Using Principles of Course Design to Enhance Cultural Competence and Confidence: Examples from the Undergraduate and Graduate Level

Kyle L. Thompson, MS, RD, CNSCLecturer in Nutrition and Director, Dietetic InternshipAppalachian State University

Melissa Gutschall PhD, RD, LDNAssistant Professor and Director, Didactic Program in DieteticsAppalachian State University

Course Design: Creating an Online Course to Enhance Cultural Competency

Successful Rural Practice for Health Professionals• Class size: Variable• Level: Junior/Senior/Graduate• Delivery: Totally online• Description:

▫Exploration of the rural health environment, along with consideration of issues common to rural health practice. Consideration of the elements of cultural competency necessary to promote effective patient/client communication in rural settings. Development of a plan for continued learning in rural health topics. (3 credits).

Big Purpose of the CourseThe purpose of this course is to develop the abilities of current and future health care professionals to practice their disciplines successfully in rural health settings in the United States.

Course Development•Major steps:

▫Selection of “Rural Health” as the Appalachian State University Dietetic Internship’s program concentration area

▫Decision to create a rural health course to support the program concentration

▫Development of the course at a Course ReDesign workshop at Appalachian State University; summer 2011

Course Development•Designation of the course design as

eligible for publication at the “Designing Better Learning Experiences” web portal

•Dr. Fink mentored this writer in further refinement of the course design and preparation of the course design for publication

•Publication of the course design in the winter of 2012

Course Development• Approval of the course for inclusion in the

Appalachian State University course catalog (Spring 2013)

• This writer applied for and was selected to develop the course for online delivery as part of the “14 by 2014” online course initiative sponsored by Appalachian State University (November 2013)

• May 2014: Course approved by “14 by 2014” peer reviewers; will be offered during the summer of 2014; students are signing up!

Research Base for the Course•The course features original research

completed at Appalachian State University by Dr. Melissa Gutschall and this writer

•The research has two focus areas:▫Rural health, particularly in regards to

nutrition▫Development of rural-focused simulation

scenarios for inclusion in the Appalachian State University dietetic education programs Scenarios are based on Dr. Gutschall and Ms.

Thompson’s research

Course OutlineModule Major Question

(thank you, Dr. Fink!)

Activities

1. Introduction to rural health

How is rural health care (RHC) organized and delivered at the current time?

• Readings• Forum discussions• Quiz• Definition of cultural

competency2. Rural patients What are the

characteristics of people receiving RHC?

• Readings• Forum discussions• Rural stereotype

assignment3. Rural health care providers

What are the characteristics of the people currently involved with direct delivery of RHC? What characteristics do they need to have?

• Readings• Forum discussions• Rural health care

provider interview assignment

• Re-visit definition of cultural competency

Course OutlineModule Major Question

(thank you, Dr. Fink!)

Activities

4. Effective care for rural patients

What are effective techniques for facilitating health care interactions with patients/clients in rural health settings?

• Readings• Forum discussions• Computer-based

simulation: Unfolding case study focused on a rural patient

2. Plan for ongoing learning in rural health topics

What is your plan to continue your near-future learning about RHC?

• Final definition of cultural competency

• Forum discussion of cultural competency definitions

• ‘Continuing My Learning’ assignment

• Course Reflection assignment

• Final quiz

Computer-based Simulation• Based on an original case study completed by

this writer• Incorporates basic principles of simulation

development (Jeffries, 2005):▫Defined objectives▫Emulation of reality to the greatest extent possible▫Moves from simple to more complex tasks in order

to promote an orderly progression of student learning

▫Consideration of cues provided to students▫Debriefing of simulation experience

Examples Mrs. Jones is 62 years old. Several months ago, she traveled to a major hospital in the city to have a stent placed due to discovery of serious narrowing of her cardiac artery related to atherosclerosis. Mrs. Jones's heart disease was discovered when she experienced chest pain while working in her garden. She is seeing you for follow-up care in a primary care clinic located about 25 miles from her rural home. After her heart procedure, she did not participate in cardiac rehab due to the lack of a suitable facility near her home.

The referral provides the following information:

• FBG (Fasting Blood Glucose): 110 mg/dL• Total cholesterol: 232H• LDL (Low-density cholesterol): 158H• HDL (High-density cholesterel): 32H• TG (Triglycerides): 210H• Height: 62"• Weight: 197#• Blood Pressure: 158/96 H

Based on the information provided, what diagnoses might be indicated for Mrs. Jones?

ExamplesDuring your conversation at the clinic, you learn the following about Mrs. Jones:

• She is very concerned about her recent cardiac incident, and is highly motivated to make lifestyle changes. She is unsure of her ability to successfully implement these changes, however.

• She describes herself as a "good old country cook", and loves to spend time in her kitchen creating "goodies". She frequently fries foods, and is praised for her pork ribs, green bean casserole, and pies at the weekly church potlucks. She is concerned that her husband will be unhappy if she changes her way of cooking.

• She and her husband have kept a garden for many years. She enjoys working in the garden, and freezes/cans much of her vegetable harvest. Mrs. Jones considers fresh and canned vegetables from her garden to be a treat.

