Patient Involvement in Education of Nutrition and Dietetics Students: A Systematic Review

A client-centred approach sits at the core of modern healthcare. Exploration of the patients’ role within the education of nutrition and dietetic students has not previously been undertaken. This review aimed to synthesise the learning outcomes that result from involvement of patients in nutrition and dietetic student education, and to consider whether these interactions promote patient-centred care. Five electronic databases were searched, supported by hand-searching of references of included studies. Screening of title/abstract and then full text papers was undertaken; key characteristics and outcomes were extracted and synthesised narratively. The likely impact of interventions was evaluated using Kirkpatrick’s Hierarchy; study quality was assessed using the Medical Education Research Study Quality Instrument and Critical Appraisal Skills Programme checklist. Of 7436 studies identified through database searching, and one additional study located through hand searching of reference lists, the final library consisted of 13 studies. All studies reported benefits for student learning from patient involvement, while one paper identified patient benefits from student interventions. Patients as recipients of care mostly contributed in a passive role in student education activities. Quality assessment identified methodological limitations in most studies. Patient involvement in the education of dietitians supports skill development and therefore progression to professional practice. Although nutrition and dietetics education has a focus on client-centred care, the translation of these concepts into an interactive student educational experience has been investigated to a limited extent. Collaboration with patients in student education is an area for further development.


Introduction
There is variability in academic programmes in nutrition and dietetics internationally [1]; however, inherent to each is student progression though performance increments or stages of proficiency. Through education and experience, student progression results in entry-level competence as a dietitian/nutritionist by programme completion. An essential component of this transition to professional practice [2] is the development of effective nutrition counselling skills, usually undertaken through interactions with service users (including patients, clients, and other end users) of nutrition and dietetic services. Service users, hereafter referred to as patients, have valuable contributions to offer beyond their role as recipients of healthcare. Their interactions in an educational capacity have

