Individual Case Management Workbook

Master of Nutrition & Dietetic Practice Program Individual Case Management Workbook Professional Placement Internship ICM A (PPI ICM A) & Professional Placement Internship ICM B (PPI ICM B) 2016

CONTENTS INTRODUCTION TO THE WORKBOOK... 3 REFERENCE INFORMATION ALL STUDENTS SHOULD KNOW PRIOR TO COMMENCING PPI ICM A... 4 MEDICAL NUTRITION THERAPY... 4 NUTRITION CARE PROCESS...4 Nutrition Screening... 5 Nutrition Assessment... 5 Nutrition Diagnosis... 5 Nutrition Intervention... 6 Nutrition Monitoring and Evaluation... 7 Additional Skills in the Nutrition Care Process... 8 THE PATIENT INTERVIEW.11 THE MEDICAL RECORD 11 ACTIVITIES AND RECORDS 12 Activities Schedule... 12 Casemix Record... 12 Weekly Competence Completion Form & Action Plan for Learning... 12 Interview Peer Evaluation Form... 13 Interview Self Evaluation Form... 13 Nutrition Care Process Form... 13 Record of Competency Completion Status Form... 13 Reflective Journal... 14 Practice Simulation Reflective Exercise 14 Case Study... 14 Supervisor Observation Form (optional).14 STUDENT LED DISCUSSIONS / CASE DISCUSSIONS..14 PRACTICE SIMULATION (ICM B). 14 APPENDIX A ACTIVITIES SCHEDULE FOR PPI ICMA & ICM B... 15 APPENDIX B WEEKLY COMPETENCE COMPLETION & ACTION PLAN OF LEARNING FORM... 17 APPENDIX C RECORD OF COMPETENCY OF COMPLETION STATUS FORM FOR PPI ICM A... 19 APPENDIX D RECORD OF COMPETENCY OF COMPLETION STATUS FORM FOR PPI ICM B.25 APPENDIX E INTERVIEW PEER EVALUATION FORM... 30 APPENDIX F INTERVIEW SELF EVALUATION FORM... 32 APPENDIX G BOND UNIVERSITY NUTRITION CARE PROCESS FORM... 33 APPENDIX H CASE MIX RECORD FORM... 35 APPENDIX I STUDENT CASE STUDY GUIDELINES... 36 APPENDIX J REFLECTIVE JOURNAL PROFORMA... 37 APPENDIX K PRACTICE SIMULATION REFLECTION PROFORMA... 38 APPENDIX L SUPERVISOR OBSERVATION FORM (OPTIONAL)... 39 2

INTRODUCTION TO THE WORKBOOK This workbook, along with the Bond University Nutrition and Dietetic Practice Program Handbook and the e- portfolio (on ilearn), will provide the tools for you and your supervisor to achieve the milestones that meet the standards for entry level dietetics. The workbook has been created to allow a flow of increasing expectation of professional practice. At the end of each five week internship, you will have completed many competencies that will allow you to move confidently to your next internship experience. Professor Liz Isenring PhD Adv APD Lead, Master of Nutrition & Dietetic Practice Program Christina Turner APD Internship Coordinator, Master of Nutrition & Dietetic Practice Program 3

REFERENCE INFORMATION ALL STUDENTS SHOULD KNOW BEFORE COMMENCING PPI ICM A MEDICAL NUTRITION THERAPY (MNT) Understanding the steps involved in the process of nutrition care is required to achieve competency, as well as improving confidence in managing a clinical caseload. The steps of MNT are outlined in the Nutrition Care Process (NCP), often referred to as ADIME (Assessment Diagnosis, Intervention, Monitoring and Evaluation). It provides a framework for dietitians to use as a common language in Australia and around the world. The NCP applies, communicates and follows the outcomes of MNT. 1 NUTRITION CARE PROCESS (NCP) ITION CARE PROCESS The following NCP is included as a reference to what you have been taught and are expected to know. The following serves as a standard of patient communication management. The NCP provides a consistent, systematic framework and method for nutrition care. It improves outcomes by using common language and an evidence-based approach. It is the recognised method for dietitian communication in Queensland as well as internationally. It can be summarised in the following steps: Nutrition Screening: nutrition screening involves the use of a validated tool (e.g. MST) to determine nutritional risk and the use of hospital procedures that will be taught while on placement Nutrition Assessment: nutrition assessment involves the collection and documentation of information such as nutrition related history, medical tests & procedures, anthropometric measurements, nutrition-focused physical findings and client history. Validated nutrition assessment tools include SGA and PG-SGA. Diagnosis: nutritional diagnoses are formulated using the assessment data. This is ideally worded using standard International Dietetics & Nutritional Terminology (IDNT now referred to as encpt). Intervention: nutrition interventions will be directed to the main cause (aetiology) of the nutrition problem. The intervention will aim to alleviate the signs and symptoms of the diagnosis Monitoring / Evaluation: monitoring and evaluation is to determine if the client has achieved, or is progressing toward the goal/s. Evaluation of the client during ongoing treatment can mean that this process is cyclical. 1 Dietitians of Australia (2014). Health Informatics and e-health. Retrieved from Dietitians of Australia website: http:/daa.asn.au/for-health-professionals/daa-committees/health-informatics-and-e-heath/ 4

