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Peer Assisted Learning Resource Pack A guide for Practice Educators London Cluster Placements Team January 2012 0

Peer assisted learning resource pack for PEs

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Page 1: Peer assisted learning resource pack for PEs

Peer Assisted Learning

Resource PackA guide for Practice Educators

London Cluster Placements Team

January 2012

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Page 2: Peer assisted learning resource pack for PEs

Welcome to the London Cluster Peer Assisted Learning Resource Pack

This resource pack has been developed by the London Cluster Placements Team to support

Practice Educators to incorporate peer assisted learning activities into clinical placements

offered to dietetic students.

It is anticipated that Practice Educators will select the most relevant activities to support the

stage of the student’s placement, the student’s key areas for skill development and the

resources available in their clinical setting. It is also anticipated that activities will be adapted

to meet specific student or service requirements.

If you are accessing this pack electronically, you can navigate to a specific section from the

contents page by hovering over the page number with your mouse, pressing Ctrl and then

pressing the left click on your mouse.

If you have any queries about the resources in this pack, please contact a member of the

London Cluster Placements Team on either: [email protected] or

[email protected]

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ContentsContents...................................................................................................................................21. Introduction..........................................................................................................................4

1.1. Introduction to Peer Assisted learning (PAL).........................................................41.2. Using PAL for dietetic placements learning activities............................................4

1.3. Essential components to a successful PAL activity...............................................51.3.1. Planning.................................................................................................................5

1.3.2. Facilitated debrief sessions...................................................................................61.3.3. Feedback...............................................................................................................7

Peer feedback......................................................................................................................7Supervisor feedback............................................................................................................7

1.3.4. Using PAL activities as evidence towards assessment.........................................8 1.4. Frequently asked questions...................................................................................8

1.4.1. Supporting students who are not getting on with each other................................81.4.2. Supporting students who are progressing at different rates..................................9

2. Induction............................................................................................................................10

2.1. Expectations and Orientation..............................................................................102.2. Policies and procedures......................................................................................11

2.3. Role of the Dietitian/ Dietetic Assistant................................................................112.4. Meal Production Activity......................................................................................12

2.5. Meal Service Activity...........................................................................................132.6. Ward Orientation.................................................................................................13

2.7. Dietetic Shadowing..............................................................................................152.8. Doctor and Nurse Observation activity................................................................17

3. Assessment - Anthropometry............................................................................................18

3.1. Commonly used anthropometric variables..........................................................193.2. Estimating anthropometric measurements..........................................................19

3.3. Choosing appropriate anthropometric variables to use.......................................203.4. Gathering anthropometric data............................................................................20

4. Assessment - Biochemistry...............................................................................................21

4.1. Identifying relevant biochemical parameters.......................................................224.2. Identifying abnormal biochemistry.......................................................................22

4.3. Biochemistry and dietetic interventions...............................................................234.4. Assessing biochemistry.......................................................................................23

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5. Assessment - Clinical........................................................................................................24

5.1 Medical notes familiarisation activity – part 1 of 2...............................................245.2. Medical notes familiarisation activity – Part 2 of 2...............................................25

5.3. Medication familiarisation activity........................................................................265.4. Familiarisation with unfamiliar clinical conditions................................................28

6. Assessment - Dietary........................................................................................................29

6.1. Compilation of oral nutrition support and enteral feed ready reckoner................296.2. Differing approaches to gathering dietary information.........................................29

6.3. Qualitative and quantitative assessments of dietary intake.................................306.4. Food record charts/food diaries...........................................................................30

7. Assessment - Environmental.............................................................................................31

7.1. Individuals............................................................................................................317.2. Groups.................................................................................................................32

7.3. Populations..........................................................................................................32

8. Nutrition and dietetic diagnosis..........................................................................................338.1. Identifying nutritional priorities.............................................................................33

8.2. Identifying dietetic diagnosis statements.............................................................33

9. Intervention, planning and implementation........................................................................349.1. Identifying dietetic management goals................................................................34

9.2. Implementing dietetic management goals...........................................................359.2.1. Devising implementation plans............................................................................35

9.2.2. Implementing the dietetic care process...............................................................35

10.Monitoring and evaluation.................................................................................................3610.1. Identifying appropriate follow-up arrangements..................................................36

10.2. Identifying appropriate outcome measures.........................................................3610.3. Reviewing dietetic interventions..........................................................................37

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1. Introduction

1.1. Introduction to Peer Assisted learning (PAL)Peer Assisted Learning has been defined by a number of different people:

“To get knowledge through study, experience, observation or teaching of an equal” (Lincoln

et al, 1993)

“Peers helping each other to learn” (Crouch et al, 2001)

“Individuals with equal status actively help and support each other in learning tasks”

(Ladyshewsky 2006)

The Oxford dictionary defines a peer as “an equal in civil standing or rank or equal in any

respect”

Ladyshewsky (2006) states that PAL is “a natural way of learning or completing tasks if the

same task has been set for more than one person” and that it is a “way of pooling resources

and reducing duplication of effort”. In essence PAL is a way of increasing knowledge and

skills by working in partnership with someone else.

There is a substantial amount of medical and allied health professional research in using

PAL to enhance student learning (Cate & Durning 2007, Field et al 2007, Roberts et al

2009a & b) but little in the way of practical guidance.

1.2. Using PAL for dietetic placements learning activitiesStudents are usually allocated to placements in even numbers so as they are able to work in

pairs. PAL activities can be used to facilitate induction into a new clinical area and support

the development of key skills in assessment, identifying nutrition and dietetic diagnoses,

planning and implementing interventions and reviewing, monitoring and evaluating dietetic

interventions. PAL activities can also support the development of key professional skills

such as communication skills, team working and reflective practice skills. Sections 2 – 10 of

this resource pack include suggestions for PAL activities to support skill development in a

range of areas.

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1.3. Essential components to a successful PAL activity

1.3.1. PlanningPairing studentsWe suggest that you either pair students randomly or if appropriate take transport

arrangements into account. If you are basing students at sites that are some distance from

each other than it would make sense to pair students according to who lives nearest the site

at which they will be based. If the students will be required to make frequent visits to

community clinics then it may be sensible to pair drivers or car owners with non-drivers. It is

not advisable to allow students to select their own pairings as there may be one person in

the group that everyone would prefer not to work with. Randomly allocating partners avoids

making this obvious.

