Public Health Placements for Nutrition Students

Background:

Nutrition students complete a number of placements during their training one of which is a three week public health placement. The purpose is to ensure that students have an understanding of the application of nutritionists in the public health context. The remit of the project is broad and flexible, and may take place in a wide range of settings. For example, some students might work within a local authority public health team, whereas others may complete projects with voluntary organizations, health campaign/advocacy agencies, or charities.

The key requirement is that the student is able to appreciate how the nutritionists care process they learn in a clinical setting (assessment and analysis, planning and implementing the intervention, monitoring and evaluation can be applied at a population level. A population in this context could be anything from all the people living in a specific region, to the inhabitants of a care home or the sixth formers in a particular school.

In the time available it is not possible for a student to actively participate in each of these stages so it is likely they will be directly involved at only one (e.g. needs assessment, evaluation of an intervention), but their experience should enable them to understand where this work fits into the process overall.

· The work undertaken on placement should contribute to meeting one of the two outcomes set out in the Public Health Outcomes Framework:

Outcome 1: Increased healthy life expectancy: taking account of the health quality as well as the length of life.

Outcome 2: Reduced differences in life expectancy and healthy life expectancy between communities: through greater improvements in more disadvantaged communities.

· In addition, the project should be relevant to one of the following four domains described in the Public Health Outcomes Framework:

Domain 1: Improving the wider determinants of health

Objective: Improvements against wider factors that affect health and well being, and health inequalities

Domain 2: Health improvement

Objective: People are helped to live healthy lifestyles, make healthy choices and reduce health inequalities

Domain 3: Health protection

Objective: The population’s health is protected from major incidents and other threats, while reducing health inequalities

Domain 4: Healthcare public health and preventing premature mortality

Objective: Reduced numbers of people living with preventable ill health and people dying prematurely, while reducing the gap between communities

· Finally, projects should be related to one or more of the indicators listed for the above 4 domains (please refer to Appendix 2 for the full list).

(Improving Outcomes and Supporting Transparency Part 2: Summary technical specifications of public health indicators, updated 2016)

What kinds of things do students actually do on placement?

Previous students have completed a wide range of tasks in a diverse range of settings. Some examples are given below, but this list is by no means definitive.

· Evaluation of a pilot childhood obesity intervention

· Creating teaching materials on healthy nutrition for use by those working with people living with HIV

· Survey of (healthy/less healthy) food and beverage provision in local-authority run premises (e.g. leisure centres, libraries etc)

· Developing a survey tool to assess nutritional status and level of food insecurity in homeless young people

· Assessment of user experience of a Healthy Start Maternal Vitamin scheme, and development of recommendations to increase uptake of the scheme

· Scoping local food retailers prior to implementation of a proposed healthy catering scheme

· Quality assurance of lay health educators’ practice

· Mapping community gardens and food growing projects in a London borough

· Audit of food provision for NHS staff against government standards for NHS staff health

Similarly, placement ‘products’ are also diverse; the ‘product’ should simply be whatever is appropriate to the needs of the project in the format most usable by you and your organisation. Some placement providers have asked students to produce a brief PowerPoint presentation to illustrate their findings as this is what they will find most useful to share with funders/commissioners. In other cases (e.g. where students have worked on developing a resource) the draft resource materials are the natural project products, and where a student has completed a survey or carried out an audit an executive summary of their work with a more detailed results paper might be appropriate. Overall, it is important to consider what is realistic within the short time-frame and what is most useful for your project/organisation.

Please note: Nutrition students are usually diligent and very keen to please, and unless you give them clear and realistic guidelines about what is expected they sometimes spend many additional hours producing great tomes – so please support them in acquiring the skill of time management and setting realistic goals!

In terms of day-to-day activities during the three weeks this will depend entirely on the nature of the project. However, there are some elements that should be common to all settings:

· Induction – all students will need an initial meeting with their project supervisor and to be introduced to other key people. Early on somebody will need to orientate them to the work of the organisation, how work is commissioned and delivered, the organisation’s goals and strategy etc. You will also need to help your student understand where your organisation (and their specific project) sits in relation to the national and local public health agenda. You will need to brief them about the project you are asking them to complete and agree a work plan and arrangements for supervision. Students will also need a potted version of all the information you would give to a new employee – data protection and confidentiality, health & safety, local procedures etc (please see Appendix 3 for a suggested list).

· Orientation/background reading – you will need to direct the student to some key resources to help them make sense of the project. This might include more information about your organisation, the community or population you work with, relevant needs assessments and public health reports and further details about the larger programme of work within which their project is set, plus any other information you consider relevant. Students will be familiar with searching for evidence in a clinical context but may be much less confident about searching for ‘grey’ literature so are likely to need clear signposting for these types of resources.