N U T R I T I O N S C R E E N I N G Each hospital may have different procedures in place for the nutritional screening of patients. A common screening tool in use by acute care facilities includes the Malnutrition Screening Tool (MST). The MST can be viewed under Resources on the e-portfolio. N U T R I T I O N A S S E S S M E N T The nutritional assessment process is the foundational work of the dietitian and encompasses a full history of the patient including biochemistry, anthropometric data, medical history, social and cultural conditions, allergies and digestion concerns, patient food history including a diet recall and other information that is pertinent. Validated tools can be used to assist with the assessment of malnutrition, including the Subjective Global Assessment (SGA) and Patient Generated Subjective Global Assessment (PG-SGA). For the purposes of this program you will use the Bond Nutrition Care Process Form found in in this Workbook, in the ICM Workbook Supplement and under Resources on the e-portfolio. N U T R I T I O N D I A G N O S I S A nutritional diagnosis is made to identify and label the nutrition problem. It is NOT a medical diagnosis. The nutritional diagnosis is worded in the PES format: Problem (A)etiology Signs or Symptoms describes alterations in client s nutritional status (diagnostic label) causes or contribution risk factors defining characteristics The PES statement is worded as such: (problem) related to (aetiology) as evidenced by (signs or symptoms). Commonly used encpt/idnt (Hospital Wards - General Medical, Oncology, ICU etc.) Malnutrition Inadequate Protein-Energy Intake Inadequate Energy Intake Increased Nutrient Needs (specify) Inadequate Enteral Nutrition Infusion Inadequate Parenteral Nutrition Infusion Excessive Fluid Intake Decreased Nutrient Needs (specify) Excessive Energy Intake Altered Gastrointestinal (GI) Function Inadequate Oral Intake Altered Nutrition-Related Laboratory Values (specify) 5

NOTE: Please assign Malnutrition and degree of severity (E.g. Mild, moderate or severe) as your priority PES if identified. Specific types of malnutrition e.g. Protein-energy malnutrition are not required. E.g. Moderate malnutrition related to grossly inadequate oral intake for 2/52 of hospital admission as evidenced by NBM/clear fluid diet (<2MJ day) since admission with vomiting and large NG aspirates, weight loss of 7kg or 10% body weight in 2/52 and SGA B with moderate muscle wasting. A full reference to the IDNT terminology can be found under Resources in e-portfolio. N U T R I T I O N I N T E R V E N T I O N Nutrition interventions are purposefully planned actions designed with the intent of changing a nutritionrelated behaviour, risk factor, environmental condition, or aspect of health status. The prescription and the communication of the plan are referred to as Medical Nutrition Therapy. Use the nutritional diagnosis as the starting point to plan the intervention. Goals Before determining the goals of treatment, first work out global statements about the diet (e.g., high in saturated fat, low in fibre, poor carbohydrate distribution). Use these to determine the overall goal of treatment. The goal(s) are what you think the patient needs to achieve. The overall goal(s) are to be in the SMART format (i.e., specific and measurable, with timelines). Examples of the goal: to reduce saturated fat intake to <10 % total energy within the next month; to achieve blood glucose levels between 4-8mmol/L within 3 months. Although we stress the need for patients to set their own goals, you can use the steps above to guide them nutritionally. You need to teach the diet disease relationship as a prelude to determining or assisting the client to set the goals. 6

Nutrition prescription The nutrition prescription is the specific outline of the dietary components that you recommend. The nutrition prescription is important as you need to understand what you are prescribing in terms of nutrients, alterations etc. This ensures that the diet is appropriate and that your interventions and actions are correct. Examples include: 125-145 kj/kg and 1.4g protein/kg of body weight per day 100 mmol Na Low allergen 10 g fibre, adequate energy This prescription is then interpreted into a meal plan or strategies for action (this is the intervention). An example of an intervention/strategy for the first point above could be 3 x 250mL Sustagen /day in addition to usual meals. Strategies Strategies are the actions that the client needs to take, or the specific things that the client must do to reach the goal. If supervisors are using different terminology (for goals / strategies etc.), it is a good idea to work together with them using this guide as a basis to ensure consistency and provide a framework for practice. In longer-term practice, these become second nature, but as a novice practitioner it is better to use a standard framework. Example of the strategy: exchange sour cream at dinner with natural yoghurt; include one additional serve of vegetables at both lunch and dinner for the next two weeks. It is critical that dietitians understand what their treatment is meant to achieve. If you use this framework to formulate both goals and strategies, it will make the cycle of nutrition care (see figure above) more meaningful when it is time to re-assess the patient. N U T R I T I O N M O N I T O R I N G A N D E V A L U A T I O N The purpose of monitoring and evaluation is to determine the progress being made towards the client s goals or desired outcomes. It is impossible to know if your treatment is working unless you monitor and evaluate; and it is at this point that you see the importance of setting goals in the earlier stages to reference against. Monitoring involves review and measurement of status at scheduled times. Evaluation involves systematic comparison with previous nutritional status, intervention goals, and reference standards. For example, weight, PG-SGA score, waist circumference compared to results at follow up. 7

A D D I T I O N A L S K I L L S I N T H E N U T R I T I O N C A R E P R O C E S S Knowledge To become clinically competent you must have the knowledge to provide the basis for your practice. Unit 1 of the DAA National Competence Standards for Entry Level Dietitians refers to knowledge that academic subjects have taught to date. As you have been taught the theory behind nutritional practice prior to placement, it is important to refresh your background information as you require it. This includes: Physiology & biochemistry (so you can explain the diet-disease link) Nutrition (nutritional requirements and food sources as part of therapy) Food science (to help provide practical advice on food modifications and the food supply). You now need to use your content in an applied form. It is your responsibility to ensure your knowledge is upto-date. This will be a constant throughout your working life, to refresh knowledge as evidence changes or when you enter a new clinical area. To assist your continuous refreshing of knowledge, you can draw on the following: Textbooks and review papers Peer study groups to work through the content, as well as to develop a good understanding of where the content is located and where to look for it when you need it Discussion with your Supervisor and the Clinical Educator If you are unsure of something, don t be afraid to ask your Supervisor for direction Remember that poor knowledge leads to problems in practice as it underpins competence. You cannot wing it. If you are unsure of something, it is much better to look it up or discuss it with your Clinical Educator than to attempt patient management with incomplete knowledge. Counselling Your clinical placement is your opportunity to practice the counselling skills you learned in theory. It is important in the NCP to focus on what the patients says / wants and negotiate the dietary goals /strategies together. It will be much more meaningful for the client, and easier for them to adhere to the changes, if they are central to the decision making processes. The dietary goals and behaviour changes should be determined in conjunction with the client first, before determining the supporting materials and strategies for implementing changes. Resist the temptation to choose the resources first and simply using them to structure the counselling session. This can be approached as such: 1. Work out the nutritional diagnosis 2. Determine goals and negotiate what the client wants / is prepared to do 3. Choose the resource (or section of the resource) that matches this. Try some of your own strategies and suggestions in addition to the ones listed to demonstrate your ability to tailor advice to the individual and apply your knowledge. 8

