Identification and Evaluation of Competencies of Public Health Nutritionists LAURA S. SIMS, PHD, MPH
Abstract: The Delphi Technique was used to elicit a number of essential competencies expected of the "entry-level" public health nutritionist from members of Graduate Faculties of Programs in Public Health Nutrition. Questionnaires composed of "competency statements" were constructed from these responses and sent to practitioners in public health nutrition. The questionnaire requested evaluation of the "necessity" of each competency. Responses served as the basis for "factor analysis" procedures, employed to obtain clusters of competency functions expected of the nutritionist. From the 109 competency items originally identified, 17 competency scales were derived
from the factor analysis. A ranking from both faculties and practitioners revealed that both groups highly rated competencies to communicate, to counsel and deal with clients/patients, and to interpret scientific data in "lay language." Less important in the ranking were competencies which dealt with administrative abilities, program planning, legislative activism, and consumer advocacy. These findings have implications for the practitioner in public health nutrition as well as for academic groups who must plan and evaluate curricula in public health nutrition and in other fields of public health. (Am J Public Health 69:1099-1105, 1979.)
Introduction
tionist.1-13 These include roles as program administrator/ manager; program planner and evaluator, policy maker, community planner and facilitator, provider of direct services (in areas such as client counseling, nutrition education, training), consultant, investigator, human relations expert, change agent, consumer advocate and, finally, as liasion between the scientific and governmental communities. Such a variety of roles require a diverse array of skills and knowledge; hence, it is little wonder that nutritionists, as well as other health professionals, have been uncertain about the exact nature of the nutritionist's responsibilities within the
The nutritionist has been regarded as an important, contributing member of the public health team. The responsibilities of this position require competencies which typically are developed through a formal plan of graduate education and from field experience and training. By identifying the specific competencies required of the public health nutritionist, it may be possible to define more accurately the general responsibilities s/he may assume in the organization, or to evaluate how effectively s/he functions as a contributing member of the health care team. This study was conducted to identify specific behavioral competencies expected of the "entry-level" public health nutritionist, and to rank these specific competencies in priority order. Roles of the Public Health Nutritionist Two specialized roles distinguish the nutritionist in public health from other types of dietitians/nutritionists: 1) the community approach to the solution of nutrition problems, and 2) a special focus on the promotion of health and the prevention of disease rather than treatment and/or rehabilitation. A literature search revealed that several major responsibilities have been described for the public health nutriAddress reprint requests to Laura S. Sims, PhD, MPH, Associate Professor of Nutrition in Public Health, Division of Biological Health, College of Human Development, Pennsylvania State University, University Park, PA 16802. This paper, submitted to the Journal February 22, 1979, was revised and accepted for publication June 13, 1979. Editor's Note: See also related editorial, page 1096, this issue.
AJPH November 1979, Vol. 69, No. 11
agency/community setting. Educating for Competencies An increasingly popular trend in contemporary education is to rely on "competency-based" curriculum planning. Competencies may be defined as the "'minimum knowledge, skills, values, and/or attitudes a person can be certified to possess based on a specified set of criteria."114 Segall, et al,'5 concluded that the key to guaranteeing the relevancy of a particular course of study is the identification of future professional roles and performance within these roles. Duncan16 has emphasized that it is important for public health personnel in universities and in health agencies to ""plan, communicate and coordinate our efforts." To date, no systematic study has been undertaken to identify those specific competencies expected of practicing public health nutritionists or to determine whether graduate curricula are preparing students to assume those competencies actually being performed by the practitioner. This paper presents the results of research designed to answer 1 099
SIMS
these questions. Two separate phases for data collection were employed: Phase I: Identification of competencies by graduate educators in public health nutrition; and Phase II: Evaluation of these competencies by practitioners in the field. Further data analysis was performed to compare the responses of faculty with those of practitioners, and to compare public health nutritionists' responses with those of nonpublic health nutritionist practitioners. In addition, the differences in the ratings of these competency scales were examined in relation to selected demographic characteristics of the practitioners.
