Realist synthesis of educational interventions to improve nutrition care competencies and delivery by doctors and other healthcare professionals

Objective To determine what, how, for whom, why, and in what circumstances educational interventions improve the delivery of nutrition care by doctors and other healthcare professionals work. Design Realist synthesis following a published protocol and reported following Realist and Meta-narrative Evidence Synthesis: Evolving Standards (RAMESES) guidelines. A multidisciplinary team searched MEDLINE, CINAHL, ERIC, EMBASE, PsyINFO, Sociological Abstracts, Web of Science, Google Scholar and Science Direct for published and unpublished (grey) literature. The team identified studies with varied designs; appraised their ability to answer the review question; identified relationships between contexts, mechanisms and outcomes (CMOs); and entered them into a spreadsheet configured for the purpose. The final synthesis identified commonalities across CMO configurations. Results Over half of the 46 studies from which we extracted data originated from the USA. Interventions that improved the delivery of nutrition care improved skills and attitudes rather than just knowledge; provided opportunities for superiors to model nutrition care; removed barriers to nutrition care in health systems; provided participants with local, practically relevant tools and messages; and incorporated non-traditional, innovative teaching strategies. Operating in contexts where student and qualified healthcare professionals provided nutrition care in developed and developing countries, these interventions yielded health outcomes by triggering a range of mechanisms, which included feeling competent, feeling confident and comfortable, having greater self-efficacy, being less inhibited by barriers in healthcare systems and feeling that nutrition care was accepted and recognised. Conclusions These findings show how important it is to move education for nutrition care beyond the simple acquisition of knowledge. They show how educational interventions embedded within systems of healthcare can improve patients’ health by helping health students and professionals to appreciate the importance of delivering nutrition care and feel competent to deliver it.

[1]  P. Pedersen,et al.  Implementing nutritional guidelines -- the effect of systematic training for nurse nutrition practitioners. , 2012, Scandinavian journal of caring sciences.

[2]  J. Carson.  Pocket tape measure for waist circumference: training medical students and residents on a simple assessment of body composition. , 2003, The Journal of nutrition.

[3]  M. Kohlmeier,et al.  Getting nutrition education into medical schools: a computer-based approach. , 2000, The American journal of clinical nutrition.

[4]  D. Hosmer,et al.  Increasing the efficacy of physician-delivered smoking interventions , 2007, Journal of General Internal Medicine.

[5]  H. Laschinger,et al.  An exploratory study of nursing and medical students health promotion counselling self-efficacy. , 1999, Nurse education today.

[6]  D. Galuska,et al.  Are healthcare professionals advising obese patients to lose weight? A trend analysis. , 2005, MedGenMed : Medscape general medicine.

[7]  B. Gance-Cleveland,et al.  Changes in nurse practitioners' knowledge and behaviors following brief training on the healthy eating and activity together (HEAT) guidelines. , 2009, Journal of pediatric health care : official publication of National Association of Pediatric Nurse Associates & Practitioners.

[8]  D M D'Alessandro,et al.  Longitudinal follow-up comparison of educational interventions: multimedia textbook, traditional lecture, and printed textbook. , 1997, Academic radiology.

[9]  D. Shahar,et al.  Development and implementation of a nutrition education program for medical students: a new challenge. , 2006, Education for health.

[10]  D. Anthony.  Evidence-based Policy: A Realist Perspective , 2007 .

[11]  C. Boelen,et al.  Social accountability and accreditation: a new frontier for educational institutions , 2009, Medical education.

[12]  M. Rea,et al.  Infant and young child feeding counseling: an intervention study. , 2008, Jornal de pediatria.

[13]  B. Sunguya,et al.  Nutrition Training Improves Health Workers’ Nutrition Knowledge and Competence to Manage Child Undernutrition: A Systematic Review , 2013, Front. Public Health.

[14]  N. Rigotti,et al.  Impact of a preventive medicine and nutrition curriculum for medical students. , 2004, American journal of preventive medicine.

[15]  K. Buckley,et al.  Evaluation of classroom-based, Web-enhanced, and Web-based distance learning nutrition courses for undergraduate nursing. , 2003, The Journal of nursing education.

[16]  M. Kohlmeier,et al.  Introducing cancer nutrition to medical students: effectiveness of computer-based instruction. , 2000, The American journal of clinical nutrition.

[17]  M M Carr,et al.  Comparison of Computer-Assisted Instruction and Seminar Instruction to Acquire Psychomotor and Cognitive Knowledge of Epistaxis Management , 1999, Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery.

[18]  T. Greenhalgh,et al.  Realist review - a new method of systematic review designed for complex policy interventions , 2005, Journal of health services research & policy.

[19]  J. Stein,et al.  Personal Exercise Habits and Counseling Practices of Primary Care Physicians: A National Survey , 2000, Clinical journal of sport medicine : official journal of the Canadian Academy of Sport Medicine.

[20]  Nutrition Recommendations and Interventions for Diabetes , 2007, Diabetes Care.