• When Mrs. Jones returns home from work in the evenings after her 12-mile commute (one way), she often helps her husband with bookkeeping and other clerical tasks related to the farm.

• Mrs. Jones has been cleared to walk up to one mile per day by her cardiologist.

What are some cultural/rural environment factors you would consider as you make recommendations to Mrs. Jones?

Using Simulation within a Designed Course to Build Cultural Competency Skills

•Within your discipline:▫Where does your discipline intersect with

cultural competency?▫Which cultural competence skills are most

amenable to simulation? Repeatable, “rehearse-able” experiences “Debrief-able” experiences Experiences requiring “people skills” or “soft

skills” Experiences requiring the application of

critical thinking

Examples from DieteticsTypes of experiences which

may be addressed with simulation methodology

Dietetics Education

Repeatable experiences Entering a patient’s hospital roomDocumenting in the patient’s medical record

De-briefable experiences Nutrition counselingNutrition educationInteracting with other members of the interdisciplinary health care team

“People skills” or “soft skills” Interacting with the patientInteracting with patients’ family members

Critical thinking skills Choosing a nutrition diagnosisChoosing a nutrition interventionReacting to a change in patient conditionReacting to an emergency situation

Activity

Now fill in the chart based on your discipline:

Types of experiences which may be addressed with

simulation methodology

Your Discipline

Repeatable experiencesDe-briefable experiences“People skills” or “soft skills”Critical thinking skills

Course Design: An Exemplar

Education and Counseling for Dietetics Practice•Class size: 25•Level: Senior/Graduate•Delivery: Face-to-Face•Description:

▫Principles of dietary counseling for the general population and for individuals with special health problems. Principles of teaching and learning applied to nutrition education of patients with specific health problems (3 credits).

Big Purpose of the CourseStudents will be confident and competent in their ability to effectively counsel or educate clients for successful dietary behavior change and maintenance. The skills gained will be transferable to a variety of diet and disease situations and sensitive to individual client characteristics. Skills such as improved communication and self-assessment abilities will also enhance the continued personal and professional development of the student.

Simulated Training Models•Emulating the real world by providing

directed, fully interactive experiences in a low-risk environment

•Attainment of knowledge and competency equal to clinical experiences

Advantages of Simulation Training•Reduction of risk•Focus on student learning rather than

actual patient care•Optimization of resources•Standardized documentation of student

progress; consistency in training•Enhance quality of patient care•Repeatable experiences tailored to

student learning needs

Advantages of Simulation Training•Development of situational critical thinking

skills•Ability to promote interprofessional

communication skills•Prompt debriefing to advance student

learning•Continuous quality improvement related to

training in designated competency areas•Increased confidence for students prior to

actual practice

Cultural Competence•Ability to interact effectively with people

of different cultures and socio-economic backgrounds▫Awareness of one’s own cultural worldview▫Attitudes toward cultural differences▫Knowledge of different cultural values and

worldviews▫Cross-cultural skills

Intersection of Nutrition and Cultural Competence•Socioeconomic status•Influences on food choices •Traditional food habits •Definition of health

Situational Factor #1Factor Solution• Meeting accreditation

competencies for dietetics education. We must prepare competent practitioners with the ability to move on to greater professional training, while some students in the course will not qualify to move on the next level of training.

• Strive to relate the lessons learned to each career pathway students might select for the future.

Situational Factor #2Factor Solution• The number of

nutrition majors is growing rapidly such that the course enrollment could be 35-50 students in a very practicum natured course.

• Use the principles of course design to effectively deliver the course despite the class size. Consider multiple sections or summer offerings as alternative strategies to meeting growing demand.

Situational Factor #3Factor Solution• The course is a co-

requisite with Medical Nutrition Therapy 1, taught during the fall semester of senior year.

• Coordinate coverage of particular topics and disease states with instructor of co-requisite course. Students will be covering diet therapy for particular disease states in that course, e.g., diabetes, heart disease, which provides a unique opportunity for integration in this course within counseling scenarios and educational sessions.

Situational Factor #4Factor Solution• I’ve never taught this

course, but it is my area of expertise. I am very interested in teaching it for that reason, but also because I am now the director of our undergraduate program and would like to increase my contact with students at the senior level.

• I hope that by using these principles of course design, I can develop an effective, powerful, dynamic course from the start and somehow add it to my teaching load in the near future.

Special Pedagogical ChallengeChallenge Solution• Students have a lack of

experience and exposure to patients in the field at this point in their curriculum. Thus, they may be naïve to individual client characteristics and motivations that affect readiness to change dietary behaviors.

• My research and practice experiences have been highly based on behavioral theories and education planning, implementation and evaluation. I hope to be able to provide many examples from those experiences that will help students relate to course material. I also plan to provide rich learning experiences, such as simulated counseling scenarios with peer critique that will enhance the students’ knowledge, professional development, and passion for the profession of dietetics.

Principles of Course Design:Foundational KnowledgeLearning Goals Assessment

ActivitiesLearning Activities

Describe the theoretical basis for dietary behavior change. Identify key principles and techniques from theoretical frameworks to use in nutrition counseling and education roles.