Method and Results Phase I: Identification of Competencies The initial phase of the research involved the identification of specific behavioral competencies expected of the "'entry-level"* nutritionist by faculty associated with graduate-level public health nutrition programs. It made use of the Delphi Technique,** a "group process utilizing written responses as a means for aggregating the judgments of a number of individuals.'"20 Respondents All program coordinators and other faculty involved in graduate-level accredited public health nutrition programs at universities listed in the Nutrition Directory, State Health Agencies and Graduate Programs of Public Health Nutrition2' were asked to participate as the group best qualified to determine baseline competencies for entry-level public health nutritionists. Of these, 18 individuals from 11 universities offering graduate programs in public health nutrition agreed to participate in the study. Procedure: For Round I, participants were instructed to respond to the following two general questions: 1) What are the behavioral competencies*** which all entry-level public *''Entry-level" nutritionist: one who has completed a Master's
Level approved curriculum in Public Health Nutrition and who is an RD or RD-eligible. Upon assuming a first time role as nutritionist in a health agency, s/he may not be in an administrative or supervisory position, but should be educated to assume these responsibilities if and when needed. **The Delphi Technique'" is characterized by several features, including multiple iterations of responses to achieve convergence, anonymity of respondents, relatively efficient use of respondents' time, controlled feedback to participants, and statistical analysis on "'group" rather than individual responses.'81'9 The initial phase is concerned with the development of the basic question, usually openended, which deals with broad issues such as program planning, suggested solutions to identified problems or forecasting future events. Respondents are selected on the basis that they can provide expert testimony/opinion to the identified issue; the process requires that respondents have adequate time to make responses, high motivation, and skill in written communication. Responses to the first questionnaire determines construction of the second, and so forth. The iterations continue, usually to the third or fourth round, until convergence or divergence on the issue is reached.20 ***A "behavioral competency" was operationally defined for the respondents as "that specific behavior, based on appropriate knowledge, skills, values and/or attitudes deemed essential for the practicing professional." Examples of behavioral competencies for a hospital nurse and secretary were given. 1100
health nutritionists in a ""generalist" position should be expected to possess?; and 2) What are the responsibilities of the public health nutritionist today that such a person should not generally be expected to do ten years from now? Eighteen individual responses were received. Responses were condensed into a series of unduplicated competencies and included in a second questionnaire, along with 25 additional competencies which had appeared in the literature but which had not been specifically mentioned by the faculty participants. The second questionnaire asked respondents to rate, on a Likert-type format of 1 to 7, the importance of each listed competency for the entry-level public health nutritionist. Fourteen of the 18 participants responded. On the third questionnaire, 13 of the 14 second-round respondents ranked the top six competencies (from most important to least important) from among the 15 competencies rated highest on the previous round. Results: From the faculty participant's responses to the second questionnaire, a mean score for each of 109 competencies was computed. The majority of the top eight ranking competencies dealt with the provision of direct services to clients rather than with administrative/planning duties. The two highest-ranked competencies (with scores of 6.846 out of 7.000) dealt with evaluating outcomes of nutrition programs in terms of stated objectives and being able to discriminate between questionable and proven nutrition information-opinion. Conspicuously absent from this list were legislative-political functions and higher level program planning functions. t An examination of the lowest-ranked competencies is also of interest. Lowest mean scores were received by those competencies which seem to require additional education, such as ""speaking more than one language fluently" and "'ability to carry out research programs." The faculty participants may have considered these requirements too high for
"'entry-level."
Another part of the second questionnaire completed by the faculty group asked responses on a seven-point (1 = strongly disagree to 7 = strongly agree) Likert-type scale to those competencies which would be considered "'unnecessary" for the nutritionist in the next ten years. None of the 15 items received a score greater than 4.7, perhaps indicating a reluctance on the part of the educators to have nutritionists relinquish responsibility in any of these areas. However, items which dealt with direct service skills, such as the taking of diet histories and measuring and recording of anthropometric data, recieved the highest "'agreement" ratings, indicating that these competencies may become unnecessary for nutritionists. Such activities are increasingly being performed by paraprofessionals, and the evaluations of the educators seemed to indicate that this trend would continue. Activities long regarded as integral to the role of the nutritionist such as working as part of the health team and participating in the planning of programs-received the lowest scores, thus indicating that the academic group felt that these would continue to be essential for the nutritionist. able
WFurther details regarding the results of this analysis are availon
request to the author.