Although it can be useful to take learning styles into account when planning activities for

students and might therefore seem sensible to put students with similar learning styles

together, often students with complementary learning styles make good pairs. The activists’

tendency to jump in and have a go can be tempered by the reflector who might prefer to

watch someone else before performing the activity themselves. The problem with this type

of complementary pairing is that it can then be difficult to move the students beyond their

comfort zone and encourage them to develop a more rounded learning style. It is important

that the students are encouraged to be explicit with their peer about their individual learning

style to support their effective peer working.

Planning for activitiesIt is essential to plan a PAL activity to ensure that the exercise meets its aims and objectives

and facilitates a valuable learning experience. Core components of a PAL activity will

include:

An opportunity to brief the students in relation to the expectations of the activity

Time for the students to complete the activity, including designated time for peer

discussion and reflection

Opportunity for a facilitated debrief with a supervisor and individualised feedback (see

section 1.3.2 for further information)

Sections 2 – 10 of this resource pack include a series of briefing sheets for Practice

Educators for a range of PAL activities. These briefing sheets have been designed to

support you in planning PAL activities and include details of the aims and objectives of the

activity and the resources required for the students to successfully complete the activity. It is

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envisaged that activities may need to be modified to suit individual learning environments

and so this resource pack is meant to support practice educators to develop tailored PAL

activities rather than be a definitive list of activities that can be used.

1.3.2. Facilitated debrief sessionsDebrief sessions can take two formats, debriefs following individual PAL activities and

student led facilitated group discussions.

Debriefs following individual PAL activitiesIt is important that students have the opportunity to debrief from a PAL activity to consolidate

learning and identify specific learning needs. Debrief sessions should be arranged as part of

the planning of a PAL activity and should happen as near to the activity as possible. It may

be helpful to prepare specific questions to direct the debrief session or you may want to ask

the students to lead the direction of the session. It is particularly important that all students

have the opportunity to participate in the debrief session. Students should be encouraged to

be prepared to speak about the entire activity and not just the section they complete to

promote a more holistic learning experience.

Student led facilitated group sessionsStudent led facilitated group sessions also provide an important opportunity for students to

meet and share their learning experiences. If you are only working with two students, it may

be most appropriate to timetable these sessions at times when they are working more

independently of each other to facilitate ongoing peer support and shared learning. In cases

where there are only two students attached to one placement site other members (e.g. Band

5 Dietitians) could also be encouraged to attend these sessions and present a case they

have seen in order to facilitate a greater breadth and depth of learning. Although student led,

a facilitator (usually a member of the placement team) should also be present to support the

students get the most out of these sessions.

Although the format of the sessions can vary, and should be directed by the students, it

would be common for each student to prepare a case presentation of a patient that they

have seen during the previous week. In the early stages of their training, students can

present a case that they saw whilst shadowing a dietitian but as they progress they can

report on cases in which they took a more active part in the consultation. Once a case has

been presented the other members in the group are encouraged to ask questions, in early

sessions the facilitator may need to lead the questioning but the students should actively

participate and take on the leading of these group sessions. It may also be appropriate for

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students to present a reflection on a learning experience during the previous week. Student

participation in these sessions can also be recorded by the facilitating dietitian using the

proforma “observation of student in tutorials” (Appendix 1). This sheet can be used as a

basis for giving the student feedback, or used by the student as evidence of meeting

learning outcomes in the portfolio.

1.3.3. FeedbackConstructive feedback is crucial to student learning. When completing PAL activities,

feedback is specifically important to ensure that each student is aware of their own progress

and individual learning objectives. This helps to remove feelings of competition between

paired students, and helps students to understand what they were expected to learn from a

particular activity.

Peer feedbackStudents on a PAL placement have the opportunity to learn from feedback given by their

peer. The clinical observation form (Appendix 2) can be used by both practice educators

and peers to provide structured feedback following a consultation. Peers may also find it

helpful to use this form as a reminder of the skills they should be looking out for and of the

things that it is useful to have feedback on. Peers may initially find it difficult to give

constructive feedback, using the form provides a structured way of facilitating this. It is worth

spending some time during the induction period to ensure that peers understand the

importance of giving each other constructive feedback and feel comfortable doing this. If

they are unable to give each other useful feedback then many of the learning opportunities

will be lost. All of the students have also had opportunities to give each other feedback at

University. Feedback should be given as near to the event that it refers to as possible as

this is when it is most constructive and helpful.

Supervisor feedbackAlthough there are many benefits of peer feedback, supervisor feedback is vital to support

skill development and the development of competence against the placement learning

outcomes.

Individualised feedbackIndividualised, supervisor feedback can be given as part of a debrief session but should also

be based on episodes of direct observation of the students practice in a range of settings.

Students should be observed completing tasks at a minimum frequency of 2 – 3 times/week. There may be more periods of direct observation at the start of the placement

but it is important that the level of observation does not drop as the placement progresses as

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feedback based on direct observation remains crucial throughout the placement to support

the development of key skills.

Daily feedback & reflectionA half hour facilitated feedback session should also be timetabled into the programme at the

end of every day, to encourage students to reflect on the days learning. This session can be

done with both students as a pair. A record of this feedback can be kept in a student held

log book to ensure that the content of this feedback and subsequent action plans are not

forgotten about.

Weekly review meetingA student led weekly review meeting should also be timetabled into each students

programme. This session is designed to review the week’s progress and discuss objectives

for the coming week. This session presents an opportunity to see students individually and

can be used to hand over to a new supervisor if appropriate.

1.3.4. Using PAL activities as evidence towards assessmentCollaborative pieces of work can be used as pieces of formative assessment to facilitate

feedback and action planning however they should not be used towards an individual

student’s summative assessment. However, individual pieces of work that have been

collated to form a larger project (e.g. a clinical audit or a health promotion project) can be

used as evidence. Documentation of reflective discussion and the facilitator-completed

review of a student’s contribution towards a feedback session can also be used as evidence

to support summative assessment.

1.4. Frequently asked questions

1.4.1. Supporting students who are not getting on with each otherStudents should behave in a professional manner just like everyone else in the department.

We are not able to choose our work colleagues or members of the MDT, students should be

reminded that they need to “get on” with everyone and form professional working

relationships. It may be helpful to arrange a mediation process to allow each member of the

pair to express their difficulties in a safe environment. Each student should have an equal

time to speak and also a right to reply. It is also important that a practice educator is present

to facilitate discussion between the students. Questions such as “What would you like to

see happen?” “What would help you to work together?” and “Is there anything that you

could do differently in future?” may be helpful. Often discussing issues openly rather than

allowing things to fester can promote understanding between a pair and allow them to

overcome their differences and work together more easily.8

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1.4.2. Supporting students who are progressing at different ratesIt is important to ensure that each student has equal time with the dietitian available to them.

