Our nursing facility has continued to explore strategies for reinforcing nutrition concepts in clinical nursing courses. Although we are fortunate to have a nutritionist on the faculty who teaches a required basic nutrition course, and who provides supplemental clinical nutrition content related specifically to other nursing courses, student deficiencies in this area continue to exist. The students have difficulty relating previously taught basic nutrition concepts and diet therapy principles, and applying these concepts in upperlevel clinical nursing courses. These observations, along with our senior nursing students' low performance on the nutrition category of the pre-RN examination, prompted us to take action.
Overview of Nutrition Education
A review of the nursing literature reveals that nutrition and diet therapy have been included in nursing curricula for more than a century. Florence Nightingale, in Notes on Nursing (1859/1946), devoted two of the 14 chapters to the importance of nutrition in the care of the sick. According to Englert, Crocker, and Stotts (1986), nursing students were taught to prepare and serve food for sick patients as early as the 1870s. While the focus was on teaching nursing students the art of preparing food for the sick, the health profession in general was becoming increasingly aware that special diets were important for patients with specific diseases.
In the early 1900s, courses in food, nutrition, and diet therapy were offered, and the nutrition content in nursing curricula increased. Students not only learned techniques of preparing and serving food, but also were expected to acquire knowledge of nutrition and diet therapy principles. In the 1960s, when nursing curricula changed from a medical to a conceptual model, nutrition became integrated throughout the nursing curriculum (Stotts, Englert, Crocker, Bennum, & Hoppe, 1987). The integrated approach continues in nursing curricula today, because this approach provides opportunities for application to various patient populations, for repetition of nutrition and diet therapy principles, and for reinforcement of the value of nutrition in total patient care.
Throughout the years, traditional methodologies have been used to teach nutrition and diet therapy principles. As the characteristics of the learners in nursing programs have changed, creative and contemporary teaching strategies are being advocated. Hohol, Mcintosh, and Girard (1984) suggest that more creative, effective teaching of nutrition theory within nursing curricula would improve attitudes about nutrition, knowledge, and dietary practices of nursing students. Cutler (1986) recommends using the expertise of a registered dietitian to present nutrition content where and when it can most effectively enhance the education of nursing students.
Stotts et al. (1987) recommend increasing clinical time spent in nutrition-related activities, such as history and physicals focused on nutrition, caring for patients receiving enteral and parenteral nutrition, and dietary counseling of patients on special diets. Johnson and Johnson (1987) are proponents of using cooperative learning strategies to teach nutrition. In particular, they support strategies that require students to take action and to be involved in the instructional session through discussion and through teaching each other nutrition information. These strategies influence enduring knowledge acquisition, attitude development, and behavioral habits. Goodwin, Skagge, and Renshaw (1988) suggest creative ways of using computer programs on nutrition to provide student assignments that reinforce concepts about nutrition in the nursing care of clients.
Module Development and Implementation
The authors used the exciting ideas from the review of nursing literature, as well as past experience with learning modules to reinforce nursing leadership concepts (Spickerman, Lee, & Eason, 1988), to design a two-hour learning module entitled "Nutritional Pursuit: A Nursing Perspective." The module was presented to senior nursing students with the belief that a variety of structured learning activities would ensure that all students have the same reinforcement opportunities. The purpose of the module was to "review basic human nutrition, diet therapy, and nutritional principles applicable in promoting and maintaining health throughout the Ufe cycle." The overall objective was to reinforce the previously taught nutrition concepts in a relaxed, active learning environment.
The module's learning activities were designed based on Knowles" (1950) principles of adult teaching and learning. In particular, the following principles were applied:
1. There should be a friendly and informal climate in the learning situation.
2. The student should participate and should accept some responsibility for the learning process.
3. Learning should be related to and make use of the student's experiences.
4. The teacher should be enthusiastic about bis or her subject and about teaching it.
5. The method of instruction should be varied.
6. The teacher should have a sense of humor.
In an effort to promote active participation and to encourage the students to accept some responsibility for their learning process, a module preassignment was given. In addition to a reading assignment, the students were asked to prepare a pictorial description of a selected therapeutic diet, and be prepared to share with other learners (during the module) the purpose of the diet, the dietary principles involved, a correlation with patient diagnoses, pertinent nursing implications, and a sample three-meal plan. They were encouraged to be creative, and to consult with the school's nutritionist as necessary in preparing the display.
The module consisted of five different learning activities. The first was a large group lecture/discussion facilitated by the nutritionist. The module learner objectives for the first activity were to describe the relationship between nutrition and nutritional status, and to discuss human nutritional requirements/needs from preconception to the older adult. The focus of the content was a review of the nutritional needs of individuals throughout the life cycle. Handouts, a study guide, and audiovisual aids were used to vary the methods of instruction. In addition, the students were asked to recall patient situations from previous nursing courses to provide examples of the nutritional needs of individuals in different age groups.
Following the review, smaller cooperative learning groups were formed to review therapeutic diets. The students' pictorial displays of selected therapeutic diets met the module learner objective, to describe at least seven therapeutic diets including their purpose, dietary principles, and nursing implications.
