Planning Nutrition Education Interventions for the Medical Workforce: 'Nutrition Education Workshop for Tayside Doctors' (NEWTayDoc) - A pilot project to inform development of the Need for Nutrition Education Programme (NNEdPro)

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Planning Nutrition Education Interventions for the Medical Workforce
1 | Ray S, Laur C, Rajput Ray M, Gandy J, and Schofield S P a g e
MedEdWorld Publish www.mededworld.org
Planning Nutrition Education Interventions for the Medical Workforce:
‘Nutrition Education Workshop for Tayside Doctors’ (NEWTayDoc) - A pilot
project to inform development of the Need for Nutrition Education Programme
(NNEdPro)
Dr Sumantra Ray1, Celia Laur1, Dr Minha Rajput Ray2, Dr Joan Gandy2, Dr Susie Schofield3
1Medical Research Council, Human Nutrition Research unit, Cambridge 2Need for
Nutrition Education Programme group, c/o British Dietetic Association 3Centre for Medical
Education, Dundee
Corresponding Author: Sumantra Ray, MRC Human Nutrition Research, Elsie
Widdowson Laboratory, Cambridge CB1 9NL; E-mail: Sumantra.Ray@mrc-
hnr.cam.ac.uk; Tel 01223 426356; Fax 01223 437515

Planning Nutrition Education Interventions for the Medical Workforce
2 | Ray S, Laur C, Rajput Ray M, Gandy J, and Schofield S P a g e
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ABSTRACT
Background: It is estimated that one in three hospital patients in the UK is affected by
malnutrition. Increased awareness of the problem could help prevent hospital
malnutrition and associated problems including delayed recovery, increased length of
hospital stay, worsening of prognosis and an increased risk of serious complications.
Evidence suggests there is a gap in nutrition teaching across a number of medical school
curricula and that this may be filled through an innovative approach to nutrition
education.
Aim: To conduct a pilot education intervention ‘Nutrition Education Workshop for Tayside
Doctors’ (NEWTayDoc) aimed at developing a wider reaching programme, targeting
later-stage medical students or junior doctors.
Study Design: An intervention was developed and piloted at Ninewell Medical School,
Dundee, with eight foundation year doctors working in NHS Tayside. A malnutrition
questionnaire was used pre and post intervention to assess knowledge. Two focus
groups were held, that evaluated using thematic analyses that explored related issues.
Results: Analysis of pre and post intervention questionnaires demonstrated a 24% (p
=0.001) increase in knowledge following intervention. Thirty per cent showed no
improvement in knowledge, while 34% maintained residual knowledge. Qualitative
results highlighted the potential to apply this innovative approach to educational
intervention, on a larger scale. Participant feedback also demonstrated the need to
deliver nutrition training earlier within the undergraduate medical curriculum.
Discussion and Conclusion: Based on objective responses from the tutors as well as
participants, this intervention was deemed successful. The strengths and limitations of
the NEWTayDoc education innovation pilot were reviewed and incorporated to form the
basis for a national initiative, the UK Need for Nutrition Education Programme
(NNEdPro), which is currently underway. Key suggestions from the tutor and participant
feedback incorporated into NNEdPro, included introducing nutrition earlier in medical
training and development of an evaluation questionnaire based on learning outcomes to
assess knowledge, attitudes and practices (KAP); as well as conducting post-training
evaluations after a three month interval to reduce recall bias.

Planning Nutrition Education Interventions for the Medical Workforce
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PURPOSE OF THE STUDY
One in 3 patients in the UK is predicted to be at risk of malnutrition. [1-3]. Malnutrition
is defined as ‘a state of nutrition in which a deficiency, excess or imbalance of energy,
protein, and other nutrients causes measurable adverse effects on tissue/body form
(body shape, size, composition) and function and clinical outcomes’ [1]. Increasing
awareness of this among health professionals could help prevent hospital malnutrition
and associated problems including delayed recovery, increased length of hospital stay,
worsening of prognosis and an increased risk of serious complications of illness [4].
These physical consequences of malnutrition contribute to an increased burden of
morbidity and premature mortality as well as incurring substantial costs.
It has been suggested that gaps in medical doctors’ knowledge and skills regarding
clinical nutrition may be having an effect on hospital malnutrition [5]. The Council of
Europe Alliance (CoE), and the General Medical Council (GMC) have recommended
nutrition education for all junior doctors [6]. Other pilot projects have not included junior
doctors and few initiatives have considered thescalability or affordability of training. A
number of training courses relate to the prevention of obesity but do not consider
hospital malnutrition [7-9]. Therefore the NHS Tayside Nutrition Standards Group piloted
the Nutrition Education Workshop for Tayside Doctors (NEWTayDoc) intervention in 2008
to determine if it could be scaled up to be a larger, more robust programme. The aim of
the NEWTayDoc was to conduct a pilot education intervention aimed at forming the basis
for developing a wider reaching programme, targeting late-stage medical students or
junior doctors.
STUDY DESIGN
Development, Approval and Recruitment
This pilot intervention was developed by the NHS Tayside Nutrition Standards Group, in
compliance with the ‘Quality Improvement Scotland’ Clinical Standards[10]. The teaching
team of seven tutors comprised of doctors, dietitians, and nurses who developed the
pilot intervention and delivered the teaching. The project was reviewed by Tayside NHS
Research Ethics Committee and exempted by the chairman from the requirement for
ethical approval, as it comprised delivery and evaluation of an educational course.
Recruitment took place through internal advertising, via NHS Tayside, the Graduate
School of the University of Dundee, College of Medicine, Dentistry and Nursing, as well