· Supervision – undergraduate nutrition students are doing placements in their 2ndyear of their three years of study. This means that they are able to show initiative and be able to work fairly independently once they are clear what is expected of them. Nevertheless, all students require supervision meetings to establish goals for the project and to develop a work programme, as well as deal with any difficulties that arise. Frequency of supervision will vary depending on the nature of the project but as a guide we would suggest weekly meetings (in addition to the initial orientation meeting and a final review meeting). Please also make sure the student knows how to contact whoever is supervising them by phone or email in between meetings. Please note that supervisors do not necessarily need to be registered dietitians or nutritionists.

Where possible, it is beneficial for students to take the opportunity to see the wider context of public health work so if you are able to facilitate any additional activities this would be greatly valued by the students. Again, this will depend on your setting, but examples might include:

· Observation of training sessions such as facilitator training for lay health educators

· Attending a cook and eat club or healthy weight session

· Observing at a meeting discussing commissioning/funding a public health intervention or service

· Doing a self-guided ‘tour’ of the local area – with some basic directions and some questions to answer/tasks to do around food prices, food access, transport, green space, food outlet types etc. This type of activity can be very successfully used to orient a students to the health needs of a local population

Project plans:

Prior to the placement, a project plan should be agreed with the university. Placement tutors are happy to support placement providers in developing project plans, and can also supply examples of previous project plans as a reference. The project plan does not need to be lengthy; it just needs to clarify the overall aim, the project objectives and the main tasks the students will be required to do to achieve these, plus the anticipated products. – Please note: a placement can’t go ahead without a plan, so if you are struggling to put one together please let us know so we can support you with it. A template is provided in Appendix 4, and a sample plan is shown in Appendix 5.

Practical arrangements:

· Placement dates: Placements are needed for London Metropolitan University students for 3 weeks in September starting 6th September. (14:09:15- 2:10:15)

· Pre-placement process: once we have agreed with a placement provider that they are willing to host a placement we will ask you to develop a project plan. Approximately 4 weeks prior to the start of the placement we will send you some background information about the student(s) who will be working with you, along with their contact details. You will then be expected to contact the student directly to agree a start time and location for their first day. We also recommend that you send them some suggested reading to help orient them to your organization and the nature of the project they will be working on.

· Office space/IT access/working hours:students are expected to work full-time for the three week period, but this need not necessarily be all on-site with you, and need not necessarily be standard office hours (although this should be agreed in advance with the student if they have responsibilities such as child-care). Students can spend part of their time working at home or at university where this is not detrimental to the progress of the project. However, you should ensure they have access to all the resources they will need, so it is very helpful to plan ahead for IT access to data they might be working with for example. The students should be capable of working independently and showing initiative so you do not need to feel they must be timetabled or supervised all-day everyday as long as they are clear about their overall work programme and tasks.

· Contact with university/college: We do not routinely contact students on public health placements but if there are any concerns please let us know immediately, we can support by phone, email or video conferencing as necessary where concerns have been raised.

· Sickness: if a student has a brief absence due to sickness and you and the student are in agreement that the project is still viable in the available time no action needs to be taken. However, if the student has a longer period of absence then please notify the university as soon as possible so alternative plans can be discussed.

· Multiple students: where more than one student is placed with the same host organisation it is often most practical for them to work together on a larger piece of work. However, it is important that the work should be divided up such that each student has individual objectives to work towards. This makes it simpler to assess whether a student has completed the project satisfactorily and also reduces the chances of an imbalance of workload (should a more industrious student happen to be placed with one who is less well motivated).

· DBS checks/occupational health: All students undergo DBS checks at the start of their course, and also have to have clearance from the University occupational health service in order to be able to go on placement. If their DBS and occupational health clearances are more than a year old at the start of placement they are also required to make a declaration stating there has been no change to their status.

· Insurance/indemnity: Depending on the nature of the project that the student will be involved in you might need to confirm that your insurer is aware that you will be taking student(s) to make sure that your public and employer’s liability insurance is valid for them.

Assessment:

Students are required to complete two types of assessment for their portfolio (the portfolio is used to assess both the public health and clinical placements) – however, you are only responsible for one of these. You are required to sign-off to confirm that the student has demonstrated professionalism, good communication, and reflective practice. This will include confirmation that they have completed the task(s)/project assigned to them (taking into account any constraints or setbacks encountered). The form is primarily completed by the student but should be informed by discussion between the placement supervisor and student. There is space for your comments too, with notes to indicate areas to consider when giving your comments, (see Appendix 6). If at any stage during the placement you feel a student’s behavior is not consistent with them being signed off as having been professional and demonstrated reflective practice please broach this with them at the earliest opportunity so that they have the chance to remedy the situation, and if the student is not able to respond positively to this feedback then contact the university as soon as possible. Ultimately, if you feel you will be unable to sign a student off as having completed their task(s) and shown evidence of professionalism, good communication and reflective practice you will need to inform the university – we will then take up the matter and arrange a remedial plan. As in the vast majority of cases the students move directly from their public health placement to their clinical placement weeks there is no option for ‘add-on’ time to be given to enable a student to meet their learning outcomes. However, we will of course seek your recommendations on any remedial plan that is to be put in place.