Listening is also core to the process. An ability to really listen to the client empowers them and can be of benefit by having their problem acknowledged by a counsellor / health professional. Demonstrate your knowledge of the food supply and the ability to provide advice regarding the most appropriate food choices, including commercial products. Motivational interviewing can provide a good structure for counselling that allows clients to achieve their own desired outcomes. An abbreviated summary of the principles of motivational interviewing is provided below. It is not an exhaustive guide; however, it is recommended to obtain a resource to guide you (example: www.motivationalinterview.org/quick_links/about_mi.html ) Motivational Interviewing Motivational interviewing (MI) can be defined as a collaborative, person-centred form of guiding to elicit and strengthen motivation for change (2009). Rather than trying to impose change on a client, MI focuses on exploring and resolving ambivalence (i.e., feeling two ways about behaviour change), and centres on the motivational processes within the individual that facilitate change. Ambivalence is a normal part of the behaviour change process, and the practitioner can become skilled in tuning into it, as well as the client s readiness for change, and develop techniques that are responsive to the client. The MI process is grounded in respect and rapport building in the initial stages of the counselling process. The spirit of MI is based on 3 key elements: Collaboration between the therapist and the client (as opposed to confrontation). This is the partnership between the 2 people, grounded in the point of view and experiences of the client, rather than the therapist assuming the expert role by imposing their perspective. Evocation (drawing out the client s thoughts and ideas, rather than imposing the therapist s own). Motivation and commitment to change is most powerful and durable when it comes from the client. Lasting change is more likely to occur when the client discovers their own reasons and determination to change. Autonomy (Vs authority). Rather than the clinician being an authority figure, MI recognises that the power for change rests within the client. It is up to the individual to follow through with making changes happen. Clients can decide whether they will make a change, as well as developing a menu of options as strategies to achieve that change. 9

Principles of Motivational Interviewing Express empathy this provides the basis for clients to be heard and understood, and in turn, are more likely to share their experiences in depth. Support self-efficacy a clients belief that change is possible (self-efficacy) is needed to instil hope about making difficult changes. The clinician supports self-efficacy by focusing on previous successes and highlighting skills and strengths that the client already has. Roll with resistance Resistance can occur when the client is ambivalent about change or feels their autonomy or freedom under threat. Rather than confronting a client showing resistance, clinicians can roll with it by avoiding challenging resistive comments from the client. Having the client define the problem and develop their own solutions leaves little for the client to resist. Develop discrepancy Motivation for change occurs when people perceive a mismatch between where they are, and where they want to be. The clinician can help clients become aware of how current behaviours may lead them away from, rather than toward, their goals. Motivational Skills and Strategies OARS is a brief way to remember the approach used in MI. Open-ended questions (those that are not easily answered with a yes/no). Affirmations statements that recognise a client s strengths and assist the client to feel that change is possible. Reflective listening expresses empathy, and guides the client towards change. Summaries recap what has occurred in the counselling session. Change Talk Change talk involves statements by the client regarding their future change. This can involve their wants or reasons for, ability or need to change. Talk involving their commitment to change, or activation and steps towards change are most predictive of positive outcomes. For example: Ask for the pros and cons of both changing and staying the same Ask what might happen if things continue as they are Ask if you were 100% successful in making the changes you want, what would be different? How would you like your life to be in 5 years from now? 10

T H E P A T I E N T I N T E R V I E W The interview process includes the application of ADIME, knowledge from your training to date and counselling skills. All of this is summarized on the Interview Peer Evaluation Form and the Interview Self Evaluation Form found in the appendices of this workbook T H E M E D I C A L R E C O R D A record of the NCP is written into the medical chart. The format of this communication to the interdisciplinary team varies among medical centres. The health care team is interested in a succinct summary of the dietitian assessment in the ADIME format. Each placement site may have a detailed (such as the Bond University NCP Form) that is not included in the medical record but it is saved for dietitian reference. Refer to your placement s departmental instructions for any specific chart write up requirements. T H E S T U D E N T P 11

