ongoing date and time stamps were not feasible. This limited opportunities to follow these patients over their entire hospital stay.

Directions for further development

Based on student feedback, improvements to the simulation are needed. Links to definitions of medical terms and abbreviations, and a review of writing nutrition assessments will be added to the orientation segment. Examples of completed assessment notes will also be made available. Although possibly desirable, an overall answer key for all assessments will not be included, to retain the value of the simulation cases as an exercise in critical thinking, rather than replication.

The results of this study provide an impetus for further development of the simulation to include additional patients and additional supporting materials for instructors. To better meet experiential needs, additional cases featuring pediatric patients and patients requiring nutrition support will be included in future iterations of this simulation. It would also be desirable to seek additional funding to improve the production values of the simulation itself. It is likely that such a pedagogical tool would be cost-effective and in demand by other programs.

CONCLUSIONS

Simulations provide supplemental experience to internships, apprenticeships, and general training opportunities for health care professionals. Health simulations promote education, provide rehearsal opportunities, foster teamwork, speak to a variety of different health care situations, encourage communication, and ground concepts in practice.

As other health fields look to incorporate simulation into teaching practice, opportunities to do so remain limited in dietetics education. Simulated nutritional assessment tools will fill a void in experiential learning options for dietetics students. Simulations offer educational experiences that can be tailored to specific patient personas and diseases leading to a repeatable and cost-effective alternative to on-site clinical experience. Simulations are a valuable teaching tool in both DPD and DI programs. This study has shown the value of a simulated hospital unit in both DPD and DI programs and provides a model for development of similar programs.

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