Poor diet is one of the leading risk factors for morbidity and mortality worldwide (GBD 2016 Risk Factors Collaborators, 2017; Mokdad et al., 2018). Unhealthy dietary patterns are linked to increased risks of cardiovascular disease, cancer, stroke, and diabetes mellitus (Beaglehole et al., 2011; Hu et al., 2001; Micha et al., 2017). Disease burden could be reduced through improved nutrition and dietary behaviors. The importance of dietary and nutrition counseling from health care providers is reflected in recommendations from organizations such as the U.S. Preventative Task Force and the American College of Cardiology/American Heart Association for conditions such as cardiovascular disease, diabetes, and obesity (American Diabetes Association, 2017; Eckel et al., 2014; LeBlanc et al., 2018). Despite the importance of nutrition to the health and wellness of patients, this is rarely translated to clinical practice.
Few patients report receiving nutrition counseling and advice. Less than one third of patients with overweight or obesity state that they receive lifestyle advice from their health care provider (Booth & Nowson, 2010). It is crucial that health care providers are competent and skilled at providing accurate and effective nutritional prevention and treatment care for patients. However, several concerns have been raised about nutrition education for health care professionals (Bleich et al., 2012). Many health care providers do not feel prepared to provide nutritional counseling to their patients (Vetter et al., 2008). In other health care disciplines such as medicine, the lack of education in nutrition has been identified and documented as a crucial barrier to improving patient outcomes (Sacks, 2017). Fewer than 30% of medical schools meet the minimum of 25 hours of nutrition education recommended by the National Research Council (Adams et al., 2015). One fourth of physicians feel inadequately trained to counsel their patients on healthy eating or physical activity (Howe et al., 2010). Surprisingly, little is known about the amount or type of nutrition education that other health care providers, such as nurses, receive.
Nurses are one of the largest health care groups, with more than 2.9 million providers in the United States (U.S. Department of Labor, 2018). As the United States faces increasing rates of chronic diseases directly related to poor nutrition, it is critical that nurses have the skills and knowledge necessary to provide effective nutrition counseling to patients. Although nutrition education is suggested as a component of nursing education in the American Association of Colleges of Nursing's (2016) baccalaureate essentials, the sufficiency of nutrition education within Bachelor of Science in Nursing (BSN) curricula has not been addressed.
The purpose of this exploratory study was to describe faculty perceptions of nutrition education in BSN programs in the United States. The specific aims were to quantify the number of hours of nutrition education required for BSN students at U.S. nursing schools, to describe the nutrition content offered in BSN programs, and to assess barriers for providing nutrition education in BSN programs.
We used a cross-sectional design to gather data using emailed surveys on nutrition education provided in U.S. BSN programs from a nationwide sample of faculty. The primary exclusion criteria were the participant was unwilling to consent to study procedures, the institution did not offer a 4-year BSN program, or the staff or faculty member reported that they were not familiar with the BSN curriculum. This study was approved by the University of Pennsylvania's Institutional Review Board. Participants were provided with a document of informed consent. Completion and return of a survey implied that the individual voluntarily consented to participate.
We used a convenience sample of staff and faculty members from 4-year BSN student programs in the United States. We used a multimodal strategy to recruit individuals from the National League for Nursing database, American Association of Colleges of Nursing website school directory, and web-based searches of Niche's top 100 nursing programs with BSN programs.
Procedures were based on Dillman's tailored design method and guidelines to maximize response rates (Dillman et al., 2014). These included using multiple contacts and varying the message across them, keeping emails short and to the point, personalizing contacts, and offering questionnaires optimized for web and mobile access (Dillman et al., 2014). Questionnaires were self-administered online via REDCap®. Direct online solicitation emails were sent to chief administrative leaders of schools of nursing (e.g., dean, chair, BSN program director, nutrition faculty). The invitation to participate explained the aims of the study and contained a link to a consent form and the surveys. There were up to four emails per participant, including the informed consent and questionnaire; a thank you and reminder sent approximately 1 week after the initial mailing; a replacement link to the questionnaire to nonresponders sent approximately 2 weeks after the thank you and reminder; and a final reminder and thank you email sent approximately 2 weeks later. Collected data were kept in a secure REDCap database.