Materials and Methods
This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [16] and was prospectively registered with the International Prospective Register of Systematic Reviews (CRD42019124085) [17].
Searches were run in five databases: Ovid Medline, CINAHL, PsycINFO, Scopus, and ERIC from database inception to 30 November, 2018. Search terms were determined through refinement of those utilised in the meta-narrative review of Rowland et al. [15]. The full search strategy implemented in MEDLINE is presented in Figure 1. This strategy was then adapted as appropriate for the other databases. There were no limits on outcomes or study design placed on the search strategy, nor were restrictions on setting or language applied. Database searches were imported into Endnote (version 8.2) [18], where duplicate articles were removed. The Participant-Intervention-Comparison-Outcomes (PICO) format [19] was used to develop inclusion and exclusion criteria. Studies investigating education of nutrition and dietetics students interacting with patients (or clients or users, including simulated patients) were considered. Broader health system approaches (e.g., public health interventions) and patient care/treatment that did not involve teaching/learning were ineligible. Outcomes of interest were student learning outcomes and patient-related outcomes (including health outcomes). Full papers of original research (qualitative or quantitative) were eligible; conference abstracts, commentaries, and systematic reviews were excluded. Papers that evaluated broader aspects of objective structured clinical examinations but did not report on the specific results of simulated patient interviews, and studies reporting interprofessional patient education where data pertaining to nutrition and dietetics students were not able to be separately extracted were also excluded.
Study selection was undertaken using Covidence [20]. Studies were selected by review of titles and abstracts as well as full text papers against the inclusion/exclusion criteria. Each stage was conducted by authors working independently and in duplicate. Discrepancies were resolved by a third team member. Reviewers did not screen their own authored publications. Reference lists of included publications and key systematic reviews were hand-searched to identify additional studies for inclusion.
Data were extracted into a piloted worksheet detailing key study characteristics (including study location and design and demographic details describing patients and students), student learning outcomes, and patient-related outcomes. One reviewer extracted all data; data extracted from reviewers' own authored publications were cross-checked by a second author. Analysis was undertaken narratively to synthesise the student learning outcomes and patient-related outcomes.
Methodological quality of quantitative studies was evaluated using the Medical Education Research Study Quality Instrument [21]. This tool is widely used to evaluate medical education research that uses quantitative study designs and yields an overall score of between 4.5 and 18. The Critical Appraisal Skills Programme checklist (CASP) [22] was used to evaluate the quality of studies using qualitative and mixed method studies. Two reviewers (JP and NK) independently assessed each publication, with discrepancies resolved through discussion to reach consensus.
The likely impact of interventions was evaluated using Kirkpatrick's Hierarchy [23,24] by two reviewers. This framework uses four levels: Level 1 (participation), Level 2a (attitudes and perceptions) and Level 2b (knowledge and skills), Level 3 (behavioural change), and Level 4a (organisation practice) and 4b (patient benefits) to evaluate the impact of medical education research. The Participant-Intervention-Comparison-Outcomes (PICO) format [19] was used to develop inclusion and exclusion criteria. Studies investigating education of nutrition and dietetics students interacting with patients (or clients or users, including simulated patients) were considered. Broader health system approaches (e.g., public health interventions) and patient care/treatment that did not involve teaching/learning were ineligible. Outcomes of interest were student learning outcomes and patient-related outcomes (including health outcomes). Full papers of original research (qualitative or quantitative) were eligible; conference abstracts, commentaries, and systematic reviews were excluded. Papers that evaluated broader aspects of objective structured clinical examinations but did not report on the specific results of simulated patient interviews, and studies reporting interprofessional patient education where data pertaining to nutrition and dietetics students were not able to be separately extracted were also excluded.
Study selection was undertaken using Covidence [20]. Studies were selected by review of titles and abstracts as well as full text papers against the inclusion/exclusion criteria. Each stage was conducted by authors working independently and in duplicate. Discrepancies were resolved by a third team member. Reviewers did not screen their own authored publications. Reference lists of included publications and key systematic reviews were hand-searched to identify additional studies for inclusion.
Data were extracted into a piloted worksheet detailing key study characteristics (including study location and design and demographic details describing patients and students), student learning outcomes, and patient-related outcomes. One reviewer extracted all data; data extracted from reviewers' own authored publications were cross-checked by a second author. Analysis was undertaken narratively to synthesise the student learning outcomes and patient-related outcomes.
Methodological quality of quantitative studies was evaluated using the Medical Education Research Study Quality Instrument [21]. This tool is widely used to evaluate medical education research that uses quantitative study designs and yields an overall score of between 4.5 and 18. The Critical Appraisal Skills Programme checklist (CASP) [22] was used to evaluate the quality of studies using qualitative and mixed method studies. Two reviewers (JP and NK) independently assessed each publication, with discrepancies resolved through discussion to reach consensus.
The likely impact of interventions was evaluated using Kirkpatrick's Hierarchy [23,24] by two reviewers. This framework uses four levels: Level 1 (participation), Level 2a (attitudes and perceptions) and Level 2b (knowledge and skills), Level 3 (behavioural change), and Level 4a (organisation practice) and 4b (patient benefits) to evaluate the impact of medical education research. This model considers educational beneficiaries from the student, organisation, and patient perspective [24].
Patients tended to play a passive role in student education activities, mainly as recipients of care. Only three studies involved patients in providing feedback on student performance [34][35][36], and another had patients rate their experience and the students' counselling skills [29]. Table 2 reports student skill development, including communication skills and interview or counselling skills associated with the patient education experience. Improved confidence in clinical skills [29,37], self-reflection [33], and professionalism [29] were also reported. These skills were gained irrespective of whether the education was undertaken with real or simulated patients. Patient-related outcomes were reported less frequently. Students in the study of Gibson et al. [34] demonstrated that they could perform the technical skills of malnutrition screening, referring patients at risk of malnutrition to a dietitian. Another study that reported students counselling a group of overweight and obese patients [26] delivered weight loss outcomes. Patient-centredness arising from the education process was not described.  In evaluating the impact of educational programmes using Kirkpatrick's Hierarchy [23,24], eight of the 13 studies were rated as Level 2a, whereby they sought to modify student attitudes or perceptions. Four studies were rated as Level 3, Behavioural change, where they sought to apply and/or evaluate new knowledge and skills of learners. Just one of the included studies [26] was rated as Level 4b, with benefits to the patient or client as a direct result of the learning intervention. Table 3 reports the quality assessment of all studies. Of the qualitative and mixed methods studies, the report of Swanepoel et al. [37] rated highly across all aspects of the Critical Appraisal Skills Programme. Three studies [34][35][36] were downgraded for reasons including not adequately considering the relationship between researcher and study participants (both students and patients). Results ranged from 9 [25,30,33] to 13 [27] of a maximum 18 for quantitative studies. Downgrading occurred across the study library for studies conducted within only one sampling institution and for the use of non-validated outcome assessment tools. Two studies reported on randomised controlled trials [25,27].