ACTIVITIES AND RECORDS The Professional Placement Internship is a formalized process of learning dietetics practice. This workbook is where student work is completed and monitored to ensure continual progression through the internship. The e-portfolio on Bond University s ilearn site is a record of completion as well as one site of interface with the academic aspect of the internship process. The work activities outlined in the following pages are a step by step guide to learning the professional work of a practicing dietitian. The Practice Supervisor and the Clinical Educator play important roles in leading you along this journey. Their roles and your responsibilities have been discussed in your Internship Handbook. T H E W O R K B O O K F O R M S THE ACTIVITIES SCHEDULE The PPI Activities Schedule form (Appendix A), serves as a master director to pace and summarise student work over each five week ICM internship. The DAA competencies are organized into blocks of increasing skills development. Students are expected to meet the goals each week. The supervisor will assist with this and sign off as the student progresses from Needs Improvement to Satisfactory. C A S E M I X R E C O R D The practice supervisor is responsible for finding a wide range of cases for students exposure. The supervisor s signature on the Case Mix Record (Appendix H) on a weekly basis ensures the intention for a wide case mix. Students should keep this form up to date on a daily basis and it should be uploaded weekly to e-portfolio. WEEKLY COMPETENCE COMPLETION FORM AND ACTION PLAN OF LEARNING The Weekly competence completion form and action plan of learning (Appendix B) should be completed once/week. The competence completion form is a weekly summary of the Record of Competency Completion Status for the Individual Case Management form (Appendix C) Ideally, the action plan of learning allows you to identify key learning goals and particular tasks to achieve these goals. It is also helpful to pass the action plan of learning from PPI A to your next supervisor at PPI B to enhance your learning experience. 12

I N T E R V I E W P E E R E V A L U A T I O N F O R M The peer pair model of training is one best practice model that allows for growth in leadership and enhances self-directed learning. Peer review of the interview is the formal application whilst the informal assistance over the course of the internship is unmeasurable. You are directed to upload a completed Interview Peer Evaluation Form (Appendix E) to your e-portfolio as per the PPI Activities Schedule (Appendix A). I N T E R V I E W S E L F E V A L U A T I O N F O R M Self-reflection is recognized as a form of leadership development and is applied in the internship formally by the completion and submission of an Interview Self Evaluation Form (Appendix F) as well as ongoing in the reflective journal. Students are directed to upload a completed Interview Self Evaluation Form (Appendix D) to their e-portfolio as per the PPI Activities Schedule (Appendix A). N U T R I T I O N C A R E P R O C E S S F O R M The use of the Bond University Nutrition Care Process Form (Appendix G) is a regular expectation t hrou ghout ICM internsh ip s. Students might also wish to collate additional forms of evidence of learning and utilisation of the NCP via items such as de-identified chart entries or letters/correspondence (approval required from placement site). Weekly update of one chosen will go into your e-portfolio. R E C O R D O F C O M P E T E N C Y C O M P L E T I O N S T A T U S F ORM Competency goals are outlined and recorded on Record of Competency Completion Status for the Individual Case Management form (Appendices C and D). This document is a record of competency against DAA competencies and will be completed on an ongoing basis throughout your internship. The Clinical Educator and or Internship Coordinator will transfer completion dates of competencies into the student e- portfolio upon completion of each five week ICM internship. Student progress is assessed as either Needs Improvement, Satisfactory or Not Applicable/Not Observed. Please note satisfactory means a student is meeting competencies for that particular stage of placement. By the end of PPI B, satisfactory will mean competent or entry level. It is not expected for students to complete all competencies during this internship as it takes more than 5 weeks to become competent. Additionally, students will revisit PPI A competencies in the first week of PPI B and be expected to transfer skill to the new site. All competencies of the PPI A and PPI B will be completed at the end of 10 weeks. See a full overview of the DAA competencies for both PPI A and PPI B in Appendix A/Activities Schedule and the Internship Handbook. 13

REFLECTIVE JOURNAL Self-reflection is an essential part of ongoing professional development. The importance of the reflection journal and expectations of the style of journal is well described in the Internships Handbook. The proforma for completing self reflection during your ICM internships can be found in Appendix J. At least one reflective journal entry should be uploaded on i-learn each week. PRACTICE SIMULATION REFLECTION EXERCISE As part of the 3 day-long practice simulation intensives you will be asked to reflect on the experience and upload your reflections to the e-portfolio. A sample reflection exercise can be found in Appendix K. CASE STUDY Your supervisor will assist you to find the appropriate case in week 2. You will complete the case in week four and present in week 5. A copy of case study guidelines can be found in Appendix I. SUPERVISOR OBSERVATION FORM (optional) This form is an optional form (Appendix L) that some supervisors may find useful for observing your practice. It is not required to be kept or uploaded into i-learn. STUDENT LED DISCUSSION / CASE DISCUSSIONS Where possible, student-led discussion on particular cases should be conducted each Friday. The Clinical Educator or Internship Coordinator will observe this student facilitated case. Supervisors may be included in these discussions on occasion. PATIENT CASE SIMULATION PPI ICM B (ONLY) You will not be on site three different days during the ICM B Internship when you participate in Dietetic Practice Simulations. This is a learning method of an articulated and practiced approach to a healthcare scenario that allows for each student to practice skills in a peer environment. The model relies upon the use of standardized patients (SP) who are real people trained to portray patients and give feedback to learners on their interactions. There is a main focus on communication in this PPI so the use of SP simulations allows for specific and paused conversation for a deeper review of the impact of communication in patient care. Supervisor, peer and selfreview are embedded in the process. You will be asked to complete a self-reflection of the experience and upload into the e-portfolio. Practice Simulation scenarios also provides for assurance of consistent case mix exposure among the student pairs situated at different locations. These take place at the Bond University and Robina Clinical Skills Room at Robina Hospital. 14