Planning Nutrition Education Interventions for the Medical Workforce
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as the local deanery. Focus was placed on recruiting foundation year one (FY1) and two
(FY2) doctors. The pilot study had capacity for ten junior doctors from the Tayside
Region and eight foundation year doctors were recruited. The Foundation doctors’
attachments at that point in time, included general medicine, general practice, intensive
care, medicine for the elderly, orthopaedics and palliative care.
Intervention
The intervention consisted of a half day workshop delivered through a multi-speaker and
facilitator-led interactive workshop. This combined short lectures, interactive voter-pad
response system sessions, focus-group type breakout sessions and a sum up session.
The main aims were to:
Reiterate that nutrition forms an important part of a doctor’s responsibilities.
Educate foundation doctors about core principles of food, fluid and nutritional care
in hospital related to recognition, prevention and management of malnutrition.
Improve knowledge about ‘Quality Improvement Scotland’ Clinical Standards and
the NHS Tayside Nutrition Standards Project.
Ensure medical staff have working knowledge of the Malnutrition Universal
Screening Tool (MUST) scoring, recording this in medical notes and care plans, as
well as coding for malnutrition and including in discharge documents.
Promote protected patient mealtimes.
Evaluation
A questionnaire was administered pre and post intervention to assess knowledge of
clinical nutrition [5]. Each question carried a score of one with a maximum score of 20.
The data were assessed for normal distribution and pre and post intervention scores
were analysed in a parametric paradigm with a paired samples t-test in PASW Statistics
Data Editor 18.
The eight participants were split randomly into two equal focus groups. Each group was
facilitated by a set of two tutors who each made hand written notes during and
immediately after the session. The notes were transcribed and cross checked by both
sets of facilitators. Thematic analysis of the data was conducted by hand, split between
three individuals, including one tutor involved in the teaching intervention and two
others who were independent of the teaching.

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RESULTS
Eight participants were recruited and completed the training, as well as the pre and post
questionnaires. Table 1 indicates the knowledge change based on the scores from the
questionnaires. Twenty nine per cent of responses demonstrated an increase in their
knowledge of malnutrition following the intervention. Thirty per cent showed no
improvement in knowledge, while 34% maintained residual knowledge.
Response
Knowledge Change (%)
Incorrect Scores Pre and Post Test (no improvement in
knowledge)
30.6
Incorrect Pre and Correct Post (increase in knowledge)
29.4
Correct Pre and Post (residual knowledge maintained)
34.4
Correct Pre and Incorrect Post
5.6
Table 1: Knowledge change based on number of correct/incorrect responses from pre
and post intervention examination of students.
Table 2 shows the scores of the pre and post-test of malnutrition knowledge. A mean
shift of 24% between the tests was seen that indicated an increase in knowledge after
the intervention.
Average Score
(Maximum score 20)
Percentage
P value
Pre Intervention
8
40
-
Post Intervention
13
64
-
Change
5
24
.001*
Table 2: Results of pre and post intervention questionnaires test, the change and
corresponding p value (N=8)
* t test for difference
Qualitative Evaluation
Qualitative data from the focus-group style breakout sessions representing the
application of knowledge based on facilitated discussions on how to overcome barriers to
implementation of good nutritional practice in NHS. These discussions focused on

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knowledge acquired from the educational intervention. The major themes were identified
as:
Medical curriculum:
The medical curriculum requires an integrated nutrition component.
Nutrition is not typically taught explicitly in the curriculum.
Determining the correct point to place nutrition in the curriculum can be difficult,
but participants indicated it may be more appropriate during clinical training.
Transition from medical school to junior doctor status:
Nutrition may not be a priority in a local trust.
It is important to determine if local protocols exist; if yes locate and follow them.
It is important to determine how local protocols are implemented.
Clerking
Medical students/junior doctors are not typically taught to ask nutrition-related
questions when clerking in patients.
They may experience difficulties locating nutrition related factors in notes. For
this reason, there needs to be a way to record nutrition-related factors in a
manner which is accessible to all health care professionals.
Suggestions were recorded and used by the tutors to determine if the pilot should be
developed into a wider reaching project. A key suggestion from focus group discussions
highlighted that nutrition should be taught at an earlier stage in the medical training,
such as the latter phase of the undergraduate medical curriculum.

