CLINICAL
STUDENT TRAINING IN ENTERAL FEEDING Rachel Hall Dietitian, Betsi Cadwaladr University Health Board (East)
Rachel has worked as a Dietitian for the last five years and currently works in Gastroenterology and Obesity Management, as well as being one of the Lead Student Trainers.
Nasogastric feeding is a common request for students to observe and participate in throughout their practice placements. However, are students really prepared for ‘real life’ tube feeding? From experience I have found that students can struggle to grasp nasogastric feeding in practice, despite their knowledge of the theory. I was hoping to write this article and look at what guidance and research had previously been carried out into teaching student dietitians in this important area of practice. However, the evidence in terms of teaching students whilst on practical placement, is very limited. What I did come across was a brief statement about artificial feeding in the BDA curriculum guidance from 2013,1 which stated that Graduate dietitians are expected to have an ‘Extensive critical, integrated and applied knowledge of dietetics for the prevention and treatment of disease’, which includes artificial nutrition with enteral and parenteral feeding as one of its points. This is a very brief statement to say the least. I thought, therefore, that I would look at the tutorial which I use with students and the theories of adult learning. ADULT LEARNING2
The theories of adult learning (Andragogy) where first discussed by Malcolm Knowles in the 1980s. Through his work, he identified a number of key characteristics of Adult Learners. Our dietetic students will be aged approximately 20 plus when they commence their first practice placement, so these theories will apply to them. Knowles identified the key characteristics of the following points: 16
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• Self-concept: self-direction. • Learner experience: Experience developed though life. • Readiness to learn: learning becomes orientated to developmental tasks of their role. • Orientation to learning: learning adapts to a more problem based approach. • Motivation to learn: becomes internal. He then suggested that there are four principals of andragogy which include:3 • adults being involved in the planning and evaluation of their training; • learners’ experience, including mistakes become a basis of learning activities; • relevance: adult learners are more focused on aspects which will be involved in their job; • problem centred, rather than content centred approach. Therefore, as practice placement providers, we need to ensure that our tutorials take into consideration these learning theories. As well as taking into account the specific learning styles of the individual students. Learning styles:4 • Theorist - understand theory behind practice.
Table 1: Summary of the case studies
Case study 1:
A stroke patient who has been referred day one post admission, with a past medical history of hypertension and Type 2 diabetes. The patient is prescribed Ramipril, Gliclazide and Simvastatin. Weight: 90kg Height: 5ft 3ins
Case study 2:
A patient who has been admitted following a VF arrest. They have been nil by mouth for three days before being seen by Speech and Language who advise six teaspoons of Stage 2 thickened fluids and six teaspoons of level B/C diet maximum hourly. Weight: 57kg Height 5ft 6ins
Case study 3:
A stroke patient who has been admitted to hospital for eight days before the medical team request nasogastric feeding. Ulna:22cm Weight: 46.9kg In all case studies, blood results are provided for the initial assessment.
• Activist - students who learn by doing. • Reflector - students who learn by observing and thinking about what has happened. • Pragmatist - students who need to see how to put learning into practice. TUTORIAL
The tutorial that I use with students, although not exhaustive, covers points that have come to light through spending time teaching students the practicalities of enteral feeding and continues to be an evolving teaching tool. Initially the tutorial starts with some basic questions on enteral feeding: 1. What are the routes of enteral nutrition? 2. What are the indications for enteral feeding? 3. How do you confirm the position of nasogastric feeding tubes? 4. What are the advantages and disadvantages of bolus and continuous feeding? We include these questions as a recap of what will have been learnt at university to link theory into the students’ practical training. This also links into the guidelines which should have been highlighted at university, such as NICE guideline 32: Nutrition Support for Adults (2006) and the Guidelines for Enteral Feeding in Adult Hospital Patients (2003). It is essential for students to be aware of the practical implications of these documents, and also allowing them to recap what is written in The Manual of Dietetic Practice.
We also refer to local policy in the tutorial and highlight the need to seek out the local policies with regards to tube feeding in future Trusts where they work, as these local policies may differ to some of the generic guidelines. Following these general questions we then move onto case studies. We include three case studies that cover the basic patient types which students may come across both during placement and as a basic grade: • A patient with a BMI of over 30kg/m2 • A refeeding patient • Patients who need progressing from nasogastric feeding to diet • Patients who need their feeding method switched from continuous to bolus. Initially the questions are based around calculating anthropometrics, nutritional requirements, devising feeding regimens and entries (including nutritional diagnoses) that would be suitable for the medical notes. In addition to the above case studies, the students are also asked to consider what would happen when multiple nasogastric tubes are required daily and the patient remains nil by mouth. Students are asked to think about how nasogastric feeding impacts on the rehabilitation of the patient and the care provided by other members of the multidisciplinary team. This helps the students to think holistically and to work alongside the wider multidisciplinary team, and so links back to the learning outcomes of the practical placements. www.NHDmag.com May 2017 - Issue 124
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CLINICAL
The learning styles of the individual students on placement can be suggestive of when your individual students would most benefit from participating in an enteral feeding tutorial. Although the aim of the tutorial is to ensure that the students are comfortable and competent with nasogastric feeding, as this is a learning tool, there are always some aspects of the tutorial which require further discussion during the session to clarify these points for the students. These points include the following: • Devising the regimen - discussions focus on the timings and rates of continuous feeds, as well as the types of feed to use, especially for bolus regimens. • Frequency of review - although students are not incorrect with this aspect, we do discuss the practicalities of reviewing patients when you have a caseload to manage. • BMI greater than 30kg/m2 - the difference in requirements for individuals over 30kg/ m2 is almost always missed by students and is, therefore, why this has been included to highlight this to students.
CONCLUSION
The tutorial does take into account the characteristics and principals of adult learning set out by Knowles and also takes into account the four different learning styles. The learning styles of the individual students on placement can be suggestive of when your individual students would most benefit from participating in an enteral feeding tutorial. However, I would suggest that this be completed early on in their second placement, as a way to consolidate their learning and put theory into practice before starting to devise feeding regimens on the wards. I am aware that this is very much my opinion and, therefore, other dietitians and clinical trainers may have their own opinions with regards to tutorials and enteral feeding. But hopefully this may shine a light on an area of Dietetics which may require more research.
References 1 British Dietetic Association (2013). A Curriculum Framework for the pre-registration education and training of dietitians. Accessed 19/02/2017; www. bda.uk.com/training/practice/preregcurriculum 2 Pappas C (2013).The Adult Learning Theory - Andragogy - of Malcolm Knowles. Accessed 08/03/2017; https://elearningindustry.com/ the-adult-learning-theory-andragogy-of-malcolm-knowles 3 Culatta R (2015). Andragogy (Malcolm Knowles). Accessed 08/03/2017; www.instructionaldesign.org/theories/andragogy.html. 4 Mobbs R. Honey and Mumford. Accessed 08/03/2017; www2.le.ac.uk/departments/gradschool/training/eresources/teaching/theories/ honey-mumford
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