APPENDIX A: ACTIVTIES SCHEDULE ICM A Activity Week 1 Week 2 Week 3 Week 4 Week 5 Case Mix Record Completed in workbook Uploaded to e- portfolio Daily Daily Daily Daily Daily 1 1 1 1 1 Weekly Competence Completion Form & Action Plan for Learning Completed in workbook 1 1 1 1 1 Uploaded in e- portfolio 1 1 1 1 1 Interview Peer Evaluation Form Completed in workbook 2 2 2 Interview Self Evaluation Form Uploaded to e- portfolio Completed in workbook 1 1 1 2 2 2 Nutrition Care Process Form Uploaded to e- portfolio Completed in workbook 1 1 1 2 4 5 5 5 Uploaded to e- portfolio 1 1 1 1 Reflective Journal Completed in E-portfolio 1 1 1 1 1 Case Study Uploaded to e- portfolio Choose patient Follow case Write up case Present Case 1 Completed throughout placement (ongoing) Clinical Educator uploads completion date in e-portfolio Record of Competency Completion Status Demonstrates Understanding 3.1, 3.2, 4.1 3.3, 3.4, 3.5 3.6, 4.2, 4.3, 4.4 8.1 (Expectation of DAA National Competencies met) Applies with Supervision 3.1, 3.2, 4.1 3.1, 3.2, 4.1 3.6, 4.2, 4.3, 4.4 Applies Independently 3.3, 3.4, 3.5 3.1, 3.2, 3.3, 3.4, 3.5, 3.6, 4.1, 4.2 3.1, 3.2, 3.3, 3.4, 3.5, 3.6, 4.1, 4.2, 4.3, 4.4, 8.1 To be reviewed by Supervisor To be reviewed by Clinical Educator 15

APPENDIX A: ACTIVITIES SCHEDULE ICM B Activity Week 1 Week 2 Week 3 Week 4 Week 5 Case Mix Record Completed in workbook Uploaded to e-portfolio 1 1 1 1 1 1 1 1 1 1 Weekly Competence Completion Form & Action Plan for Learning Completed in workbook 1 1 1 1 1 Uploaded in e- portfolio 1 1 1 1 1 Interview Peer Evaluation Form Completed in workbook Uploaded to e-portfolio 1 1 1 1 1 1 Interview Self Evaluation Form Nutrition Care Process Form Reflective Journal Completed in workbook Uploaded to e-portfolio Completed in workbook Uploaded to e-portfolio Uploaded in e-portfolio 1 1 1 1 5 5 5 5 1 1 1 1 1 1 1 1 1 Practice Simulation 3 x day- long intensive Group reflection Upload self reflection to e-portfolio Upload selfreflection to e-portfolio Case Study Written and Uploaded to e-portfolio Choose patient Follow case Write up case Oral presentation Completed throughout placement (ongoing) Clinical Educator uploads completion date in e-portfolio 1 Record of Competency Completion Status (Expectation of DAA National Competencies met) Demonstrates Understanding Applies with Supervision Applies Independently 4.2, 4.3, 4.4, 4.5, 7.1, 7.2 3.1, 3.2, 3.3, 3.4, 3.5, 3.6, 4.1, 4.2, 4.3, 4.4, 8.1 4.6, 4.7, 4.8, 8.1, 9.1,9.2 4.2, 4.3, 4.4, 4.5, 7.1, 7.2 3.1, 3.2, 3.3, 3.4, 3.5, 3.6, 4.1, 4.2, 4.3, 4.4, 8.1 4.6, 4.7, 4.8, 8.1, 9.1,9.2 4.2, 4.3, 4.4, 4.5, 7.1, 7.2 4.2, 4.3, 4.4, 4.5, 7.1, 7.2 4.6, 4.7, 4.8, 8.1, 9.1,9.2 Competent 3.1, 3.2, 3.3, 3.4, 3.5, 3.6, 4.1, 4.2, 4.3, 4.4, 8.1 4.6, 4.7, 4.8, 8.1, 9.1, 9.2 4.2, 4.3, 4.4, 4.5, 7.1, 7.2 Competent 3.1, 3.2, 3.3, 3.4, 3.5, 3.6, 4.1, 4.2, 4.3, 4.4, 8.1 3.1, 3.2, 3.3, 3.4, 3.5, 3.6, 4.1,4.2, 4.3, 4.4, 8.1 16

APPENDIX B: WEEKLY COMPETENCE COMPLETION FORM SIGNATURE PAGE Week l Week 2 Week 3 Week 4 Week 5 Student Comments Student signature of activities completed weekly Practice Supervisor Comments Practice Supervisor signature of activities completed weekly Clinical Education signature of all activities completed* *Discuss with the Internship Coordinator and t ra nsfer results of record w e-portfolio 17

APPENDIX B: ACTION PLAN FOR STUDENT LEARNING Week 1 Week of Placement Learning Goal/s Identified for the next week Strategies (specific tasks and actions that will help achieve goals) Week 2 Week 3 Week 4 Week 5 18

APPENDIX C: R E C O R D O F C O M P E T E N C Y C O M P L E T I O N S T AT U S F O R I N D I V I D U A L C A S E M A N A G E M E N T ICM A Instructions 1. Placement Supervisor dietitian provides initials and date of assessment into each box as the student progresses 2. The Clinical Educator reviews evidence upon completion of the competency and transfers competence completion date into the e-portfolio 3. Non shaded for Individual Case Management Professional Placement A and shaded in Placement B DAA National Competency Standards for Entry Level Dietitians in Australia Needs Improvement (NI): Student can talk about the skill and can identify it when used by dietitians and/or conducts the skill with some prompting or correction by supervising dietitian Satisfactory (S): Student provides accurate application of the skill/activity at the required level for stage of placement (see the Record of Competency section of the Activities schedule for guidance as to competency expectations for each week). Not Assessed (NA): Student has not had the opportunity to display the skill Competencies for Evidence NI S NA Comments 3.1 Collects food intake and food systems data 3.1.1 Uses dietary methodology to collect retrospective, current and prospective food and nutrient intakes for individuals which identify nutrient and food intake patterns as required by the situation 3.1.2 Identifies appropriate dietary methodology to collect retrospective, current and prospective food and nutrient intakes for groups and populations which identify nutrient and food intake patterns as required by the situation Dietary hx 24 h recall Diet-disease 3.2 Collects health and medical, social, cultural, psychological, economic, personal and environmental data 3.2.1 Identifies and records health and medical, social, cultural, psychological, physical activity, economic, personal and environmental data, which are necessary to plan nutritional management 3.2.2 Uses a variety of sources to obtain health and medical, social, cultural, psychological, economic, personal and environmental data, taking into account ethical issues Assessment form Assessment form 3.3 Provides assessment of food intake data 3.3.1 Selects a suitable method and level of detail for assessing intake of foods and nutrients identified by referral, the client, previous history or epidemiological data 3.3.2 Is able to estimate nutrient intake for individuals using food composition tables and/or databases and compare with Nutrient Reference Values (NRVs) or estimated requirements 3.3.3 Is able to interpret nutrient intake for groups and populations using food composition tables and/or databases and compare with Nutrient Reference Values (NRVs) or estimated requirements Patient diet hx Use hospital diet Food & fluid record Use food database 19