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DISCUSSION
This pilot intervention was conducted in order to determine if and indeed how, it could be
rolled out into a wider reaching and more robust programme. The strengths and
limitations identified during this pilot were incorporated in making this decision.
Strengths
This pilot was innovative, as other similar projects conducted to access nutrition have
not included junior doctors or obtained detailed feedback from participants. Many of
these previous nutrition education pilots related to the prevention of obesity but did not
consider hospital malnutrition [7-9]. Differences also exist in the length of time required
to teach the material, as most relied on a longer timeframe than the NEWTayDoc pilot. A
pilot project completed at two UK Higher Education Institutes with second year nursing
students and third year medical students attempted to enhance inter-professional
collaboration and change attitudes, knowledge and skills [11]. Students were brought
together for four weeks of a variety of clinical practice, taught classroom sessions, self-
directed study and facilitated reflective sessions. Although the inter-professional
collaboration pilot was longer than the NEWTayDoc intervention (only half a day), the
evaluation method of a questionnaire and focus group were equivalent [11]. Both
interventions reported similar shifts to knowledge scores suggesting that brief
interventions may be at least as effective as longer ones.
As the NEWTayDoc pilot was a small scale project, it was able to obtain detailed opinions
from the participants. In addition the rapport built with participants was helpful for
honest feedback on the material and the workshop as a whole and useful discussions
continued with some tutors for several months after the project. Several participants
initiated contact when they were looking for nutrition training or had nutrition related
questions. Participant and tutor suggestions from the focus groups and from continued
communication all formed the basis for a larger scale educational intervention.
Limitations
This pilot was conducted on a limited number of self-selected participants which may
affect the representativeness and generalizability of the results. Post-training evaluation
indicated that some participants did not improve their nutrition knowledge from baseline
(30% of questions were answered incorrectly pre and post training). This suggested that
some of the material needed to be adapted and/or changes made to the teaching and/or
evaluation methods. As the sample size was limited, some results, including changes

Planning Nutrition Education Interventions for the Medical Workforce
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from baseline, may have been affected by random error rather than as a direct effect of
the intervention.
Improvements to the reliability of the evaluation could have been made by using a
questionnaire that was more reflective of the teaching material. Use of a pre-validated
questionnaire from the Nightingale study not created by the tutors may have indicated
that some questions may not have been addressed precisely by the training [5].
As the post-training evaluation was conducted immediately after the training, results
may be due to recall bias as opposed to knowledge acquisition. Other studies have also
indicated it would be beneficial to have long term follow-up and evaluation [7-9].
Confounding factors may have also affected the results due to varying baseline levels of
nutrition knowledge among participants who were at different stages in their medical
curricula.
CONCLUSION
Based on the overall outcome of this pilot project, and taking into account the
strengths, limitations and participant feedback of the NEWTayDoc education innovation
pilot a larger, more robust, programme called the Need for Nutrition Education
Programme (NNEdPro) was established [12]. Some suggestions incorporated from the
pilot in NEWTayDoc, included: teaching nutrition earlier in the curriculum (NNEdPro
focused on medical students, not junior doctors); creating an evaluation questionnaire
based on the teaching material which assess knowledge, attitudes and practice (KAP);
conducting post-training evaluations at one and three month intervals to eliminate recall
bias; and developing rapport with participants to gain insight into the training from the
participant perspective.
NNEdPro was successfully conducted in 2009, and results indicated that it increased
nutrition KAP in a population of fourth year medical students [12]. The NEWTayDoc pilot
intervention provided the key to establishing the NNEdPro group, which lays the
foundations of nutritional knowledge to clinical practice in tomorrow’s doctors [12].

Planning Nutrition Education Interventions for the Medical Workforce
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What is already known on the subject:
One in three hospital patients is affected by malnutrition.
Increased awareness of the problem, particularly in the medical workforce, could
help prevent hospital malnutrition and associated problems.
There is a gap in nutrition teaching across a number of medical school curricula.
This gap may be filled through an innovative approach to nutrition education.
What this study adds:
This study demonstrates the key elements required to conduct a successful pilot
nutrition education intervention for junior doctors (NEWTayDoc).
This intervention adds to the evidence supporting nutrition education of later-
stage medical students and/or junior doctors.
Tutors determined that this intervention could be converted into a wider reaching
national programme, Need for Nutrition Education Programme (NNEdPro).
ACKNOWLEDGEMENTS AND DECLARATIONS
Funding: Supported by an educational grant from the NHS Tayside Endowment Fund.
Competing interests: None
Contributors: The NEWTayDoc Teaching Team – Dr Sumantra Ray, Dr Minha Rajput-
Ray, Debbie Baldie, Caroline Hubbard, Dr Poonam Rana, Joyce Thompson, Anne Hobbs
and Anne Woodcock. The NEWTayDoc Analysis Team - Dr Sumantra Ray, Celia Laur, Dr
Minha Rajput-Ray, Dr Susie Schofield and Dr Joan Gandy.
Ethics Approval: The project was evaluated by Tayside NHS Research Ethics
Committee and exempted from the need for formal ethical approval.
Provenance and Peer Review: Not commissioned. Externally peer reviewed.
Data sharing statement: Data may be shared as long as anonymity and confidentiality
are preserved.

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