Research Article
Effect of Simulated Patient Practice on the Self-Efficacy of Japanese Undergraduate Dietitians in Nutrition Care Process Skills

https://doi.org/10.1016/j.jneb.2017.12.013Get rights and content

Abstract

Objective

To examine the effect of an adapted simulated patient (SP) intervention on self-efficacy in nutrition care process skills.

Design

A repeated-measures design using a 25-item survey divided into 7 nutrition professional practice competencies (PPCs) employing a 5-point self-efficacy scale (1 = lowest to 5 = highest) administered immediately before and after the intervention.

Setting

A private Japanese university.

Participants

Ninety Japanese third-year dietetics undergraduates aged 20–38 years.

Intervention

An adapted SP activity practicing nutrition care process skills for the infirm elderly population.

Main Outcome Measures

Pre- to postintervention self-efficacy response scores and feedback.

Analysis

Mean preintervention survey scores were used to divide participants into statistical quartiles (Q1 indicated lowest mean scores and Q3, highest mean scores). Wilcoxon signed-rank tests compared each PPC's pre- and postintervention means. Kruskal-Wallis tests examined changes in quartiles' scores within each PPC.

Results

Self-efficacy improved significantly in PPCs relating to application of appropriate medical ethics and interpersonal skills (P = .02), appropriate nutrition assessment (P = .04), and creation of a nutrition management plan and nutrition intervention (P = .03). Self-efficacy of Q1 and Q2 rose significantly in most PPCs, although not for acting as a dietitian within a medical care team, whereas that of Q3 decreased for all PPCs.

Conclusions and Implications

Among initially low self-efficacy dietetics undergraduates, the SP intervention enhanced self-efficacy in 3 of the 6 PPCs practiced directly and may facilitate more realistic self-views among initially high self-efficacy students. However, further research in the design, implementation, and efficacy of this type of training is recommended to gauge its effects on the quality of related professional practice.

Introduction

Between 2015 and 2025, the number of elderly people in Japan aged >65 years is estimated to rise by 2.66 million (3.6% of the national population), from 33.92 million (26.7%) to 36.58 million (30.3%). Simultaneously, those aged >75 years are estimated to increase by 5.38 million (5.2%), from 16.41 million (12.9%) to 21.79 million (18.1%).1 This has the potential for a subsequent increase in the number of infirm elderly individuals, ie, home-bound elderly people who cannot perform activities necessary for daily living. Although existing, partially publicly funded hospitals and nursing homes can meet this greater demand, their use is relatively low because people prefer to stay at home. To prevent malnutrition among home-bound infirm elderly people, it is important to provide in-home nutrition support2 including meals and/or supplemental foods, tube feeding, and assisted feeding. This is particularly important for those with medical conditions such as diabetes, the prevalence of which is already high and is estimated to increase considerably in the future among Japan's elderly population.3

In response to this need, in 2014, Japan's Ministry of Health, Labor, and Welfare announced a policy of securing medical treatment and nursing care for people aged >65 years and initiated the development of the Integrated Community Care System, which specifically provides for in-home dietetic support to Japan's infirm elderly population. This raised the issue of how those who provide such support would receive appropriate training.

One solution is to offer instruction in the Japan Dietetic Association's (JDA's) General Nutrition Care Process (GNCP).4 The GNCP is a 3-step approach to individualized nutrition assessment and quality care for which dietitians need to develop the 7 professional practice competencies (PPCs) established by the JDA (Table 1).

The 3-step GNCP and associated 7 PPCs could form the bases of experiential learning activities for enhancing the self-efficacy of undergraduates in dietetics programs in providing in-home nutrition care to infirm elderly individuals. Self-efficacy, defined as “one's belief in one's ability to succeed in specific situations or accomplish a task,”5 strongly influences how individuals view and apply themselves to tasks,6 and has been correlated positively with effort and persistence to complete tasks generally successfully7 and in dietetic student training.8 As with other psychological constructs such as motivation and self-esteem, self-efficacy is often measured objectively via participant surveys using Likert scales.

