Models of nutrition-focused continuing education programs for nurses: a systematic review of the evidence

Globally, unhealthy diets are a leading risk factor of deaths and disability, with nearly one-tenth of the world’s disability adjusted life years (DALYs) being attributable to dietary behaviours (Forouzanfar et al. 2015). Dietitians are recognised as experts in providing medical nutrition therapy in Australia, the UK, USA and Canada; however, they remain a relatively small workforce both in hospitals and primary care (Australian Institute of Health and Welfare 2009; Ball et al. 2013).

Conversely, nurses working both in hospitals and primary care settings have frequent and multiple patient encounters and are therefore uniquely placed to provide basic nutrition education to patients as part of routine care (Halcomb et al. 2008; DiMaria-Ghalili et al. 2014). Nurses are seen as trustworthy, and often have good rapport with patients (Halcomb et al. 2007; Cass et al. 2014). It is recognised that nurses have an important role to play in health promotion and nutrition education activities (DiMaria-Ghalili et al. 2014).

There is some limited research available, which suggests that lifestyle education provided by nurses in routine community care results in patient behaviour change and improved risk factors. A systematic review of interventions to reduce cardiovascular disease (CVD) showed that nurse-led interventions generally had positive effects on dietary risk factors and increased physical activity levels (Halcomb et al. 2007). Similarly, nurse-led education interventions on nutrition risk factors and weight loss have shown positive results in patients’ readiness to change (Harris et al. 2013), as well as small reductions in patients’ weight (Usher et al. 2013). Training programs that upskill nurses on lifestyle-related topics, including nutrition, have resulted in an increased frequency of nurses providing brief interventions for physical activity and nutrition with clients (Chan et al. 2013). This is in addition to increased and sustained referral rates by nurses to other healthcare providers for lifestyle counselling (Chan et al. 2013).

Despite their prime position in primary care, it has been recognised that globally (Warber et al. 2000; Park et al. 2011), and in Australia particularly (Kowanko 1999; Schaller and James 2005; Arrish et al. 2014), nurses lack nutrition knowledge. This has been largely attributed to inadequate training at the undergraduate level, as well as limited continuing education (CE) opportunities to address this deficit (Lindseth 1990, 1994; Arrish et al. 2014). There is therefore an increased interest in educating nurses about nutrition to improve patient outcomes (Touger-Decker et al. 2001; Pradignac et al. 2011; Buxton and Davies 2013).

In order to maintain professional registration, nurses are required to undertake CE in many countries including Australia (Australian Health Practitioner Regulation Agency 2009), UK (Nursing & Midwifery Council 2017) and the USA based on state of registration (American Association of Colleges of Nursing 2010). Evidence suggests that CE programs, which are based on active learning such as those models utilising case studies, clinical simulations and participatory discussion, are more effective than traditional didactic models of learning (Bluestone et al. 2013). It has been suggested that a blend of online and face-to-face education, which includes supervised clinical experiences, is optimal for nurse education (National Council of State Boards of Nursing 2015). The aim of this systematic literature review was to determine whether nutrition education for nurses results in improved knowledge and practices in delivering nutrition advice and programs to patients. Furthermore, it aims to unpack which models of CE for nutrition may be most acceptable and effective in practice.

A literature search was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (Moher et al. 2009; Fig. 1) in April 2015 using Scopus and Web of Science. The following terms were used in various combinations to perform searches: Practicing Nurse (Nurse, Midwife, Student); Continuing Education (education, program); Nutrition (healthy eating); Knowledge; Evaluation (Pre-test; post-test; before and after; effect); see Box 1 for an example search. Outcome measures that encompassed changes in either perceived or actual knowledge as determined by pre- and post-test surveys were included. Only articles published in peer-reviewed journals and reported in English were included. Eligible studies were those with practicing nurses or midwives undertaking a nutrition CE program that assessed their knowledge pre-test and post-test. Publications before 2000 were excluded from the review, as current education technologies would not have been available. Other exclusions applied were articles where the content of the CE program could not transcend to nurses providing patient education on nutrition (such as parental or enteral feeding), and articles that did not report knowledge outcome results specific to nurses. Additional articles were retrieved through citation searches.