Readiness Assessment Test of counseling and education principles and techniques.

Identification of counseling and education principles and techniques within a preliminary computer-based counseling simulation that presents their patient for subsequent counseling scenarios.

Background reading and lecture.

Computer-based counseling simulations demonstrating fundamental concepts.

Each group will develop 3 readiness assessment quiz questions based on their topic to construct a test for the class.

Addressing “Foundational Knowledge” in Your Discipline to Increase Cultural Competence

Learning Goals Assessment Activities

Learning Activities

Principles of Course Design: ApplicationLearning Goals Assessment

ActivitiesLearning Activities

Develop goals in collaboration with a client and provide reinforcement to maintain improved dietary behaviors. Goals should be specific to client’s individual needs and sensitive to differences in health beliefs and lifestyle choices.

Implement and evaluate interventions and strategies to facilitate dietary behavior change.

Demonstrate communication skills that encourage client discussion, clarification, and problem-solving.

Practice cultural competence skills and discipline-specific techniques within counseling and education scenarios.

Select and develop appropriate content, strategies, and resources for effectively educating clients about dietary interventions for their specific disease state.

Students will self-assess and peer-assess their performance on the simulation using an established rubric.

Instructor will assess the improvement from scenario 1 to scenario 2.

Instructor and peers will assess the quality and appropriateness of resources chosen for patients.

Each student will participate in 2 simulated counseling scenarios about a given disease state, which will be videotaped.

Students will use selected resources within counseling scenarios and education session.

Students will share resources within an online group resource repository (e.g., diigo.com or delicious.com).

Addressing “Application” in Your Discipline to Increase Cultural Competence

Learning Goals Assessment Activities

Learning Activities

Principles of Course Design: IntegrationLearning goals Assessment

ActivitiesLearning Activities

Use prior knowledge and research to design evidence-based interventions.

Connect knowledge and experience from this course within remaining coursework, internships and future nutrition practice.

Final education session presentation rated by instructor and peers.

Students will integrate what is learned from counseling experiences to develop an educational presentation for patients with multiple chronic diseases.

Students will generate the rubric for evaluating the educational sessions.

Addressing “Integration” in Your Discipline to Increase Cultural Competence

Learning Goals Assessment Activities

Learning Activities

Principles of Course Design: Human DimensionLearning Goals Assessment

ActivitiesLearning Activities

Human Dimension:Learning about ONE-SELF:Students will gain confidence in their ability to use this information and understand how personal health behaviors and perceptions of food impact decision-making about nutrition care for others.

Interacting with OTHERS:Identify promoters and barriers to dietary behavior change.  Identify a client’s readiness to change.  Understand non-verbal behaviors that affect counseling and education.

Reflection papers

Class discussion

Scenario observation

Students will write a reflection paper at the beginning of the course about a dietary change they have made, factors that influence dietary choices, and level of difficulty in making dietary change. Students will write a reflection paper following each counseling scenario reflecting on how stereotypes and biases may affect the ability to work with others.

Students will watch a videotaped counseling scenario and select successful and unsuccessful strategies for working with clients and patients.

Students will observe and take note of non-verbal behaviors within peer-assessment of counseling scenarios.

Class debriefing of all of the above items.

Addressing “Human Dimension” in Your Discipline to Increase Cultural Competence

Learning Goals Assessment Activities

Learning Activities

Principles of Course Design: CaringLearning Goals Assessment

ActivitiesLearning Activities

Students will get excited about the value of course material and techniques within their personal and professional lives.

Students incorporate what was learned from family interviews within the counseling scenario to provide appropriate goals, reinforcement, and follow-up.

Interview a family member or friend about making a dietary behavior change and reflect on what made that change successful or unsuccessful.

Counseling scenarios

Students will reflect on the personal value of course material within a learning portfolio.

Addressing “Caring” in Your Discipline to Increase Cultural Competence

Learning Goals Assessment Activities

Learning Activities

Principles of Course Design: How to Continue LearningLearning Goals Assessment

ActivitiesLearning Activities

Develop strategies and resources for continual learning and professional development in the field of nutrition.

Learning Portfolio.

Plan for continuing education and professional development.

Students will develop a learning portfolio with plan for continued learning and professional development.

Addressing “Continued Learning” in Your Discipline to Increase Cultural Competence

Learning Goals Assessment Activities

Learning Activities

Designing Appropriate Goals and Assessment Activities

Goal: Improve interpersonal, inter-professional, and cultural competency skills throughout

the semester.•Assessment

▫Performance- simple to complex▫Multi-layer▫Established rubric▫Feedback

Weekly Schedule

•Module 1: Information and Ideas▫Foundational knowledge

•Module 2: Doing and Observing▫Application▫Integration

•Module 3: Reflection▫Human Dimension

•Module 4: Continued Learning▫Caring▫Keep on Learning

Teaching Strategy•Team-based learning•Training for the inter-professional health

care team•Combination and sequence

▫Complements the progression from knowledge and skills to behaviors necessary for professional practice

▫Same strategies used to promote meaningful learning will be successful for behavior change with clients