Each student should have his or her own supervisor to ensure that weekly feedback and

goal setting is done individually. It is also important to avoid any comparison of students’

performance. Build confidence by asking questions that you know the less confident student

can answer. It is important to stretch both students, individual team members may be able

to provide opportunities for students individually.

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2. Induction

2.1. Expectations and OrientationAim: The aim of this activity is to ensure that students are aware of the basic arrangements

for the functioning of the department and what is expected of them.

Objectives: By the end of this activity, students should be able to:

Identify key staff members

Obtain refreshment and locate the toilets,

Understand their programme and what is expected of them.

Find key locations in the base building(s)

ActivityCover the following induction information with both students:

1. Introduction to the department

2. Who’s who, who sits where, hours of work, breaks, refreshments, toilets, fire exits

3. Student programme

4. Expectations – give students half an hour in their peer pair to come up with their

expectations of placement.

Discuss with Practice Educator and talk through department’s expectations of the

student. Both sign expectations agreement

5. Arrange security passes, computer log-ins etc.

6. Orientation activity – give the students a questionnaire that they can only find the

answers to by visiting key locations in the Trust/ Building/ Area – send them to complete

this together then debrief afterwards. Were there any surprises? Any places they

couldn’t find?

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2.2. Policies and proceduresAim: To familiarise students with the key policies and procedures that are relevant to dietetic

practice within the organisation where their placement is taking place.

Objectives: By the end of this activity, the students will be able to:

Identify key policies that are relevant to dietitians working in your area

Give a summary of the key points which affect dietitians.

Describe how those points influence the day-to-day practice of dietitians.

ActivityGive the students access to the policies and procedures that affect dietitians working in your

area.

The students need to divide the policies between them and read the ones that they have

been allocated, taking notes of key points that are relevant to dietitians as they do so.

Each student will then present a summary of the key points of the policies they have

covered, and how they affect the day-to-day work of a dietitian, to their partner and

supervisor

2.3. Role of the Dietitian/ Dietetic AssistantAim: To introduce the students to the different roles of the dietetic assistant and dietitian and

to the differences in their communication styles.

Objectives: By the end of this activity the students should be able to:

Identify 3 key differences between the role of the dietitian and that of the dietetic

assistant.

Identify 3 similarities or areas of overlap between the 2 roles

Identify 3 differences in the communication styles used.

ActivityBoth students should observe the Dietitian/Dietetic Assistant undertaking a consultation and

take notes on it, using the clinical observation checklist. The students should compare notes

on the different aspects they observed and discuss any queries with the Dietitian/ Dietetic

Assistant. As well as thinking about the different styles they have observed, the students

should think about the differences between the two in terms of their professional roles and

boundaries.

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2.4. Meal Production ActivityAim: The aim of this activity is for the students to become familiar with the meal production

system in use in your area along with its strengths and limitations.

Objectives: By the end of this activity the students will be able to:

Describe the meal production system used in your area.

Describe how portion control is managed in your area.

Describe the nutritional guidelines used in the development of the menu for your area.

Know how to order a “Special diet” and describe the range of meals and snacks

available for patients.

List the strengths and weaknesses of this type of meal production system.

Activity:Both students should go to the catering department and have a briefing from the catering

manager about the catering system in use, including costs, restrictions, benefits of this

system etc.

One student should then spend time with a designated member of staff in the main meal

production unit, taking note of how the meals are prepared to be sent to each ward or area

and any strengths or weaknesses that they can identify.

The second student should spend time with the “diet cook” or equivalent, learning how

special meals are ordered, prepared and sent to the correct patient, again noting any

strengths and weaknesses of the system.

The students will then debrief with a facilitator, each sharing what they have found with the

other.

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2.5. Meal Service ActivityAim: The aim of this activity is for the students to begin to understand how meals are served

to patients and the strengths and limitations of the system in use in your area.

Objectives: By the end of this activity, the students should be able to:

Describe the meal service systems in use in your area

Describe the differences between the meals provided to two different areas

List key strengths and limitations of each of the systems.

Activity: The students should each observe/ help with meal service in one area, each having different

systems in use e.g. an adult ward and a paediatric ward or a general ward and a dialysis

unit, or a nursing home and a school. The students should take note of how the food is

served, how the portions are controlled and how the correct food reaches the correct person.

They should note the strengths and limitations of the system.

The two students should then meet up to compare notes and determine the advantages and

disadvantages of the systems they observed in the places in which they were observed.

The students should then debrief with a facilitator.

2.6. Ward Orientation Aim: to provide an introduction to the dietitian practice educator as a professional role

model for students, and to give students some insight into the skills and knowledge they will

develop over the placement.

Objectives: By the end of this activity the student will be able to:

Describe the type of ward and the patients most frequently referred to the dietitian

Describe the referral process

Describe the discharge process and how dietitians are informed about discharges

Locate key areas in the ward

Locate key sources of information

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The students will need to be taken to different wards and make brief notes on the following:

Key ward staff – note their names and titles

The ward name and what types of patients are admitted to this ward?

Which patients are likely to be seen by the dietitian and why?

Is there a referral process for dietetic input?

The average patient length of stay

The discharge process? How is the dietitian informed of discharges?

Location of:

o Bed list

o Nursing handover list (if available)

o Medical Records

o Equipment for measuring anthropometry

o Enteral feeding pumps and giving sets

o Reference books eg BNF

o End of bed charts

o Ward pantry/ kitchen

o Computers

o Meeting rooms or areas

Brief training from dietitian in EPR and CRS

The students will need to be prepared to discuss their findings with each other and a

facilitator

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2.7. Dietetic ShadowingAim: The aim of this activity is to observe how the dietitian interacts with the different people

they come into contact with in their work area.

Objectives: By the end of this activity, the student will be able to:

Describe the dietitian’s main aims in the consultation

Describe the patient’s main aims for the consultation

Describe the people the dietitian liaised with before and after the consultation

Identify the differences in the dietitian’s communication style, depending on whom

he/she is communicating with.

Describe any professionalism issues that arose in connection with this consultation.