A total of 15 therapeutic diets were reviewed in each of the small groups. Faculty served as facilitators of discussion and resource persons. This involved monitoring the effectiveness of the cooperative learning group and intervening to provide task assistance, such as answering questions. Although the presentations focused on the major concepts mandated by the preassignment, the students were creative in their approach as they used their pictorial descriptions to review the therapeutic diets. Following the presentations, the students were encouraged to view all the displays at their leisure in order to enhance learning at their own pace.
The third learning activity occurred during the class break. As the students changed classroom locations for the next learning activity, they were offered the opportunity to participate in a "tasting" of commercial nutritional supplements. A variety of enteral and supplemental feeding products were provided, including Resource Plus®, Vital®, Sustacal®, Enrich®, and Citrotein®. Although this was an optional activity, most of the students participated in the tasting experience. Written literature describing the products, indications for their use, normal dilution, calories, nutritional information, and storage time was displayed. The students reviewed the information and discussed it among themselves as they tasted the products.
The fourth learning activity used board gaming as a strategy for reinforcement and motivation. The students played, "Nutriquest," a board game designed by the authors, in groups of four to six participants. The module learner objectives for this activity were to identify the function and structure of the organs of the digestive system, and to identify the essential nutrients necessary for adequate nutrition, including their dietary requirements, dietary sources, and clinical manifestations of deficiencies and toxicities. The game, with rules similar to "Monopoly," provided a review of the nutritional principles of therapeutic diets, anatomy and physiology of the digestive system, and nutrition in health care throughout the life cycle. Playing "Nutriquest" gave students and faculty an opportunity to interact in an informal atmosphere, and provided enjoyment while reinforcing learning.
The final learning activity consisted of a postassignment given to the students at the conclusion of the module. The students were assigned three clinical application activities to be completed within three weeks. By design, the student could complete the activities regardless of the clinical nursing course. The clinical application activities included:
* Conducting a nutritional assessment and developing a written nursing care plan for a patient/client experiencing an alteration in nutritional status. Pathophysiologic correlations, nutritional assessment findings, dietary planning, and counseling needs should be considered and incorporated. Review the nursing care plan with the clinical instructor.
* Identifying two patients/clients with different medical diagnoses. Review the medications being administered and discuss with the clinical instructor the effect various drug classifications have on a patient's/client's nutritional status and the nutritional implications of each drug classification identified.
* Reviewing five patients' charts/clients' records to determine what, if any, routine measures of nutritional status have been completed and followed. Identify the factors that provided useful information for dietary planning/follow up. Discuss findings with the clinical instructor.
Documentation of the date completed, and comments from the student and faculty provided verification of each completed activity.
Evaluation of the Learning Experience
The students appeared very excited about participating in the module's different learning activities. Enthusiasm remained high throughout the two-hour learning experience. There was a great deal of interaction among the students and between students and faculty, as questions were asked and points were clarified. The students were overwhelmingly positive in their reactions to the learning module. They indicated that they liked the variety of the format, the relaxed, informal learning atmosphere, and the opportunity to review nutritional concepts and diet therapy principles.
Three tools were used to evaluate the amount of nutrition-related knowledge acquired through the module's five different learning activities. These were a nutrition crossword puzzle, nutrition and clinical care sample situations, and a nutrition expressway. The tools were given to the students at the end of the learning module for completion at their leisure after the class. The faculty offered to meet with the students at a later time to discuss answers or to provide assistance in answering questions.
The authors believe that this learning module provides an excellent opportunity for nursing students to review basic human nutrition, diet therapy, and nutritional principles applicable in promoting and maintaining health throughout the life cycle. Application of adult teaching and learning principles, combined with the students' active participation in the module's learning activities, enhance the motivation to learn. This strategy is not intended to replace nutrition content in theory and clinical nursing courses. Rather, its purpose is to augment course content by providing a review in an enjoyable learning environment.
- Cutler, L. (1986). Nutrition education in baccalaureate degree nursing schools: 1983 survey results. Journal of the American Dietetic Association, 86, 932-937.
- Englert, D.M., Crocker, K.S., & Stotts, N.A. (1986). Nutrition education in schools of nursing in the United States: The evolution of nutrition in schools of nursing. Journal of Parenteral and Enteral Nutrition, 10, 522527.
- Goodwin, S., Skaggs, B.J., & Renshaw, S. (1988). Student assignments using nutrition programs. Nursing Educators Microworld, 3(1), 4.
- Hohol, C, Mcintosh, E., & Girard, D. (1984). Nutrition education and nursing students. Nurse Educator, 9(3), 29, 36.
- Johnson, D.W., & Johnson, R.T. (1987). Using cooperative learning strategies to teach nutrition. Journal of the American Dietetic Association, 87(9), S55-S61.
- Knowles, M.S. (1950). Informal adult education. New York: Association Press.
- Nightingale, F. ( 1946). Notes on nursing: What it is, and what it is not. New York: D. AppletonCentury. (Original work published 1859).
- Spickerman, S., Lee, B.T., & Eason, FR. (1988X Use of learning modules to teach nursing leadership concepts. Journal of Nursing Education, 27, 78-82.
- Stotts, NA, Englert, D., Crocker, K.S., Bennum, N. W., & Hoppe, M. (1987). Nutrition education in schools of nursing in the United States: TTie status of nutrition education in schools of nursing. Journal of Parenteral and Enteral Nutrition, 1 1, 406-411.