Kyle L. Thompson, MS, RD, CNSC Lecturer in Nutrition and Director, Dietetic Internship

1. Using Principles of Course Design to Enhance Cultural Competence and Confidence: Examples from the Undergraduate and Graduate Level Kyle L. Thompson, MS, RD, CNSC Lecturer in Nutrition and Director, Dietetic Internship Appalachian State University Melissa Gutschall PhD, RD, LDN Assistant Professor and Director, Didactic Program in Dietetics Appalachian State University

2. Course Design: Creating an Online Course to Enhance Cultural Competency

3. 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).

4. Big Purpose of the Course The 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.

5. 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

6. 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

7. 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!

8. 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

9. Course Outline

10. Course Outline

11. 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

12. 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?

13. Examples During 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?

14. 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

15. Examples from Dietetics

16. Activity

17. Now fill in the chart based on your discipline:

18. Course Design: An Exemplar

19. 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).

20. Big Purpose of the Course Students 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.

21. 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

22. 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

23. 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

24. 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

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

26. Situational Factor #1 Factor 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.

27. Situational Factor #2 Factor 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.

28. Situational Factor #3 Factor 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.

29. Situational Factor #4 Factor 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.

30. Special Pedagogical Challenge Challenge 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.

31. Principles of Course Design:Foundational Knowledge

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

33. Principles of Course Design: Application

34. Addressing “Application” in Your Discipline to Increase Cultural Competence

35. Principles of Course Design: Integration

36. Addressing “Integration” in Your Discipline to Increase Cultural Competence

37. Principles of Course Design: Human Dimension

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

39. Principles of Course Design: Caring

40. Addressing “Caring” in Your Discipline to Increase Cultural Competence

41. Principles of Course Design: How to Continue Learning

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

43. 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

44. 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

45. 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