Activity: The students should observe a dietitian undertaking a consultation and should take notes on

the following:

Did the dietitian talk to anyone else before seeing the patient? Was it helpful? Why/

Why not?

How did the dietitian greet the patient?

What were the dietitian’s main aims for the consultation?

What did the patient want to get out of the consultation? How do you know this?

What information did the dietitian collect?

What strategies did they use to collect the information?

What information would have been useful, but was unavailable?

What decision did the dietitian make in managing this patient? Propose a rationale for

the decision.

Look at the medical notes/ dietetic record card after the dietitian has made the entry for

the patient. Did the dietitian use any abbreviations? Are all of these in line with

department guidelines?

Did the dietitian liaise with anyone after the consultation? Do you feel this communication

was helpful to: the other person, the patient, yourself and how do you know this?

How did the dietitian’s communication with the patient differ from that with the

nurse/doctor/consultant, other dietitian?

How would you describe the dietitian’s manner i.e. formal, informal, chatty, or serious?

Was this appropriate? How do you know?

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Are you aware of any issues relating to:

o Anti-discriminatory practice.

o Practice in line with the Statement of Conduct.

o Professionalism.

o Team working.

Did you learn anything from this consultation? Why?

Did anything trouble you about this consultation? Why?

The students should then meet up to discuss their findings with each other, having the

opportunity to raise any queries or concerns with a facilitator.

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2.8. Doctor and Nurse Observation activityAim: The aim of this activity is for the students to observe how a doctor/ nurse

communicate with each other, both within their own profession and between the different

professions.

Objectives: By the end of this activity, the students should be able to:

Identify the key information handed over between nurses at handover.

Identify the key information communicated between doctors and nurses with regard to

patient care

Identify the format which doctors use to describe patients to each other

Describe key differences between the way doctors and nurses communicate about

patients, compared to the way dietitians communicate

Activity:Students should attend the ward at nursing handover time and gain permission to listen in as

nurses give each other handover about the patients. They should note the format used, the

information shared and any information that was omitted that the student thinks might have

been important.

Students should attend the ward when the junior doctor visits the ward and gain permission

to listen in as nurses give doctors handover about the patients. They should note the format

used, the information shared/ requested and any information that was omitted that the

student thinks might have been important.

Students should attend the ward when a consultant ward round is in progress and gain

permission to listen in as the junior doctors give their senior colleagues handover about the

patients. They should note the format used, the information shared/ requested and any

information that was omitted that the student thinks might have been important.

The students should reflect on what they have learned in the 3 sessions and identify the

differences between the way that doctors and nurses’ communication with each other and

the way that dietitians communicate. They should share their reflections with their peer/

facilitator.

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3. Assessment - AnthropometryAim: The aim of these activities are to develop the student’s understanding of and ability to

gather and interpret anthropometric measurements when assessing individual patients.

Objectives: By the end of these activities the student will be able to:

Identify how anthropometric variables are collected and recorded in dietetic notes.

Outline the possible problems in obtaining anthropometric data and seek solutions or

alternatives.

Carry out measurements of anthropometric variables with patients

Interpret anthropometric measurements within the context of a clinical condition.

Explain how a patient’s anthropometric data may affect the dietetic intervention.

Overview of the activity Students should ideally work in pairs.

These tasks can be worked through sequentially to build on assessment skills, or depending

on learning focus, parts could be carried out in isolation.

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3.1. Commonly used anthropometric variables Students should list the most commonly used anthropometric variables and take half

the list each.

For each variable students should identify:

o How it is measured (along with any reference tables used etc.)

o Equipment available for measurement

o Normal range of results and standard units

Students should come together along with a supervising dietitian and present their

findings to each other, adding to their notes as they bring together their knowledge.

Discussion should include:

o Possible causes of abnormal results

o Possible practical problems with measuring each variable

o Possible solutions or alternatives

o Possible limitations of variable and how it may affect interpretation

Findings should be discussed with their supervisor.

3.2. Estimating anthropometric measurements Students are given the same list of 5 – 10 patients who are currently being seen by

the Dietitian

Students should (separately) estimate the weight and height of each patient.

Students should come back together at an agreed time with a supervising dietitian to

compare estimates with each other, and actual measurements. Discussion should

also focus on when it is appropriate to estimate anthropometric measurements and

strategies to develop skills in this area

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3.3. Choosing appropriate anthropometric variables to use Students are each allocated a patient who is currently under the care of a dietitian.

Students should ideally be allocated patients with different clinical conditions.

Each student should identify which anthropometric variables were used within the

assessment and note how they were recorded and interpreted by the dietitian.

Students should come back together at an agreed time with a supervising dietitian

and discuss:

o Which anthropometric variables were and were not used and why?

o How the variables were recorded.

o How the measurements were interpreted by the dietitian.

Findings should be discussed with their supervisor.

3.4. Gathering anthropometric data In pairs, autonomously if possible, students should practice performing some or all of

the following anthropometric measurements:

o Height

o Weight

o Waist Circumference

o Mid upper arm circumference (MUAC)

o Hand grip strength

o Skinfolds

Students can either:

o Both take measurements from the same patient and compare, or;

o Take it in turns to measure while the other student observes, encourages,

supports and feeds back afterwards.

Students should gather a basic clinical background (e.g. reason for admission, past

medical history, age) to aid interpretation of findings during discussion.

Students should come back together at an agreed time with a supervising dietitian

and discuss:

o In each case, how the patient’s anthropometric data can be interpreted in the

context of their clinical background.

o Problems encountered in performing measurements.

o How difficulties can be overcome in the clinical setting.

o If and why measurements taken by each student from the same patient

varied.

Findings should be discussed with their supervisor.20

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4. Assessment - BiochemistryAim: The aim of these activities is to develop the student’s understanding of and ability to

interpret biochemical parameters when assessing individual patients.

Objectives: By the end of these activities the student will be able to:

Identify how biochemical parameters are collected and recorded in dietetic notes.

Outline the possible causes for abnormal measurements of dietetically relevant

biochemical parameters.

Interpret a set of blood results in the context of a clinical condition.

Explain how key dietetically relevant biochemical parameters are important as part of a

patient assessment.

Explain how a patient’s biochemistry results may affect the dietetic intervention.

Overview of the activity Students should ideally work in pairs.

This task can be worked through sequentially to build on assessment skills, or depending on

learning focus, parts could be carried out in isolation.