Competencies for Evidence NI S NA Comments 3.4 Provides assessment of nutritional status 3.5 Assesses and assigns priorities to all data 3.6 Draws justifiable conclusions from all data 4.1 Undertakes screening and assessment to identify and prioritise those at nutritional risk 4.2 Determines nutritional status using assessment data 4.3 Makes appropriate nutrition diagnoses 3.3.4 Uses food guidance systems to contribute to the assessment of the client s dietary intake 3.4.1 Selects suitable methods for assessment of anthropometry and body composition 3.4.2 Is able to interpret anthropometric and body composition and nutritional assessment data using appropriate reference ranges 3.4.3 Recognises clinical signs of malnutrition 3.5.1 Accurately interprets dietary, health, medical, anthropometric, and body composition data against standards relevant to the nutritional issues 3.5.2 Makes judgements about potential impact of health and medical, social, cultural, psychological, economic, personal and environmental factors on nutrition 3.5.3 Integrates assessment data in order to assign priorities for nutrition and resource planning 3.6.1 Defines nutrition problems/ diagnoses as a prelude to planning management 3.6.2 Documents the collection, analysis and assessment process as a basis for planning 4.1.1 Demonstrates awareness of the range of validated nutrition screening and assessment tools available, including strengths and limitations 4.1.2 Identifies and uses appropriate validated tools in nutrition screening and assessment 4.2.1 Interprets available documentation to identify problems 4.2.2 Assesses anthropometric and other body composition data 4.2.3 Assesses clinical, biochemical and other biomedical parameters 4.2.4 Assesses dietary intake, food habits, mental health and well-being issues, physical activity and lifestyle habits 4.3.1 Organises, interprets and prioritises data to undertake nutritional diagnoses 4.3.2 Refers to all available evidence to inform clinical judgement Apply diet orders Anthro Ax Anthro Ax and risk SGA Nutrition Diagnosis Nx Dx Nx Dx and pt care PES statement Knowledge of tools Application of tools Use of medical chart 20

Competencies for Evidence NI S NA Comments 4.4 Prepares plan for achieving management goals in collaboration with client or carer and other members of health care team 4.3.3 Formulates and prioritises nutrition diagnoses 4.4.1 Determines realistic goals for nutritional management in collaboration with client and other members of health care team 4.4.2 Identifies nutrition outcome measures and performance indicators 4.4.3 Develops dietary prescriptions and formulates meal plans and feeding regimens consistent with nutrition goals 4.4.4 Communicates food service and supply needs of individual clients to appropriate persons 4.4.5 Considers discharge planning and/or referral to other services PES NCP intervention Communicati on Intervention Plan 8.1 Applies organisational skills in the practice of nutrition and dietetics 4.5 Uses client-centred counselling skills to facilitate nutrition and lifestyle change and supports clients to self-manage 8.1.1 Manages workload and resources to complete tasks within required timeframes 4.5.1 Considers an environment conducive to effective counselling 4.5.2 Assists client to clarify issues, identify the barriers to resolution of the problem, and identify appropriate goals and strategies As per the Activities Schedule Peer Review Self Review Peer Review Self Review 4.6 Implements nutrition care plan in collaboration with client or carer and other members of health care team 4.5.3 Negotiates client oriented goals and strategies 4.5.4 Provides information and/or referral if necessary, and responds to client concerns 4.5.5 Evaluates process and outcomes of counselling with client and/or others including family members and carers 4.6.1 Selects the most suitable strategy in terms of feasibility and client outcome 4.6.2 Implements nutrition plan and a system for monitoring and review with client and other health care team members 4.6.3 Promotes physical activity guidelines in care plan with client and other health care team members 4.6.4 Participates in multi-disciplinary team activities (such as case conferencing) to achieve nutrition goals Use of MI Peer Review Self Review Peer Review Self Review Peer Review Self Review NCP NCP Case or NCP form 21