Questionnaires were designed to take approximately 10 minutes to complete. The surveys were developed based on previously published research that has examined nutrition education given within medical school curricula and programs (Adams et al., 2015; Chung et al., 2014; Khandelwal et al., 2018; Vetter et al., 2008).
Professional and Institutional Information. Professional and institutional information was assessed using five questions. We collected data on the academic title of the respondent (e.g., dean, associate dean), type of institution, and geographic location using closed-ended questions. The number of BSN students at institution was measured with an open-ended question.
Nutrition Education. We used nine questions to assess whether nutrition was offered in the curriculum and whether there was a required nutrition course for students. Participants were asked if their BSN program required specific instruction on nutrition. Possible responses were “required,” “not offered,” or “optional.” We also asked whether a nutrition course was required for students. Possible responses were “no,” “yes, 1 course,” “yes, 2 courses,” or “yes, 3+courses.” The total number of hours that can be identified as primarily concerned with nutrition across the 4-year BSN curriculum was measured using closed- and open-ended questions. The nutrition content offered in courses was assessed using multiple-answer, multiple choice questions. Participants were asked who teaches nutrition courses to BSN students at their institution using a multiple-answer, multiple choice format.
Perceptions of Nutrition in Nursing Education. Participants were asked eight questions about their perceptions of nutrition in nursing education. Participants were asked whether they think BSN students in their school receive adequate training in nutrition. Perceptions about students' ability to effectively counsel patients in nutrition for behavior change was measured on a 5-point Likert scale, with responses ranging from strongly disagree to strongly agree. Participants were asked about barriers their institution faces when offering education content on nutrition to BSN students using a multiple-answer, multiple choice format. Participants were also asked what resources were needed to include nutrition content in BSN courses and in the BSN curriculum at their institution on a Likert scale of 1 (not important at all) to 6 (extremely important).
All data were first assessed for missingness and out-of-range values with basic statistical procedures (e.g., ranges). Results were reported using descriptive statistics, such as univariate statistics (i.e., means, standard deviations, frequencies, proportions, percentiles), and graphs, such as histograms and scatter plots.
A total of 140 faculty members were contacted. Of the surveys that were emailed, the response rate was 35% (N = 50 faculty members from 50 schools). Respondents included directors of BSN programs (36.7%), faculty members (24.5%), deans (16.3%), associate deans (8.2%), associate directors of BSN programs (4.1%), or those who identified as “other” (8.2%). The majority of participants worked in private institutions (55.1%). Most participants were from nursing programs located in urban/metropolitan areas (61.2%), followed by suburban (30.6%) and rural areas (4.1%). Nutrition was offered as a second major for BSN students in 16% of schools and as a minor in 22% of schools.
Nutrition Education and Content
The percentage of BSN programs that required one nutrition course for students was 72.7% and two courses was 4.5%. The mean and standard deviation (SD) of total hours that were identified as primarily concerned with nutrition across the 4-year BSN curriculum was 52.6 ± 49.1 (range = 0–200). The majority (68.6%) of schools reported more than 25 hours of nutrition education. Figure 1 shows the nutrition content provided at each institution. The most common content was growth and development (97.7%), enteral nutrition (97.7%), and parenteral nutrition (97.6%). The least common content was nutritional genomics (26.8%), food sciences (27.5%), and nutritional epidemiology (30.8%). Nutrition courses were most frequently taught by RNs (54%) and registered dietitians (44%). Nurse practitioners (18%), medical doctors (4%), and exercise physiologists (8%) also taught nutrition courses in some schools. Most respondents believed that their BSN students received adequate training in nutrition (59.5%). Some respondents stated that they agreed (33.3%) or strongly agreed (2.4%) that their students received adequate training on how to effectively counsel patients in changing nutrition behaviors.