The second part of the assessment takes place once the student has moved from their public health placement into their clinical placement and is the responsibility of the clinical placement team. Students will be required to demonstrate to their clinical supervisory team that they understand how the Process for Nutrition and Dietetic Practice (Appendix 1) can be applied to populations and that are able to reflect on the skills they have developed and implications of what they have learned for their future practice.

Please note that London Metropolitan students are also required to complete a piece of academic coursework which links their placement to the public health module they have studied at university. This is a separate piece of work and you are not required to input to it directly or to assess it. However, students may well have it in mind as they are doing their placements and if they are sensible they may take the opportunity to ask questions or access relevant information – but they should not allow this to impact their work on your project.

Appendix 1 – Nutrition and dietetic care process

1. Assessment

Assessment is the first step in the nutrition and dietetic process. Its purpose is to obtain adequate and relevant information in order to identify nutrition-related problems and to inform the development and monitoring of the intervention.

It is initiated by identification of need, such as public health data, epidemiological data or similar.

Information sources for assessment at the population level:

· Nutrition surveys

· Local health surveys

· Epidemiological studies

· Field activities including Community-based surveys and focus groups

· Joint Strategic Needs Assessment

Factors that may need to be considered as part of assessment:

• Population/group knowledge, willingness to change and potential for changing behaviour.

• Opportunities to effect change.

• Population / group perceptions of health issues.

• Identifying and assessing health conditions and wider determinant factors and associated risk to long term health.

• Nutritional and food intake.

• Physiological measurements, anthropometrics, disease incidence and prevalence.

2. Identification of nutrition and dietetic diagnosis

Within a public health needs assessment framework the nutrition diagnosis involves determining a nutritional health priority for action; choosing nutritional health conditions and determinant factors with the most significant size, impact and severity.

It includes the identification and categorisation of an actual occurrence, risk of, or potential for developing a nutritional problem that a dietitian is responsible for contributing to the strategy to manage/prevent.

Data sources/tools:

• Service user or population perspective and priorities

• Assessment information (from step 1)

• Joint Strategic Needs Assessment

• Practice based Evidence in Nutrition (PEN)

• Evidence based guidelines or professional consensus such as professional guidelines or BDA professional guidance documents

• NICE/SIGN or other national guidance or strategy

• Current research literature, meta analysis such as Cochrane reviews and Campbell Collaboration

• National and local health and social policy

• Results of audits

• Behaviour change and educational theories applied at individual and population level.

• Interpersonal skills

• Campaign and health improvement theories

• Reflection and professional experience

3. Plan nutrition and dietetic intervention

The intervention is a set of actions and activities designed with the intent of changing nutrition related behaviours, risk factors, environmental factors or aspect(s) of physical or psychological health or nutritional status of the group or population. All interventions are planned in conjunction with the group or population that will be the recipient of the intervention.

A) Define outcomes – which may include:

• Anthropometric change (weight, MUAC, waist:hip ratio)

• Biochemical indicators (laboratory values, indicators of nutritional status)

• Clinical / Symptoms (clinical status, complications, symptom scales)

• Environmental/behavioural/Social (Client-focussed outcomes: quality of life, client identified outcomes, satisfaction, self-efficacy, self-management, functional ability)

• Behavioural (food related behaviour, physical activity)

• Psychological (self – efficacy, self management, mental health state)

• Health care utilisation and cost outcomes (medication changes, special procedures, planned/unplanned clinic visits, preventable hospitalisations, length of hospitalisation, prevent or delay nursing home admission)

• Diet and nutrition goals (food or nutrient intake changes)

• Environment/behavioural/social (self management, physical activity, functional)

B) Determine the intervention plan required to meet the outcomes:

• Select interventions based on the best available evidence.

• Define length, frequency and duration of the intervention.

• Identify who will carry out which part(s) of the intervention.

• Identify any resources needed.

• Optimise intervention within resource allocation.

• Apply risk management strategies as necessary.

4. Implement nutrition and dietetic intervention

Factors to consider:

· Project management/timeline

· Developing opportunities for involvement.

· Community capacity building

· Collaboration with other professionals, community, voluntary and statutory agencies

· Apply and tailor evidence based approaches to population health

· Mentoring, education and supervision of other team members

· Provision of evidence based nutrition resources

5. Monitoring and review

This process should determine if the intervention is being implemented as planned, as well as monitoring outcomes.

The data to be collected should be directly related to the proposed outcomes and the form of the intervention and should provide evidence to show that the intervention is or is not changing group or population knowledge, behaviour, nutrition or health status. Where possible use standardized methods to increase the validity and reliability of measurements of change and facilitate consistent recording, coding, and outcomes measurement.

6. Evaluation

Evaluate process

• Evaluate intervention against the original aims and objectives of the project; identifying what went well and not so well, plus barriers and facilitators

• Identify further action to be taken.

Evaluate outcomes

• Compare current findings with previous status, intervention goals, and/or reference standards.

• Evaluate overall effectiveness of intervention

Decide on further action

• Identify health needs for further action

• Identify and communicate research gaps

• Identify and communicate learning for practice