Fig. 1.  PRISMA flow diagram for inclusion of journal articles in the systematic literature review.

The initial search retrieved 203 articles after duplicates were removed. Articles were removed according to title (n = 84) and abstracts (n = 119), based on the inclusion and exclusion criteria. Full-text articles were assessed for eligibility (n = 26), 12 of which were included for the final review.

Data extraction was completed by the lead author and reviewed by the second author. Endnote X4 (Clarivate Analytics, Philadelphia, PA, USA) was used to manage the citations. An evaluation of quality of each article was completed using the National Health and Medical Research Council (NHMRC) levels of evidence recommendations (National Health and Medical Research Council 2009). A narrative synthesis of the studies was completed because of the heterogeneity in reporting outcomes of the studies.

All 12 articles were quasi-experimental pre- and post-test in design and deemed to be low quality (Level IV) (National Health and Medical Research Council 2009). The sample size of nurses included in the studies ranged from 8 to 364; the median number of participants across the studies was 25 (Table 1). Studies were conducted in a range of countries: Australia (Manafi et al. 2008; Williams et al. 2013), Canada (Mayer et al. 2005), Spain (Arroyo et al. 2008), UK (Barrowclough and Ford 2001; Kennelly et al. 2010; Basu et al. 2014), USA (Crogan and Evans 2001; Bell et al. 2006; Wallner et al. 2007; Bernaix et al. 2008; Pregler et al. 2009) as well as in a range of healthcare settings: aged care (Crogan and Evans 2001; Arroyo et al. 2008), community (Pregler et al. 2009; Basu et al. 2014), hospital (Barrowclough and Ford 2001; Mayer et al. 2005; Bernaix et al. 2008; Manafi et al. 2008; Williams et al. 2013) and primary care (Kennelly et al. 2010). Two studies did not specify nurse practice settings (Bell et al. 2006; Wallner et al. 2007).

Table 1.  Summary of articles included in the systematic literature review
Note: all studies had a pre-and post-test design and used a convenience sample. Results are reported as pre-test v. post-test. NHMRC, National Health and Medical Research Council; CI, confidence interval; NICU, Neonatal Intensive Care Unit; GP, General Practitioner; MCQ, Multiple Choice Questionnaire; MUST, Malnutrition Universal Screening Tool; CVD, cardiovascular disease; ANOVA, analysis of variance; HSD, honestly significant difference

The effectiveness of nutrition CE models in improving nurses’ nutrition knowledge was explored in terms of the mode of delivery, duration of the intervention and the educational strategies employed.

Eight studies (Crogan and Evans 2001; Arroyo et al. 2008; Bernaix et al. 2008; Manafi et al. 2008; Pregler et al. 2009; Kennelly et al. 2010; Williams et al. 2013; Basu et al. 2014) delivered a nutrition CE program to nurses utilising face-to-face learning. Of these, six studies (Arroyo et al. 2008; Bernaix et al. 2008; Manafi et al. 2008; Pregler et al. 2009; Kennelly et al. 2010; Basu et al. 2014) observed improvements in nurses’ nutrition knowledge from pre-test to post-test.

Two studies (Barrowclough and Ford 2001; Mayer et al. 2005) successfully distributed self-directed learning packs to nurses and reported improvements in nutrition knowledge. Barrowclough and Ford (2001) provided an open-learning pack on general and pregnancy nutrition that consisted of a nutrition education resource pack, an audiocassette and printed material including interactive exercises, and found a significant increase in midwives’ knowledge. Mayer et al. (2005) demonstrated similar improvements following a self-directed learning pack, which included independent activities designed to encourage critical thinking and reflection through experiential learning.