Nutrition topics covered in 4-year Bachelor of Science in Nursing programs.
Barriers to Providing Nutrition Education
The most frequently cited barriers were insufficient time in the curriculum (52%), other content areas of higher priority (34%), and insufficient number of qualified faculty (22%). The most important resources needed to include nutritional content in BSN courses and in the BSN curriculum at respondents' institutions (mean ± SD; range = 1 [not at all] to 6 [extremely important]) were case scenarios (4.4 ± 1.0), faculty training in nutrition (4.2 ± 1.5), interprofessional education opportunities (4.2 ± 1.2), model curricula (3.7 ± 1.4), web-based tool-kit resources (3.5 ± 1.4), and didactic modules (3.5 ± 1.3).
In a nationwide survey, faculty reported that 4-year BSN students received an average of 52.6 hours of nutrition content. The majority (68.6%) of schools reported more than 25 hours of nutrition education and 77.2% required at least one nutrition course. However, faculty noted barriers to providing nutrition content including insufficient time in the curriculum and other content areas of higher priority. Our survey data suggest that many nursing curricula are incorporating nutrition topics and that nurses may be well situated to address nutrition-related issues in clinical practice.
In this sample, on average, nursing faculty reported that their students received more nutrition training than has been reported in previous studies examining a similar question in medical students. Fewer than 30% of medical schools meet the minimum of 25 hours of nutrition education recommended by the National Research Council (Adams et al., 2015), whereas 68.6% of schools who responded to our survey met this threshold. However, given the rapid pace and changes in the nutrition field and that one third of nursing schools did not meet this benchmark, these data highlight the need for innovative strategies to incorporate nutrition content into training. The degree that this content prepared nursing students and graduates to effectively address nutrition-related issues was not assessed and should be explored in future research. Although 25 hours is the minimum number of hours recommended by the National Research Council, it is likely that students need more hours of nutrition-related instruction to cover essential nutrition-related information and to provide competent care related to nutrition.
The topics covered by courses for nurses varied and primarily were directed to many of the role functions of hospital-based nursing practice. For example, topics frequently covered were enteral and parental nutrition, as well as nutrition assessment. These topics were cited more often than nutrition counseling or obesity treatment or nutrition research. These skills are less well adapted to nutrition counseling skills in the community setting and prevention of chronic diseases. It would be beneficial for nursing curricula to include more of these skills—for example, implementing behavior modification strategies and enhancing effective health care communication skills related to nutrition.
Frequently cited barriers to incorporating nutrition education included insufficient time in the curricula, other content areas of higher priority, and insufficient number of qualified faculty. These barriers have been reported in other disciplines (Sacks, 2017). Many nursing schools may not have affiliated nutrition schools or departments and there may be limited expertise of faculty in nutrition. Thus, teaching of nutrition courses and topics may be passed to faculty without specialty training in nutrition. Having more standardized guidance about essential competencies pertaining to nutrition for BSN students would help to guide curricula development. In addition, we believe that nutrition topics should also be integrated throughout BSN students' education, including clinical care.
A strength of this study is the novelty of the survey and the national sample of schools. Limitations include the response rate of 35%, although multiple attempts were made to contact individuals from different schools. There are inherent challenges with characterizing and quantifying nutrition instruction across a 4-year curriculum. It is possible that there were varying interpretations of what constituted nutrition education. There may have been either under- or overreporting of the curriculum scope. However, we did ask participants to respond only if they felt that they could adequately address the topic. Given that there are not well-validated measures available that have addressed this topic, we used questions similar to those that have been used in previous studies on nutrition education. In addition, we did not examine how well nutrition education led to competence in these topics among graduates.
Many nursing education programs include significant attention to nutrition knowledge and skills for their BSN students. These programs primarily address nutrition as it pertains to acute care settings. Acute care settings may have well-trained dietetic staff members available to guide nutrition care in the acute care setting. Nurses may also be front-line contacts in clinics and primary care settings. Future studies are needed to examine how prepared nurses feel to provide nutrition education in nonhospital settings.
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