Competencies for Evidence NI S NA Comments 4.7 Monitors progress of the individual s condition and care and adapts plan as necessary 4.8 Documents and communicates all steps of the process 7.1 Adopts a questioning and critical approach in all aspects of practice 7.2 Evaluates practice on an ongoing basis 8.1 Applies organisational skills in the practice of nutrition and dietetics 9.1 Demonstrates safe practice 9.2 Develops and maintains a credible professional role by 4.7.1 Implements the evaluation strategies identified in the nutritional care plan 4.7.2 Gathers data throughout the care process so that an individual s progress can be monitored against performance indicators 4.7.3 Determines a timeline for follow-up of clients as necessary 4.8.1 Maintains clear and concise records, in accordance with the organisation s policy and legal requirements, of all facets of the nutrition care process 4.8.2 Formulates unambiguous instructions for other personnel involved in the delivery of nutrition care 4.8.3 Communicates the nutrition care plan to other members of the healthcare team as appropriate, including referring practitioners 4.8.4 Maintains statistics and other reports required of the organisation 7.1.1 Formulates a clear understanding of the nature of a practice problem 7.1.2 Applies an evidence-based approach to practice 7.1.3 Identifies and selects appropriate research methods to investigate and resolve practice problems 7.1.4 Applies valid and relevant conclusions and recommendations to practice 7.2.1 Monitors and reviews the ongoing effectiveness of practice and modifies it accordingly 8.1.2 Applies the principles of personnel management, using principles of human resource management and industrial relations 9.1.1 Exercises professional duty of care in accordance with the DAA Code of Professional Conduct and the organisation s guidelines or protocols 9.1.2 Refers clients/patients/issues to appropriate professional when beyond own level or area of competence 9.2.1 Complies with legislation and regulations which define ethical behaviour, including maintaining confidentiality Case and NCP form Case and NCP form NCP Intervention Medical chart notes Medical chart notes Medical chart Dietitian duties Case study Case study Case study Case study Manage case load NCP process Manage case load Ethical conduct Understands limits Adheres to organization confidentiality policy, ethical conduct 22

Competencies for Evidence NI S NA Comments commitment to excellence of practice 9.3 Demonstrates professional leadership to promote the contribution of nutrition and dietetics to health and prevention of disease 9.4 Creates solutions which match and solve problems 9.2.2 Accepts responsibility for and manages, implements and evaluates personal professional development 9.2.3 Demonstrates consistent, reflective practice in collaboration with peers and mentors 9.2.4 Promotes a high standard of nutrition care, while respecting the goals and roles of other professionals 9.3.1 Advocates for the role of nutrition and dietetics 9.3.2 Uses negotiation and conflict resolution skills to promote best practice 9.3.3 Identifies opportunities to collaborate with other professionals/ organisations to improve nutrition outcomes 9.3.4 Demonstrates willingness to share information and act as a resource person to, and advocate for, colleagues, community and other agencies 9.4.1 Discusses and explores ideas with colleagues/others on an ongoing basis 9.4.2 Seeks external ideas 9.4.3 Demonstrates initiative by proactively developing solutions to problems Interview self evaluation form, comes prepared to feedback Interview peer and selfevaluation for, active participation during feedback Involvement in MDT, case study Involvement in MDT, inservices Involvement in MDT, case study Involvement in MDT, referrals to other Interview peer evaluation form Involvement in MDT, discussion with supervisor/s Involvement in MDT, discussion with Looking up guidelines supervisor/s: / policies / research 23

A APPENDIX D: R E C O R D O F C O M P E T E N C Y C O M P L E T I O N S T AT U S F O R I N D I V I D U A L C A S E M A N A G E M E N T ICM B Instructions 1. The student considers the competencies daily and seeks opportunities to provide the evidence. This becomes a part of the weekly e-portfolio 2. The Practice Supervisor reviews the competency progress and evidence of competencies at the start and end of each day 3. The Practice Supervisor provides initials and date of assessment into each box as the student progresses 4. The Clinical Educator reviews the evidence on this form in person or in the e-portfolio on a weekly basis 5. Shaded area for PPI -ICM_ A as reference to competencies completed to satisfactory level of competence at a previous time and new competencies for this PPI shown as Non-shaded in PPI -ICM_ B DAA National Competency Standards for Entry Level Dietitians in Australia Needs Improvement (NI): Student can talk about the skill and can identify it when used by dietitians and/or conducts the skill with some prompting or correction by supervising dietitian Satisfactory (S): Student provides accurate application of the skill/activity at the required level for stage of placement Student provides accurate application of the skill/activity at the required level for stage of placement (see the Record of Competency section of the Activities schedule for guidance as to competency expectations for each week).. At the end of Week 5 of ICM B, satisfactory will mean competent or entry level Not Assessed (NA): Student has not had the opportunity to display the skill Competencies for Evidence NI S NA Comments 3.1 Collects food intake and food 3.1.1 Uses dietary methodology to collect Dietary hx 24 h recall systems data retrospective, current and prospective food and nutrient intakes for individuals which identify nutrient and food intake patterns as required by the situation 3.1.2 Diet-disease Identifies appropriate dietary methodology to collect retrospective, current and prospective food and nutrient intakes for groups and populations which identify nutrient and food intake patterns as required by the situation 3.2 Collects health and medical, social, cultural, psychological, economic, personal and environmental data 3.3 Provides assessment of food intake data 3.2.1 Identifies and records health and medical, social, cultural, psychological, physical activity, economic, personal and environmental data, which are necessary to plan nutritional management 3.2.2 Uses a variety of sources to obtain health and medical, social, cultural, psychological, economic, personal and environmental data, taking into account ethical issues 3.3.1 Selects a suitable method and level of detail for assessing intake of foods and nutrients identified by referral, the client, previous history or epidemiological data 3.3.2 Is able to estimate nutrient intake for individuals using food composition tables and/or databases and compare with Nutrient Reference Values (NRVs) or estimated requirements Assessment form Assessment form Patient diet hx Use hospital diet Food & fluid record 24