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4.1. Identifying relevant biochemical parameters Students should obtain a list of biochemical markers commonly used by the dietitian

and take half the list each.

For each parameter students should identify:

o Reference range and standard units used within the trust

o Possible causes of high or low results

o Possible consequences of high or low results

Students should come together along with a supervising dietitian and present their

findings to each other, adding to their notes as they share their knowledge.

Any questions raised should be noted down and researched further.

Students should then use this information along with other resources available to

together construct a table summarising the above information as a biochemistry

‘ready reckoner’ for their folders.

4.2. Identifying abnormal biochemistry Students are given a patient’s blood results (one each) to look at individually and

identify parameters outside of the reference range.

Students go to the ward together and for their own patients, gather a brief clinical

history using medical notes, bed end observation charts and any other relevant

sources of information.

Students should come back together at an agreed time with a supervising dietitian

and present their patient to each other, then discuss:

o Which biochemical parameters were outside the normal reference range?

o What are the possible causes of this given the patient’s clinical condition?

o Any clinical signs that would point to a particular cause? (e.g. vomiting,

diarrhoea)

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4.3. Biochemistry and dietetic interventions Students are each allocated a patient who is currently under the care of a dietitian.

Students should ideally be allocated patients with different clinical conditions. (Better

patients for this task might include those whose dietetic treatment is more directly

related to specific biochemical parameters, for example renal patients, enterally or

parenterally fed patients, lipid-lowering).

Each student should gather a brief clinical history using medical notes, bed end

observation notes and any other relevant sources of information, and make a note of

the dietetic interventions.

Each student should note how the dietetic interventions made by the dietitian relate

to the biochemistry results for that patient.

Students should come back together at an agreed time with a supervising dietitian

and present their patient to each other, then discuss:

o How the dietetic intervention relates to the patient’s biochemistry.

o How the biochemical information was recorded by the dietitian in both the

medical notes and/or dietetic notes as appropriate.

o Which parameters were recorded and which were omitted?

o

4.4. Assessing biochemistry Students are allocated a patient each.

The patient can be either a new referral or a patient currently under the dietitian’s

care but the students should not have access to the actual dietetic intervention plan.

Students gather a brief clinical history using medical notes, bed end observation

notes and any other relevant sources of information.

Students collect and record relevant biochemical results, noting whether they are

inside or outside the reference range.

Students should come back together at an agreed time with a supervising dietitian

and present their patient to each other, then discuss:

o Which biochemical parameters were important/ relevant to note?

o What are the possible causes of any abnormalities?

o How might these findings affect your dietetic intervention plan?

o What additional biochemical parameters would be useful to consider?

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5. Assessment - Clinical

5.1 Medical notes familiarisation activity – part 1 of 2Aim: The aim of this activity is to introduce students to the format and content of medical

records as well as the variation that may occur between different health care providers.

Objectives: By the end of this activity the students will be able to:

Understand the different ways that entries are recorded within and between professions

(including the use of different formats such as SOAP or BDAP)

Become familiar with abbreviations used (often contextual e.g. Ca could mean cancer or

calcium depending on the context),

Begin to develop skills in identifying and collecting relevant information for dietetic

assessments.

Activity:Students should ideally work in pairs

Each student should have an opportunity to explore a set of patient notes for patients that

have been seen by the dietitian, individually, and gain experience trying to gather dietetically

useful information on the patient (based on written records only). This can take some time

for students at the start of their training, as they are not familiar with language, abbreviations

and organisation of medical notes (which may differ from ward to ward, and trust to trust). It

may be useful to use structured headings to guide the information gathering, for example the

‘ABCDE’ (Anthropometry, Biochemistry, Clinical, Dietary, Ethnic/Social/ Economic)

assessment model. If the students are at a later stage to their placement then it may be

useful to give a specific time-frame in which to carry out this activity to develop their time

management skills

After the specific time period, the students will swap patient notes and review the second set

of notes. The students should then compare the information they each gleaned individually

to highlight any discrepancies/ differences. The students should note down any terms or

abbreviations they don’t understand and look them up later. The information that has been

gathered will be used in the next activity so keep it in an accessible place.

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Specific notes for Practice Educator Identify appropriate patients’ medical records for students to review on the ward or in the

clinic. Appropriate patients may have had some dietetic input in the past, but should not be

overly complicated (e.g. patients on ITU may not be appropriate).

Ensure the activity is scheduled for a time when the medical records for the identified

patients are available (e.g. not at a time when ward rounds are scheduled). The record does

not have to be a patient currently admitted. It may be more practical to request the record of

a known patient not currently admitted.

Students can undertake this activity on a ward, in a clinic environment or in the dietetic office

(depending on where the records are)

5.2. Medical notes familiarisation activity – Part 2 of 2Aim: This activity aims to provide students with an introduction to the dietetic records used

by dietitians, and will help them to reflect on the usefulness of the information they gathered

in Part 1.

Objectives: On completion of this activity, the students should be able to:

Identify a ‘good’ dietetic record as compared to a ‘not so good’ record

Discuss issues of confidentiality and the need to ensure information is not easily

identifiable

Begin to develop a framework for gathering useful information for dietetic assessment.

Activity:Students should continue to work in pairs

Using the information they have gathered from the Part 1 medical notes activity, the students

will each complete a dietetic record card for each patient.

At the end of the activity, make the actual dietetic records available to the students so they

can compare what they have done to an actual dietetic record. Ideally, if you have time, look

over their completed record cards and provide direct feedback, but note that this is not

essential.

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Each student will prepare a brief (max 5 minutes) presentation on each patient; they must

both be able to present on either of the cases. They should prepare the presentations

together.

Ensure they have de-identified any notes they have made on patients before leaving the

hospital.

Specific notes for Practice EducatorsProvide the students with blank dietetic record cards.

Pull the actual dietetic records for the two patients that students have used for Part 1, and

give these to the students towards the end of the activity.

Allocate some time in your diary, if possible, to provide direct feedback to the students on

the record cards they have completed.

The activity should have a formal debrief session for all students to discuss Parts 1 and 2.

The students can also each present one of their cases in the group session, which will begin

to develop their skills in case presentation and handover.

5.3. Medication familiarisation activityAim: This activity aims to provide students with a working knowledge of commonly

prescribed medications and their potential relevance to dietetic assessment and intervention.