[21]  James F Sallis,et al.  AHA Guidelines for Primary Prevention of Cardiovascular Disease and Stroke: 2002 Update: Consensus Panel Guide to Comprehensive Risk Reduction for Adult Patients Without Coronary or Other Atherosclerotic Vascular Diseases. American Heart Association Science Advisory and Coordinating Committee. , 2002, Circulation.

[22]  T. Dornan,et al.  A realist review of educational interventions to improve the delivery of nutrition care by doctors and future doctors , 2014, Systematic Reviews.

[23]  K. Hillenbrand,et al.  Effect of an educational intervention about breastfeeding on the knowledge, confidence, and behaviors of pediatric resident physicians. , 2002, Pediatrics.

[24]  Terry Davis,et al.  Physicians’ Weight Loss Counseling in Two Public Hospital Primary Care Clinics , 2004, Academic medicine : journal of the Association of American Medical Colleges.

[25]  R. Ashraf,et al.  Training in Complementary Feeding Counselling of Healthcare Workers and Its Influence on Maternal Behaviours and Child Growth: A Cluster-randomized Controlled Trial in Lahore, Pakistan , 2008, Journal of health, population, and nutrition.

[26]  Marilyn S Edwards.  Nutrition education for medical students: 4th year transition to residency for primary care (1020.3) , 2014 .

[27]  T. Wadden,et al.  Primary care physicians' attitudes about obesity and its treatment. , 2003, Obesity research.

[28]  Trisha Greenhalgh,et al.  Internet-based medical education: a realist review of what works, for whom and in what circumstances , 2010, BMC medical education.

[30]  M. Camilo,et al.  Detection of nosocomial malnutrition is improved in Amazon region by a standard clinical nutrition education program. , 2008, Nutricion hospitalaria.

[31]  N. Kennedy,et al.  An evaluation of a community dietetics intervention on the management of malnutrition for healthcare professionals. , 2010, Journal of human nutrition and dietetics : the official journal of the British Dietetic Association.

[32]  H. Karle,et al.  Social accountability of medical education: Aspects on global accreditation , 2011, Medical teacher.

[33]  S. Ray,et al.  Nutrition education and leadership for improved clinical outcomes: training and supporting junior doctors to run ‘Nutrition Awareness Weeks’ in three NHS hospitals across England , 2014, BMC Medical Education.

[34]  E. Phillips,et al.  The impact of lifestyle medicine continuing education on provider knowledge, attitudes, and counseling behaviors , 2013, Medical teacher.

[35]  J. Protheroe,et al.  Modelling successful primary care for multimorbidity: a realist synthesis of successes and failures in concurrent learning and healthcare delivery , 2015, BMC Family Practice.

[36]  P. Rogers,et al.  Enhancing community accountability, empowerment and education outcomes in low and middle-income countries: A realist review , 2014 .

[37]  A. Bandura.  Self-Efficacy: The Exercise of Control , 1997, Journal of Cognitive Psychotherapy.

[38]  C. Ritenbaugh,et al.  Effect of an integrated nutrition curriculum on medical education, student clinical performance, and student perception of medical-nutrition training. , 2001, The American journal of clinical nutrition.

[39]  D. Deen,et al.  A mini-fellowship in clinical nutrition for primary care physicians. , 2009, Journal of cancer education : the official journal of the American Association for Cancer Education.

[40]  Merete Bjerrum,et al.  Nurses' self-reported knowledge about and attitude to nutrition -- before and after a training programme. , 2012, Scandinavian journal of caring sciences.

[41]  S. Lo,et al.  Effects of educational intervention on nurses’ knowledge, attitudes, and behavioral intentions toward supplying artificial nutrition and hydration to terminal cancer patients , 2008, Supportive Care in Cancer.

[42]  A. Kalet,et al.  How medical students' behaviors and attitudes affect the impact of a brief curriculum on nutrition counseling. , 2012, Journal of nutrition education and behavior.

[43]  D. Dolmans,et al.  A systematic review of faculty development initiatives designed to improve teaching effectiveness in medical education: BEME Guide No. 8 , 2006, Medical teacher.

[44]  A. Bernstein,et al.  Enhancing medical education to address obesity: "See one. Taste one. Cook one. Teach one.". , 2013, JAMA internal medicine.

[45]  M. Buchowski,et al.  Computer-assisted teaching of nutritional anemias and diabetes to first-year medical students. , 2002, The American journal of clinical nutrition.

[46]  P. Shekelle,et al.  Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement , 2015, Systematic Reviews.

[47]  J. Lennard-jones,et al.  Nutrition and patients: a doctor's responsibility. , 2002, Clinical medicine.

[48]  S. Ray,et al.  Evaluation of a novel nutrition education intervention for medical students from across England , 2012, BMJ Open.

[49]  C. Summerbell,et al.  Four Years' Experience of an Undergraduate Medical Nutrition Course , 1997, Journal of the Royal Society of Medicine.