The review also included two studies (Bell et al. 2006; Wallner et al. 2007) that utilised an online platform to deliver their CE program to nurses. Wallner et al. (2007) demonstrated that an online course with six web-based modules on food safety increased a small sample of nurses’ nutrition knowledge. Conversely, Bell et al. (2006) failed to demonstrate improvements in nurses’ knowledge of type 1 diabetes dietary management after completing a web-based module, which formed part of a larger online course.

Across studies that implemented face-to-face programs, the duration of intervention ranged from 20 min to 6 h, with two studies (Arroyo et al. 2008; Williams et al. 2013) delivering multiple education sessions over a specified time period. Of the two studies that provided self-directed learning packs to nurses, neither quantified the time participants spent with the nutrition education material. Additionally, only one study (Wallner et al. 2007) that delivered an online program reported the average time nurses spent on the model, which was measured at 48.2 min.

Four studies (Barrowclough and Ford 2001; Crogan and Evans 2001; Mayer et al. 2005; Arroyo et al. 2008) successfully implemented a nutrition CE program grounded in pedagogical theory, using active learning strategies. Arroyo et al. (2008) demonstrated cooperative learning strategies such as small group discussions, case studies, games and simulations, significantly increased nurses’ knowledge of general and geriatric nutrition. Although not reported to be guided by theory, four other studies (Wallner et al. 2007; Bernaix et al. 2008; Kennelly et al. 2010; Basu et al. 2014) utilised similar active learning strategies and demonstrated improvements in nurses’ nutrition knowledge. For example, Basu et al. (2014) incorporated group discussions, activities using food models, and worksheets to facilitate midwives’ achievement of learning outcomes in nutrition, physical activity and weight management advice during pregnancy. Conversely, a large study by Pregler et al. (2009) revealed a passive learning style lecture on cardiovascular disease prevention in women improved nurses’ knowledge score for three nutrition-related questions.

This systematic literature review identified that nutrition CE programs delivered face-to-face or by self-directed learning packs, and those that use active learning strategies, are associated with improvements in nurses’ nutrition knowledge. However, the review did not provide sufficient evidence to support this association in the context of online learning. Further, there was inconsistent evidence to indicate a clear association between the duration of nutrition CE programs and the extent of improvements in levels of nutrition knowledge. It is noteworthy that positive associations were demonstrated between implementation of nutrition training programs and improved knowledge of nurses in all but three of the studies.

The positive associations observed with face-to-face education programs suggest that when education material is communicated in the presence of both teacher and learner, improvements in nurses’ nutrition knowledge are observed. It has been asserted that face-to-face learning fosters non-verbal cues to convey both overt and unspoken meaning, which may contribute to the learning process (Buckley 2003). However, with current advances in technology, there is much debate in the literature between the efficacies of face-to-face learning, in comparison to online learning (Campbell et al. 2008; Bloomfield et al. 2010; Cook et al. 2010; McCutcheon et al. 2015), particularly with the context of CE and the need to balance professional commitments of nurses. In exploring this dichotomy, Buckley (2003) found no significant difference in undergraduate nurse outcomes when transitioning a traditional classroom-based nutrition course to a web-based course. Self-directed learning packs similarly offer nurses flexibility to fulfil their CE requirements in consideration of their professional commitments. This model is founded in the adult learning principles of autonomy and self-direction (Mayer et al. 2005); whereby students must assume responsibility and accountability of their learning in order to complete the training manual. Barrowclough and Ford (2001) and Mayer et al. (2005) demonstrated the effectiveness of self-directed learning packs to significantly improve nurses’ nutrition knowledge.