Objectives: On completion of this activity, the students should be able to:

List commonly prescribed medications under the following categories:

o Painkillers

o Antibiotics

o Laxatives

o Cholesterol lowering medications

o Diabetes medications

o Antiemetics

Identify specific medications that directly impact on dietetic therapy

Identify medication plans from drug charts

Understand how the pharmacist liaises with the dietitian

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Activities: Working in pairs, students should divide the following list of commonly prescribed

medications between them. Students should then independently look up common

medications under each of these categories and identify any side effects that might

impact on dietetic intervention:

o Painkillers

o Antibiotics

o Laxatives

o Cholesterol lowering medications

o Diabetes medications

o Antiemetics

Students should then meet and feedback their findings to each other. Their findings

should then be collated to form a ‘crib sheet’ to be used by both students for future

reference. This crib sheet should be shown to the dietetic supervisor to ensure that the

information collected is complete and accurate.

The students should be allocated two separate wards covered by separate pharmacists.

The student should be encouraged to introduce themselves to the pharmacist and

ascertain their role and how they work with the dietitian. During this conversation, the

student should ask the pharmacist to identify specific medications with an impact on diet

therapy. Students should then be encouraged to find out when these medications would

be prescribed, relevant side effects and specific impact on diet therapy. Students should

then meet and compare their findings with the support of a facilitator.

In pairs, students should have the opportunity to review a number of drug charts,

identifying the layout, how to ascertain regular and one-off medications and clarifying

commonly used abbreviations (e.g. od, bd, tds, qds, po).

Students should then be given two drug charts to review, in addition to the patients’

medical notes to identify key background information (e.g. diagnosis, previous medical

history). After a set time they should present a summary of the patients including the

rationale for their current medication plan to their peer and supervising dietitian.

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5.4. Familiarisation with unfamiliar clinical conditionsAim: This activity aims to support students to develop their knowledge of unfamiliar clinical

conditions

Objectives: On completion of this activity, the students should be able to:

Provide a brief description of the physiological and biochemical abnormalities associated

with the condition

Understand the key treatment strategies associated with the condition

Identify how the condition might impact on the patients’ nutritional status

Identify any specific diet therapy associated with the condition

Activity:In anticipation for the weekly facilitation session, students should be encouraged to take

responsibility to explore specific conditions that they have come across during the week,

considering the following points:

Description of the physiological and biochemical abnormalities associated with the

condition

Key treatment strategies associated with the condition

How the condition might impact on the patients’ nutritional status

Any specific diet therapy associated with the condition

Students should work together to design a format to present this information in a clear

and concise manner

Students should present their findings verbally at the weekly facilitation session in the

presence of a supervising dietitian.

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6. Assessment - Dietary

6.1. Compilation of oral nutrition support and enteral feed ready reckoner

Aim: To familiarise the students with the range of oral nutrition support options and enteral

feeding products available in your area and their macronutrient contents.

Objectives: By the end of this activity, students will have a ready reckoner that enables

them to quickly assess the energy, protein and fluid provided by a given volume of product.

Activity:The students should be given access to the nutritional composition of the menu, diet bay

items, feed store as well as data sheets for the products they will be using most frequently.

They should share the task between them, e.g one take ONS and one take Enteral Feeds.

The students will need to agree on a format for the ready reckoner and then each will

prepare their part and then share it with their partner. If there are many more products in

one area than the other, they may need to help each other out.

They should share their ready reckoner with their supervising dietitian to ensure that the

information they have collected is relevant and accurate.

6.2. Differing approaches to gathering dietary informationAim: To familiarise the students with two commonly used methods for gathering dietary

information from patients.

Objectives: By the end of this activity, students will be able to:

Gather dietary assessment data using the 24 hour recall and typical day approaches

Identify the benefits and limitations of each of these approaches in a variety of settings

ActivityEach student to be assigned two patients (these do not necessarily need to be patients who

have been referred to a dietitian – they just need to be happy to talk to the students about

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diet history while being observed by their peer. The observing student should then provide

specific feedback to their peer in respect to their questioning style, body language and

quality of information collected considering two positive aspects of their practice and two

areas for development. The students should present the summary of their feedback to the

supervising dietitian with suggestions as to how they could work to improve their skills.

6.3. Qualitative and quantitative assessments of dietary intakeAim: To develop the student’s skills in completing qualitative and quantitative assessments

of dietary intake

Objectives: By the end of this activity, students will be able to:

Complete qualitative and quantitative assessments of dietary intake

Identify strategies to ensure that accurate assessments are completed

ActivityUsing all four of the dietary assessments completed in activity 6.2, both students should

independently complete both qualitative and quantitative dietary assessments of the

information collected. The students should then compare their assessments and identify any

errors in their assessments. The students should then collate their findings and present their

assessments to their supervising dietitian.

6.4. Food record charts/food diariesAim: To familiarise the students with the dietary recording tools used by the department

Objectives: By the end of this activity, students will be able to:

Know the tools used by the department to collect written dietary intake data in a variety

of settings

Understand the limitations of using these tools

ActivityThe students should be given access to the tools used by the department to collect written

dietary intake data and should complete these tools independently over a 48 hour period.

The students should then meet to discuss suitable changes that could be made to the tools

to support the collection of more accurate dietary information in as user friendly a way as

possible. The students should then present their recommendations to their supervising

dietitian

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7. Assessment - EnvironmentalAim: The aim of these activities is to develop the skills of the student in collecting and

assessing information to support this section of the dietetic care process in individuals,

groups and populations.

Objectives: By the end of these activities the student will be able to:

Identify sources of information regarding the Environmental/ Emotional aspects of the

assessment process.

Collect relevant information from the range of sources available.

Use the information collected to assist in the formulation of a dietetic diagnosis and

treatment plan for individuals, groups and populations.

Overview of the activity Students should ideally work in pairs

Parts of this activity may happen at different times e.g. the information gathering regarding

the group or population are likely to happen prior to the actual delivery of the project/ group

session, so careful notes should be taken and kept in a safe place for comparison.

After the activity: The students should compare the information that they gathered to identify any

similarities or differences and reflect on why the discrepancies arose.

They should discuss with their partner any information that you feel was a) omitted

but should have been gathered, b) gathered but was not relevant c) you can’t agree

on.

They should discuss their findings with their supervisor.

7.1. Individuals One student should gather all of the relevant Environmental information from the

medical notes/ nursing notes/ referral letter/ care staff.