[50]  I. Santos,et al.  Nutrition counseling training changes physician behavior and improves caregiver knowledge acquisition. , 2004, The Journal of nutrition.

[51]  Tamara Dumanovsky,et al.  The Primary Care Nutrition Training Program , 2011, Health promotion practice.

[52]  A. Fox.  Evaluation of a pilot arts and health module in a graduate community nutrition program. , 2009, Canadian journal of dietetic practice and research : a publication of Dietitians of Canada = Revue canadienne de la pratique et de la recherche en dietetique : une publication des Dietetistes du Canada.

[53]  G. Miller.  The assessment of clinical skills/competence/performance , 1990, Academic medicine : journal of the Association of American Medical Colleges.

[54]  L. Ball,et al.  Nutrition in general practice: role and workforce preparation expectations of medical educators. , 2010, Australian journal of primary health.

[55]  D. McLAREN.  Nutrition in medical schools: a case of mistaken identity. , 1994, The American journal of clinical nutrition.

[56]  C. Ritenbaugh,et al.  Nutrition curriculum in medical education: An integrated and comprehensive approach , 1996 .

[57]  Lisa Douglass Danielle Jones,et al.  COURSE ? , 1983 .

[58]  D. Duerksen.  Teaching medical students the subjective global assessment. , 2002, Nutrition.

[59]  J. Rethans,et al.  Controlled trial of effect of computer-based nutrition course on knowledge and practice of general practitioner trainees. , 2003, American Journal of Clinical Nutrition.

[60]  S. Thompson.  Social Learning Theory , 2008 .

[61]  Kadriye O. Lewis,et al.  Pediatric trainees’ engagement in the online nutrition curriculum: preliminary results , 2014, BMC medical education.

[62]  David Mechanic.  Social research in health and the American sociopolitical context: the changing fortunes of medical sociology. , 1993, Social science & medicine.

[63]  J Wylie-Rosett,et al.  Computer-Assisted Diabetes Nutrition Education Increases Knowledge and Self-Efficacy of Medical Students , 1997, The Diabetes educator.

[64]  D. Waitzberg,et al.  Education program on medical nutrition and length of stay of critically ill patients. , 2013, Clinical nutrition.

[65]  T. Wadden,et al.  Treatment of Obesity in Primary Care Practice in the United States: A Systematic Review , 2009, Journal of General Internal Medicine.

[66]  C. Boelen,et al.  Social accountability: The extra leap to excellence for educational institutions , 2011, Medical teacher.

[67]  G. Ogrinc,et al.  Key characteristics of successful quality improvement curricula in physician education: a realist review , 2014, BMJ quality & safety.

[68]  Deborah E. Kipp.  Developing Interactive Computerized Modules Accessible on the World Wide Web for Medical Students , 1997 .

[69]  J. Ockene,et al.  Physician training for patient-centered nutrition counseling in a lipid intervention trial. , 1995, Preventive medicine.

[70]  S. Reddy,et al.  Enhancing self-efficacy and patient care with cardiovascular nutrition education. , 2002, American journal of preventive medicine.

[71]  D. Heimburger,et al.  Dietary habits of first-year medical students assessed during clinical nutrition course. , 1994, Nutrition.

[72]  A. Afaghi,et al.  Effect of an Integrated Case-based Nutrition Curriculum on Medical Education at Qazvin University of Medical Sciences, Iran , 2011, Global journal of health science.

[73]  Katja Jasinskaja,et al.  Elaboration and Explanation ⋆ , 2011 .

[74]  B. Palmvig,et al.  An educational model for improving diet counselling in primary care A case study of the creative use of doctors' own diet, their attitudes to it and to nutritional counselling of their patients with diabetes. , 2005, Patient education and counseling.

[75]  Alison M. Hutchinson,et al.  A realist review of interventions and strategies to promote evidence-informed healthcare: a focus on change agency , 2013, Implementation Science.

[76]  A. Kalet,et al.  Do Internists, Pediatricians, and Psychiatrists Feel Competent in Obesity Care? , 2008, Journal of General Internal Medicine.

[77]  R. Weinsier.  National Dairy Council Award for Excellence in Medical/Dental Nutrition Education Lecture, 1995: medical-nutrition education--factors important for developing a successful program. , 1995, The American journal of clinical nutrition.

[78]  E. Palmer,et al.  Computer‐aided learning: an overvalued educational resource? , 1999, Medical education.

[79]  B. Graubard,et al.  Effect of training on adoption of cancer prevention nutrition-related activities by primary care practices: Results of a randomized, controlled study , 2000, Journal of General Internal Medicine.

[80]  Henry C Lin,et al.  NASPGHAN Nutrition University as a Model for Continuing Education Within Pediatric Nutrition , 2014, Journal of pediatric gastroenterology and nutrition.

[81]  A. Bandura.  Social cognitive theory: an agentic perspective. , 1999, Annual review of psychology.