Discussion
This review aimed to synthesise learning outcomes that result from involvement of patients in nutrition and dietetic student education, and to consider whether these interactions promote patient-centred care. Nutrition and dietetics education, consistent with broader healthcare curriculum, has a focus on delivering client-centred care [8]. However, given the number of studies identified for inclusion in this review, the translation of these concepts into an interactive student educational experience has been investigated to a somewhat limited extent. Outcomes for students from the participation of patients in their training were similar to those in the broader healthcare literature. Patient involvement in the education of dietitians supports skill development and therefore progression to competence. Development of skills and confidence, as well as placing learning into context, were identified as have been reported in previous reviews [38]. However, benefits to patients, such as creating a sense of empowerment or using their knowledge and experience of their condition, were not described [38].
The research outcomes identified in this review suggest that there has been limited evaluation of active patient involvement in the education of student dietitians/nutritionists. There were few measured benefits to patients receiving nutrition and dietetic student intervention, and none reported adverse effects. In addition, few reports were of patients providing feedback to students, with evaluations and feedback led predominantly by educators. Patient-reported outcomes and their perceptions of their own care, as compared to objective patient-based outcomes, are also valuable when assessing clinical education [39].
The patient voice-surely at the centre of patient-centred care-is not being heard across the body of research examined in this review. Patients may prioritise interpersonal abilities over clinical skills when evaluating their own health care [40], yet students typically receive feedback only from supervisors, peers, and occasionally staff from other disciplines. Although patient feedback does not always align with supervisor-assessed competence [40], excluding the patient voice in student education eliminates a vital and powerful source of feedback.
The broader medical education literature describes demarcation between "authentic" patients, i.e., people who have direct lived experience with a particular illness or condition [15], and people who role-play as patients with conditions that they do not actually have (simulated patients). This review identified that in nutrition and dietetics, educational benefits can be gained from both simulated and authentic patients. While their educational roles differ from those of real patients able to contribute authenticity to curricular decisions [15], simulated patients can play a vital role in supporting student learning [41]. Other reports within healthcare education describe psychological stress for patients due to repeatedly describing their illness [42], as well as anxiety associated with being in a teaching role [43]. These issues pose challenges for future curriculum design and educational research, whereby power dynamics versus delivery of educational benefit should be considered and explored.
Patients are unwell and vulnerable; within the environment of clinical education, they may also be considered exposed, tired, and frightened [3], and so their participation in teaching and learning should not be assumed. Although ethics committee approvals were obtained for included studies, ethical considerations of bedside learning were not reported in any of the included studies. These have been described more broadly within the medical literature but warrant consideration for nutrition and dietetic student education. Issues relating to obtaining patient consent of patient participation in student education and ethical considerations in trying to balance the healthcare needs of patients versus maximising learning opportunities for students [15] were not described. The rationale for choosing simulated patients over bedside learning was not considered in the studies included within this review, although cost effectiveness [44] may influence decision making.
This review had several strengths, including a broad search across five databases with no limits on language, time period, or outcomes to ensure that all relevant literature was included. A further strength was the broad scope of setting (beyond the traditional clinical setting) using search terms including client and consumer. This enabled students across different domains of practice in nutrition and dietetics professions to be included.
The use of Kirkpatrick's Hierarchy used within this review to evaluate the impact of medical education research has been acknowledged elsewhere for its limitations [24]. These limitations include that the model does not consider broader outcomes that may arise from different research methods. However, within this review, this hierarchy did highlight that limited benefits to patients of nutrition and dietetic student interactions have been measured to this point. Challenges in assessing whether interactions between patients and students actually promote patient-centred care are also acknowledged. As identified in the quality assessment, included studies were not all methodologically strong, which limits the outcomes that can be drawn. Although five databases were searched, as in all systematic reviews, there is a possibility that eligible papers have been missed.
Given the limited description of active patient involvement in student education, there are many opportunities for future research. This research should be conducted and reported with transparent decision making and should describe why (or why not) different student and patient outcomes have been considered. Patients have the potential to provide valuable input and feedback beyond that which might be considered by educators, supervisors, peers, and indeed experienced practitioners. If student dietitians are to develop skills that service users perceive as worthwhile, their voice needs to be heard. The engagement with patients (including their consent, preparation, and training) to take on their educational role, whether they are authentic or simulated, should also be considered and reported. There is also opportunity for patients to contribute to the design of student learning through patient-centred educational research. Real engagement with patients with feedback on their experience through their participation in the curriculum is encouraged.

Conclusions
Education of nutrition and dietetics students should not exist now or into the future without the service end users. Transformation is needed-to engage and involve patients and other service users in nutrition and dietetics education. This is a challenge for our profession, where services and research involving patients and students can deliver the long-held aim of "nothing about me without me". Author Contributions: All authors conceived this research. J.P., A.B., J.D., C.P., E.V., S.G. completed title/abstract review; J.P., N.K., A.A., S.G. completed full text review. J.P., N.K. completed quality assessment; S.G. completed data extraction. J.P. coordinated the review process and wrote the manuscript. All authors contributed to the review of this version of the manuscript and approve its submission for publication.
Funding: This research received no external funding.