The second student should interview the patient, with their partner observing, using

an appropriate communication style, to elicit information regarding the environmental

aspects of the patient’s history.

e.g. For ward patients: the students should gather relevant information on who the

patient lives with, what kind of accommodation they have, cooking facilities, financial

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status, what social support, whether they are a smoker, any concerns about their

mental health/ emotional state, previous dietary interventions, physical activity level,

readiness to change, barriers to change, language skills.

7.2. Groups In the planning stage of a group education session, the first student should gather all

of the relevant Environmental information from appropriate sources e.g. referral

letters, staff who usually run the sessions, care staff etc.

The second student should gather the relevant environmental information from the

group participants in an appropriate style, during the group session. This can only

happen once the students are confident enough to reflect in action as they may need

to modify some aspects of the session, depending on what they discover.

e.g. For a group, the students should gather relevant information on the socio-

economic status of the group, previous health/ dietary education, physical activity

levels, social support networks, language skills, readiness to change, barriers to

change.

7.3. Populations In the planning stage of a health promotion activity, the first student should gather all

of the relevant environmental information from appropriate sources e.g. request

letters, staff who usually run the sessions, care staff etc.

The second student should gather the relevant Environmental/ Emotional information

from the target population in an appropriate style, during the project. This can only

happen once the students are confident enough to reflect in action as they may need

to modify some aspects of the project depending on what they discover.

e.g. For a population, the students should gather relevant information on the socio-

economic status of the group, previous health/ dietary education, physical activity

levels, social support networks, language skills, readiness to change, barriers to

change.

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8. Nutrition and dietetic diagnosis

8.1. Identifying nutritional prioritiesAim: The aim of this activity is to support students to use the assessment information

collected to identify key clinical priorities considering both the medical and patient

perspective

Objectives: By the end of this activity, students will be able to:

Identify the key clinical ‘problem’ justifying their decision with appropriate rationale

Identify possible key patient priorities

ActivityEach student should complete a thorough assessment on two patients. Using these four

assessments, students should work independently initially to identify the key nutritional

problem and possible patient priorities based on the information they collected. Students

should then share there suggested and agree the key nutritional problem for each case.

Students should then work together to provide a rationale for their decision. The students

should then present their conclusions and rationale to their supervising dietitian. The focus

of this feedback will be on the students’ ability to justify their decisions. Discussion should

also take place as to how nutritional priorities and patient priorities can be managed

simultaneously.

8.2. Identifying dietetic diagnosis statementsAim: The aim of this activity is to support students to use the assessment information

collected to identify a nutrition and dietetic diagnosis comprising of the key clinical problem,

the aetiology of this problem and how this problem is manifesting itself

Objectives: By the end of this activity, students will be able to:

Devise nutrition and dietetic diagnosis statements

Justify their decisions to a peer and their supervisor

ActivityEach student should complete a thorough assessment on at least two patients. Having

undertaken this assessment, the students should work independently to devise a nutrition

and dietetic diagnosis statement under the headings ‘problem’, ‘aetiology’ and ‘signs and

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symptoms’. The students should then meet and present their assessments and nutrition and

dietetic diagnosis statements to each other. The student who is not presenting should be

encouraged to probe the other student with regards to their justification for the statements

they make. The students will then be asked to present two of the four cases that have been

considered – each student should be equipped to present any of the cases that they have

discussed with their peer.

9. Intervention, planning and implementation

9.1. Identifying dietetic management goalsAim: The aim of this activity is to support students to use the assessment information

collected and nutrition and dietetic diagnosis to identify possible dietetic management goals

Objectives: By the end of this activity, students will be able to:

Identify appropriate dietetic management goals

Identify possible barriers to patients implementing these goals

9.1.1. Identifying dietetic management goals – stage 1Students should observe a dietitian complete an assessment on a patient. The students

should make notes during the assessment. Once the assessment is completed, the

students should leave the consultation and work together to formulate a nutrition and dietetic

diagnosis and possible dietetic management goals. The students should also be

encouraged to list the possible barriers that might exist to achieving these goals. Once the

consultation is complete, the students should present their suggestions to the supervising

dietitian who can also explain what goals were agreed in the consultation and why these

were agreed.

9.1.2. Identifying dietetic management goals – stage 2Each student should complete an assessment for a new and follow up patient. The students

should then work independently to devise appropriate dietetic management goals for the 4

patients. The students should then compare their suggestions to agree what they are going

to feedback to their supervising dietitian (including the rationale for their decisions). The

students should then have the opportunity to feedback to their supervising dietitian.

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9.2. Implementing dietetic management goalsAim: The aim of this activity is to support students to identify appropriate implementation

plans to enable patients to meet their dietetic management goals

Objectives: By the end of this activity, students will be able to:

Recognise that there may be more than one way to meet dietetic management goals

Suggest suitable actions plans for achieving dietetic management goals

Identify factors that would need to be taken into consideration to ensure the

implementation of specific action plans

9.2.1. Devising implementation plansHaving identified suitable dietetic management goals for 4 patients, students should work

independently to develop a possible action plan for achieving these goals. Students should

then meet together with their supervisor to discuss their recommendations including the

steps that would need to be taken to implement their action plan.

9.2.2. Implementing the dietetic care processEach student should be given one new and one follow up patient to assess, plan and

implement dietetic care. The students should complete these consultations while being

observed by their peer. At the end of the consultation, the peer should provide specific

feedback on the following aspects of the consultation:

Has the student considered the knowledge, beliefs and attitudes of the client/carer?

Has the student negotiated SMART goals with the client/family?

Has the student selected appropriate resources to support implementation of the

dietetic management goals?

How has the student assisted the client to overcome barriers to change?

Has the student responded to the clients questions appropriately and correctly?

How has the student responded to verbal and non-verbal cues?

The student who completed the consultation may want to reflect on their own performance

using the above prompt questions, prior to the feedback session with their peer. The

students should then work together to identify 1 strength of each others practice, one area

for development and devise an action plan to support this development. This summary

should be fed back to the supervising dietitian.

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10. Monitoring and evaluationAim: The aim of this activity is to support students develop their skills in reviewing,

monitoring and evaluating dietetic interventions

Objectives: By the end of this activity, students will be able to:

Gather reassessment data and evaluate this against previously documented goals

Negotiate and agree changes to the dietetic care plan based on accurate

interpretation of information collected

Evaluate clients/carer’s understanding of the agreed changes/nutritional care plan

and answers questions appropriately

Provide relevant written information

Arrange appropriate follow-up

10.1. Identifying appropriate follow-up arrangementsThe students should work together to review dietetic records from patients that have been

seen by their supervising dietitian. If possible, the follow up arrangements should be

removed from these records. The students should agree an appropriate follow up plan for

each patient including a justification for why this plan has been suggested. The students

should then feedback their conclusions to their supervising dietitian and compare their

proposed follow up plans with the actual follow up arrangements.