Competencies for Evidence NI S NA Comments 3.3.3 Is able to interpret nutrient intake for groups Use food database and populations using food composition tables and/or databases and compare with Nutrient Reference Values (NRVs) or estimated requirements 3.4 Provides assessment of nutritional status 3.5 Assesses and assigns priorities to all data 3.6 Draws justifiable conclusions from all data 4.1 Undertakes screening and assessment to identify and prioritise those at nutritional risk 4.2 Determines nutritional status using assessment data 4.3 Makes appropriate nutrition diagnoses 3.3.4 Uses food guidance systems to contribute to the assessment of the client s dietary intake 3.4.1 Selects suitable methods for assessment of anthropometry and body composition 3.4.2 Is able to interpret anthropometric and body composition and nutritional assessment data using appropriate reference ranges 3.4.3 Recognises clinical signs of malnutrition 3.5.1 Accurately interprets dietary, health, medical, anthropometric, and body composition data against standards relevant to the nutritional issues 3.5.2 Makes judgements about potential impact of health and medical, social, cultural, psychological, economic, personal and environmental factors on nutrition 3.5.3 Integrates assessment data in order to assign priorities for nutrition and resource planning 3.6.1 Defines nutrition problems/ diagnoses as a prelude to planning management 3.6.2 Documents the collection, analysis and assessment process as a basis for planning 4.1.1 Demonstrates awareness of the range of validated nutrition screening and assessment tools available, including strengths and limitations 4.1.2 Identifies and uses appropriate validated tools in nutrition screening and assessment 4.2.1 Interprets available documentation to identify problems 4.2.2 Assesses anthropometric and other body composition data 4.2.3 Assesses clinical, biochemical and other biomedical parameters 4.2.4 Assesses dietary intake, food habits, mental health and well-being issues, physical activity and lifestyle habits 4.3.1 Organises, interprets and prioritises data to undertake nutritional diagnoses 4.3.2 Refers to all available evidence to inform clinical judgement Apply diet orders Anthro Ax Anthro Ax and risk SGA Nutrition Diagnosis Nx Dx Nx Dx and pt care PES statement Knowledge of tools Application of tools Use of medical chart 25

Competencies for Evidence NI S NA Comments 4.3.3 PES Formulates and prioritises nutrition diagnoses 4.4 4.4.1 Prepares plan for achieving management goals in collaboration with client or carer and other members of health care team Determines realistic goals for nutritional management in collaboration with client and other members of health care team 4.4.2 Identifies nutrition outcome measures and performance indicators 8.1 Applies organisational skills in the practice of nutrition and dietetics 4.4.3 Develops dietary prescriptions and formulates meal plans and feeding regimens consistent with nutrition goals 4.4.4 Communicates food service and supply needs of individual clients to appropriate persons 4.4.5 Considers discharge planning and/or referral to other services 8.1.1 Manages workload and resources to complete tasks within required timeframes NCP intervention Communication Intervention Plan As per the Activities Schedule Competencies for Evidence NI S NA Comments 4.5 Uses client-centred counselling skills to facilitate nutrition and lifestyle change and supports clients to self-manage 4.5.1 Considers an environment conducive to effective counselling Interview Peer Evaluation Form, Interview Self Evaluation Form, Observation 4.6 Implements nutrition care plan in collaboration with client or carer and other members of health care team 4.5.2 Assists client to clarify issues, identify the barriers to resolution of the problem, and identify appropriate goals and strategies 4.5.3 Negotiates client oriented goals and strategies 4.5.4 Provides information and/or referral if necessary, and responds to client concerns 4.5.5 Evaluates process and outcomes of counselling with client and/or others including family members and carers 4.6.1 Selects the most suitable strategy in terms of feasibility and client outcome 4.6.2 Implements nutrition plan and a system for monitoring and review with client and other health care team members Interview Peer Evaluation Form, Interview Self Evaluation Form, Observation Interview Peer Evaluation Form, Interview Self Evaluation Form, Observation Interview Peer Evaluation Form, Interview Self Evaluation Form, Observation Interview Peer Evaluation Form, Interview Self Evaluation Form, Observation Interview Peer Evaluation Form, Interview Self Evaluation Form, Observation 26

Competencies for Evidence NI S NA Comments 4.6.3 Promotes physical activity guidelines in care plan with client and other health care team members 4.6.4 Participates in multi-disciplinary team activities Case Study or (such as case conferencing) to achieve nutrition goals 4.7 Monitors progress of the individual s condition and care and adapts plan as necessary 4.8 Documents and communicates all steps of the process 4.7.1 Implements the evaluation strategies identified in the nutritional care plan 4.7.2 Gathers data throughout the care process so that an individual s progress can be monitored against performance indicators 4.7.3 Determines a timeline for follow-up of clients as necessary 4.8.1 Maintains clear and concise records, in accordance with the organisation s policy and legal requirements, of all facets of the nutrition care process 4.8.2 Formulates unambiguous instructions for other personnel involved in the delivery of nutrition care 4.8.3 Communicates the nutrition care plan to other members of the healthcare team as appropriate, including referring practitioners 4.8.4 Maintains statistics and other reports required of the organisation Case Study and Case Study and and medical chart Medical chart Medical chart and communication to foodservices Medical chart, Oral Case Presentation Day to day Dietitian duties, record of patient statistics 7.1 Adopts a questioning and critical approach in all aspects of practice 7.2 Evaluates practice on an ongoing basis 8.1 Applies organisational skills in the practice of nutrition and dietetics 9.1 Demonstrates safe practice 7.1.1 Formulates a clear understanding of the nature of a practice problem 7.1.2 Applies an evidence-based approach to practice 7.1.3 Identifies and selects appropriate research methods to investigate and resolve practice problems 7.1.4 Applies valid and relevant conclusions and recommendations to practice 7.2.1 Monitors and reviews the ongoing effectiveness of practice and modifies it accordingly 8.1.2 Applies the principles of personnel management, using principles of human resource management and industrial relations 9.1.1 Exercises professional duty of care in accordance with the DAA Code of Professional Conduct and the organisation s guidelines or protocols Case study, Practice Simulation Case study, Practice Simulation, Use of guidelines during practice Case study, Practice Simulation Case study, Practice Simulation Case Study or NCP process Manages case load Patient Interventions Ethical conduct, Dress code, Meets organizational obligations 27