Experiential learning is predicated upon physical, cognitive, and social participation within a structured, supervised, and supportive educational context. Since it was first advocated in the early 20th century as part of the humanist movement,9 it has become commonplace in mainstream education and offers opportunities for realistic and practical application of fundamental academic and vocational knowledge and skills, complete with instructor and peer feedback. It also encourages trainees to reflect and identify the presence and extent of gaps that might exist between their current competence levels and those needed for professional practice. This study therefore uses experiential learning as a conceptual framework.

One technique that offers such experiential learning is the use of simulated patients (SPs), in which an individual (preferably trained) takes the role of a patient, allowing students or trainees to practice applying relevant knowledge and skills to a particular case study without endangering a real patient's well-being. Several studies used SP training through a 2- or 3-stage process.10 Generally, in the first stage, students are given an SP profile and conduct a counseling session with the SP, applying relevant knowledge and skills and eliciting additional information from the SP if needed, to devise and propose a clinical plan of action intended to enhance the SP's well-being. In the second stage, students receive feedback from the instructor and/or the SP and possibly also from peers who observed the session. Because reflection has been shown to be particularly important in the learning process within clinical settings,11 in the third stage, students reflect on their performance and the feedback they received with the aim of further enhancing the activity's learning outcomes. However, to these 3 steps can be added a fourth, preparatory stage in which students receive their case study's profile well in advance of the SP session.12 This gives them more time to familiarize themselves with the details of their case and to formulate a more considered response for the SP counseling session.

Such SP training has been used to good effect in various fields including medicine,13 nursing,14 pharmacy,10 and physiotherapy.15 Positive learning outcomes have also been reported with this technique in nutrition education16, 17 and its effective application was previously reported12 and with respect to self-efficacy.18 It was also shown to be as effective as using real patients in training dietetic students to conduct counseling sessions.19 Furthermore, SP training has yielded positive outcomes in countries as culturally diverse as North America,12, 13, 16, 17, 18, 19 and Japan.10, 14, 15 This demonstrates that the SP technique is highly adaptable and can offer positive learning outcomes across a range of disciplines, skill sets, cultures, and educational systems.

However, to the authors' knowledge, there appears to be no prior study investigating the effects of SP activities on the self-efficacy of undergraduates in dietetics programs in Japan for the specific purpose of providing training for in-home nutrition support for the infirm elderly population. Therefore, this investigation examined what effect, if any, an adapted SP activity (called the intervention in this article) might have on the self-efficacy of Japanese undergraduates in a dietetics program in relation to applying the JDA's 7 GNCP PPCs with a view to working with homebound infirm elderly people.

Section snippets

Methods

To answer this research question, the authors employed a repeated-measures design. The participants, their recruitment, and the instruments, procedures, and data analyses used to realize that design are described subsequently.

Results

In total, the researchers collected matched pairs from 90 students; 18 others declined to participate, yielding an overall return rate of 83.3%.

Wilcoxon signed-rank analysis revealed that the sample's self-efficacy increased significantly for PPCs A, D, and F and that the overall total change in self-efficacy across all 7 PPCs was also significant (Table 3).

Frequency distributions for PPCs A–G revealed that Q1 (initially low self-efficacy) participants showed a general shift to the right,

Discussion

To the authors' knowledge, no other studies appear to have examined the use of SP interventions to develop the JDA's 7 PPCs within the GNCP framework. Therefore, the authors cannot make direct comparisons of these results with others. However, the current findings of enhanced self-efficacy among dietetics students through SP training support those of Todd et al.18 More generally, these findings are also in line with the positive learning outcomes associated with SP training reported with

Implications for Research and Practice

The SP activity examined here enhanced initially low-scoring participants' self-efficacy in several PPCs while prompting others to reevaluate their initially high self-efficacy assessments, resulting in more realistic self-evaluations of their GNCP skills. Given these results and this educational technique's apparent adaptability to diverse cultural and educational settings, it appears reasonable to suggest tentatively that it be considered by program designers and educators for more widespread

Acknowledgments

This work was supported by JPSS Research Grant No. JP25350869. The authors also wish to acknowledge the cooperation of the participants, SP staff, and facilitators who made this study possible.

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    Conflict of Interest Disclosures: The authors have not stated any conflicts of interest.

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