10.2. Identifying appropriate outcome measuresEach student should take two patients who they have identified dietetic management goals

for and consider relevant outcome measures under the following categories:

Symptom change/Patient Reported Measures  

Physical 

Biochemical  

Psychological 

Behaviour Change 

Patient Focused

The students should feedback their conclusions to their peer and then work together to

identify how these outcomes will be measured/assessed. The students should feedback

their findings to their supervising dietitian

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10.3. Reviewing dietetic interventionsEach student should be given two follow up patients to review, monitor and evaluate dietetic

interventions. The students should complete these consultations while being observed by

their peer. At the end of the consultation, the peer should provide specific feedback on the

following aspects of the consultation:

Has the student gathered reassessment data and evaluated this against previously

documented goals?

Has the student appropriately negotiated and agreed changes to the dietetic care

plan based on accurate interpretation of information collected?

How has the student evaluated the clients/carer’s understanding of the agreed

changes/nutritional care plan and have they answered questions appropriately?

Has relevant written information been provided?

Has an appropriate follow up plan been arranged?

The student who completed the consultation may want to reflect on their own performance

using the above prompt questions, prior to the feedback session with their peer. The

students should then work together to identify 1 strength of each others practice, one area

for development and devise an action plan to support this development. This summary

should be fed back to the supervising dietitian.

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11. Appendix 1 – Observation of students in tutorialsAssessment of Participation of TutorialsThis form is to be completed by the group facilitator for each student for each of the tutorials.

A copy is to be given to the portfolio manager and lead assessor.

Student Name: Tutorial: Date:

Tick the most appropriate comment in each section

Attendance

Attended session on time

Attended but late

Missed session, tutor notified

Missed session, tutor not notified Preparation

Evidence of extensive reading and preparation

Evidence of adequate preparation

Evidence of some preparation

No evidence of preparation Participation

Provided regular questions/comments/new information

Provided some questions/comments/new information

Sporadic questions/comment/new information

No meaningful participation Communication Skills

Consistently communicated effectively

Generally communicated effectively

Did not communicate effectively Presentation skills

Demonstrated developed presentation skills

Demonstrated developing presentation skills

Demonstrated poor presentation skills Interpersonal Skills (GROUP)

Supported participation of others and demonstrated respect for others opinions Allowed others to participate and demonstrates respect for others opinions

Provided minimal interaction or support to other participants Learning skills

Demonstrated self-directed learning

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Demonstrated some self-directed learning

Did not demonstrate self-directed learning Critical thinking

Regularly offered critical analysis/interpretation of ideas

Sometimes offered critical analysis/interpretation of ideas

Little evidence of agreement or disagreement with ideas

No evidence of agreement or disagreement with ideas Other

Demonstrated reflection on discussion and own learning and/or introduction of innovative ideas and/or relating discussion to broader themes or context Facilitated the group process, actively encouraged others to participate Additional comments/evidence Dietitian

Signature

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12. Appendix 2 – Clinical Observation FormDate:

Week No:

Type of Patient: New/Follow-up In/out Patient Adult/Child

Other information (e.g. working through interpreter)

Summary:

Current Strengths:

Key areas to focus on to develop skills:

This has been discussed with my supervising dietitian

Signed student: ________________________________

Signed Dietitian: ________________________________

Date:____________

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STAGE OF CONSULTATION COMMENTS e.g. areas that went well, areas that didn’t go well, aspects I need to improve on.

1. OpeningWelcomes client, introduces self, ensures patient comfortable, and establishes rapport.

Clarifies patient expectations and format of consultation.

2. Data collection - communicationDemonstrates good communication skills.

Communicates at an appropriate level, eye contact, volume of speech, appropriate language.

Listens attentively.

Recognises and responds to non-verbal cues.

Collects, records and interprets relevant information from client, other health care professionals and carers/ relatives e.g..

Diet history Weight Height Fluid balance

Uses appropriate questioning style to elicit relevant information.

Recognises and notes factors that will affect clients compliance eg:

Motivation to change Lifestyle Finance

Provides information and responds to client’s concerns.

Maintains the direction of the interview.

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Ensures suitable room layout and privacy.

3. Data collection – documentationCollects, records and interprets relevant quantitative information (from referral letter, medical notes, nursing notes, computer databases) including:

Medical Biochemical Pharmacological Nutritional Social Psychological Cultural Financial Personal information

4. Formulates and justifies dietetic diagnosisCorrectly identifies the dietetic problems, their causes and presenting symptoms. Can prioritise the problems and justify this prioritisation.

5. Develops dietetic management goals.

Uses information from assessment to devise dietetic management goals that are:

Acceptable and practical for the client/carer

Evidence based

6. Designs and implements action plan to achieve dietetic goalsDevelops goals which are SMARTNegotiates goals with client/ carers/ staffFormulates plan for monitoring and reviewCommunicates the plan using effective strategies

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7. Review, monitoring and evaluation of dietary intervention

Gathers reassessment data and evaluates against previously documented goals

Negotiates and agrees changes to dietetic care plan based on accurate interpretation of information collected.

Evaluates client’s/carer’s understanding of the agreed changes/nutritional care plan and answers questions.

Provides relevant written information.

Arranges appropriate follow-up.

8. ClosingSummarises and closes consultation.9. Documentation and feedbackInforms dietetic supervisor of actions taken.

Writes concise, legible notes in appropriate documents.

10.ReflectionsKeeps to appointment time.

Monitors and reviews client at suitable time intervals without prompting (if applicable).

Practices within the Standards of Performance, Conduct and Ethics:

Maintains confidentiality Complies with departmental

referral procedures. Uses generic names for products

or mentions several brand names.

Words and actions (spoken/written) do not discriminate against clients with respect to: race, religion, age, sexual orientation, learning disability or physical disability.

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Acknowledges own limitations within consultation and seeks advice when appropriate.

Identifies any critical incidents in consultation and reflects appropriately.

Evaluates own practice and identifies areas for improvement.

Demonstrates reflection ‘in action’ and uses this to change plan during consultation when appropriate.

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