A.JPH November 1979, Vol. 69, No. 1 1
COMPETENCIES OF PH NUTRITIONISTS
Responses to the third questionnaire dealt with the ranking of those competencies which received the highest mean scores on the second round. Results from this tabulation indicated that the direct service skills of communication with clients, the ability to translate principles into action, adjusting plans, and knowing the community referral services were rated as most important. PHASE II: Evaluation of Competencies by Practitioners Sample Selection: A nationwide sample of public health nutritionists was obtained. The sample included those American Dietetic Association members having a primary interest and responsibility in public health nutrition, members of the American Public Health Association's Food and Nutrition Section, and names of attendees at various public health nutrition conferences and workshops. Care was taken to select only those individuals who were practitioners in public health nutrition; known members of a graduate faculty were eliminated from this sample, These sources were then combined and collapsed to give the names of approximately 1,240 public health nutritionists. Using a table of random numbers, (830 individuals a two-thirds sample) were selected to receive the questionnaire. Sampling with replacement was used for those persons unwilling or unable to participate in the study. Followup reminder letters and postcards were mailed at three intervals to all non-respondents. Three-hundred forty-nine of the 830 individuals completed the questionnaire, a response rate of 42 per cent.tt All respondents signed an "'Informed Consent" form signifying their voluntary participation in the study. The Instrument: The questionnaire mailed to the 830 public health nutrition practitioners contained all 109 competencies listed on the faculty participants second questionnaire, as well as the 15 additional competency statements labeled as "'perhaps unnecessary for the nutritionist in the next ten years." Practitioner respondents were asked to preface each of the 109 competencies with the phrase, "The entry-level public health nutritionist should be able to . . .", and then rank the essentiality of each competency on a Likert scale of 1 to 7. For each item, the respondent was also asked to indicate whether this particular activity was currently being performed by the nutritionist, whether it was -desirable for it to be performed by the nutritionist, and whether or not it was performed by personnel other than the nutritionist. For this last section, in cases where the nutritionist did not perform that role, respondents were asked to identify the person who did that activity. An initial section of the questionnaire requested a self-definition of whether or not the respondent was a public health nutritionist. Data were also obtained on respondent's sex, age, current employment position, professional memberships, and educational background. The Practitioner Sample: Eighty-five per cent of the 349 respondents self-reported themselves as public health nutri-
tlComparison of respondent and non-respondent characteristics was not possible. AJPH November 1979, Vol. 69, No. 11
tionists, the largest number (35.6 per cent) being employed in positions where their principal function was to provide direct nutrition services to clients; 31.5 per cent were in administrative positions; and 25.6 per cent were employed as consultants. The respondents were employed a mean of 37.8 hours per week; the mean age was 40 years, and they had been in their present position a mean of 5.5 years. Over 97 per cent were female. More than 70 per cent of the respondents held a Master's degree (either MPH, MSPH, MS, or MA degree). Ninety per cent were Registered Dietitians. Ninety-three per cent were members of the American Dietetic Association, 54 per cent belonged to the American Public Health Association, 52 per cent to the Society for Nutrition Education, and 45 per cent to the Nutrition Today Society. The demographic characteristics of 297 respondents who reported themselves as public health nutritionists were compared to 52 respondents who did not consider themselves public health nutritionists. Significant findings were: more public health nutritionists held administrative/consultant positions rather than education/training positions; their salaries were more likely to come from federal and local funds than private funds; and they possessed a Master's or higher degree. There were no significant age differences between the two groups. Results: The 109 competency items (excluding the 15 "unnecessary" items) were first grouped on a priori basis into scales.t44 Construct validity of these a priori scales was evaluated by factor analysis (oblique rotation), using a program of the Statistical Package for the Social Sciences (SPSS).22 On the basis of these results, 48 items were dropped from the final array of scales because of low communality, and others were re-arranged into different scales.* Reliability coefficients for each scale (Cronbach alpha) ranged from .67 to .92. The individual scales were named: * ability to actively function in legislative process; * ability to perform administrative/managerial func-
tions; * ability to provide nutritional services in community health programs; * ability to communicate effectively in teaching/learning
settings; * ability to communicate clearly; * ability to carry out program planning function; * ability to interpret scientific material to lay audiences; * ability to communicate in the public/mass media; * ability to supervise paraprofessional staff; * ability to manage food service delivery system; * ability to effectively do direct counseling of clients; * ability to carry out in-service education for staff; * ability to perform and interpret nutritional screening procedures; * ability to be understanding and empathic when dealing with clients; tttResults of the analysis of the responses to the 109 individual competency items are available on request to the author. The conclusions are basically the same as those derived from the scale analysis. *The final factor matrix of the 61 individual competencies belonging to 17 scales is available on request to the author. 1101
SIMS TABLE 1-Scale Scores of Essential Entry Level Competencies of Nutritionists Mean Score
Practitioners (1 = totally unnecessary to 7 = essential)
The "entry-level" nutritionist should have the ability to:
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17.