The Australian Nursing and Midwifery Council defines CE as ‘the means by which [nurses] maintain, improve and broaden their knowledge, expertise and competence … [through] … participating in relevant learning activities and reflecting on the value of those activities’(Australian Nursing and Midwifery Council 2009). This definition supports the development of CE programs based on active learning where students engage in the learning process, as opposed to passively receiving information in a traditional lecture setting (Bonwell and Eison 1991). As identified in this review, active learning strategies were positively associated with improvements in nurses’ nutrition knowledge. It has been asserted that the development of context-dependent knowledge is crucial to the integration of theory and practice within the nursing profession (Tanner 2007). The importance of active learning in improving nurses professional practice and patient outcomes has been highlighted in other systematic reviews on nursing CE (Thomson-O’Brien et al. 2002; Bluestone et al. 2013).

Although the duration of CE programs to improve nurses’ nutrition knowledge was explored among the studies, no clear association was determined. Further research is required to investigate the duration of a nutrition CE program required to produce sustainable improvements in nurses’ knowledge, while considering their professional and personal commitments.

Assessing the effectiveness of nutrition CE programs is challenging because of the complexity of measuring changes in knowledge. Several interrelated factors have been identified to influence nutrition knowledge; including age, gender, level of education and socioeconomic status (Spronk et al. 2014). Some studies in this review (Barrowclough and Ford 2001; Mayer et al. 2005; Bernaix et al. 2008; Williams et al. 2013) did consider factors relevant to CE, such as nurses’ area of practice, level of experience and previous involvement in nutrition and non-nutrition-related CE; however, no factor was universally accounted for across all studies.

Comparing changes in nurses’ nutrition knowledge between the studies was also difficult because of the variation in instrument validity; with two studies failing to report any validation procedures (Barrowclough and Ford 2001; Bell et al. 2006). Three studies (Crogan and Evans 2001; Mayer et al. 2005; Williams et al. 2013) used previously validated instruments, either in the original or adapted form; however, Mayer et al. (2005) was the only study to conduct reliability testing of an existing instrument within the relevant sample population. Most studies reported to have conducted one or two instrument validation methods; primarily construct validity or pilot testing. It has been asserted that the best practice for nutrition knowledge measurement is based on psychometric criteria, which includes content validity, construct validity and reliability (Heaney et al. 2011). Of the studies presented, Bernaix et al. (2008) was the only study to employ this level of validation.

The limited number of published randomised controlled trials limits interpretation of the findings with regard to identifying the best model of a nutrition CE program for nurses. All studies are especially vulnerable to selection bias because of convenience sampling, as participating nurses may have had a greater interest in nutrition. The internal validity of the studies is also low because of the lack of control groups exposed to the same array of intervening variables. Two databases were searched in addition to hand searching articles from reference lists. Despite this, it is possible that more articles may have been sourced if a wider database search had been conducted. Furthermore, this review is limited in that it only focussed on changes in nursing knowledge, and did not assess whether this increased knowledge translated into changes in their clinical practice, or whether there were improvements in patient outcomes.

The limited evidence available suggests that nutrition CE does improve nurses’ knowledge; however, there is an apparent lack of nutrition-focussed CE available for nurses. Dietitians and nurses should therefore work collaboratively to develop learning programs to address this gap (DiMaria-Ghalili et al. 2014). This would upskill nurses to provide and reinforce basic nutrition advice in line with their patients’ needs, as well as enable nurses to recognise when referral to a dietitian for medical nutrition therapy is warranted. The new paradigm for health care is moving from multidisciplinary to interdisciplinary care and thus inter-professional learning is essential (DiMaria-Ghalili et al. 2014).

This review provides evidence that nutrition CE programs: (1) are delivered face-to-face or by self-directed learning manuals; and (2) utilise active learning strategies are positively associated with improvements in the nutrition knowledge of nurses. However, the quality of this evidence is limited, hence further robust research is required to test the legitimacy of these recommendations, in addition to assessing whether increases in knowledge results in changes to practice and patient outcomes. Given the time constraints of healthcare professionals in the workplace, research examining online and blended nutrition education models is warranted. The increasing expectation of nurses to provide nutrition information to patients requires effective and proven models of CE in order to equip nurses with evidence-based nutrition knowledge and skills to assist in addressing global health issues.

The authors have no conflicts of interest to declare.