Communicate clearly-oral and written Perform direct dietary counseling Be empathic, sensitive to patients/clients' needs Provide nutritional care services in community health programs Correctly interpret scientific data Carry out planning function of programs Communicate well in teaching-learning settings Prepare educational materials/programs Perform nutritional screening procedures Do in-service education programs Supervise/direct paraprofessionals Be an active nutrition advocate in the legislative process Participate in long-range planning efforts Manage food service delivery systems Communicate in public/mass media Administer/manage programs, staff Be a consumer advocate regarding food and nutrition
Practitioners
All Respondents (n = 363)
Faculties (n = 14)
6.298 5.908 5.899 5.879 5.839 5.819 5.806 5.776 5.594 5,547 5.028 5.002 4.901 4.875 4.646 4.475 4.079
6.143(2)* 5.619(7) 5.686(5) 6.357(1) 5.857(4) 6.000(3) 5.262(13) 5.631(6)
6.305(1) 5.919(2) 5.908(3) 5.859(4) 5.839(5) 5.812(6) 5.828(7) 5.781(8)
5.429(10) 5.557(9) 5.619(8) 5.278(12) 5.071(14) 5.286(11) 4.429(16) 5.012(15) 3.929(17)
5.600(9) 5.547(10) 5.004(11) 4.990(12) 4.894(13) 4.858(14) 4.655(15) 4.453(16) 4.086(17)
(n = 349)
PH
Non-PH
Nutritionists (n = 297)
Nutritionists (n = 52)
6.298(1)
6.394(1)
5.963(2) 5.915(3) 5.891(4) 5.839(7) 5.814(8) 5.849(6) 5.854**(5) 5.647(9) 5.589(10) 5.002(11) 4.995(12) 4.901(13) 4.809(14)
5.673(7) 5.869(2) 5.679(6)
4.658(15) 4.481(16) 4.050(17)
5.833(3) 5.801(4) 5.705(5) 5.365(8) 5.337(9) 5.304(10) 5.013(12) 4.962(13) 4.853(14) 5.135(11) 4.635(15) 4.295(16) 4.289(17)
*ranking in parentheses **significant differences between groups by T-test statistic, p s .05
* ability to prepare educational materials/programs; * ability to participate in long-range planning effort; * ability to function as a consumer advocate regarding food and nutrition issues. Table 1 reports scores of the competency scales as mean responses for faculties and the two types of practitioners. The highest rated scales were those that dealt with communication abilities: the ability to do dietary counseling, being empathetic with client's needs, providing nutritional care plans in community health services, and the ability to interpret correctly scientific materials for the lay public. Those that received the lowest ratings (but still an overall slightly favorable response) were those that dealt with administrative/managerial responsibilities, supervision of paraprofessionals, as well as participation in policy issues.
Supplementary Analysis and Comparisons Faculty vs. practitioner responses: The rankings of the faculty respondents to the scales developed from items contained in their second round questionnaire were compared with the ranking of all practitioner respondents, as shown in Table 1. While the T-test statistic revealed that there were no statistically significant differences between faculties and practitioners, the practitioners consistently ranked those competencies dealing with direct service functions higher than did the faculty group. Public health vs. non-public health nutritionist responses: Analysis was also performed to determine the differences in ranking on the various competency scales according to whether the respondent was a public health nutritionist or not. Results, shown in Table 1, indicated that there 1102
were no statistically significant differences on the rankings between these two types of practitioners. Influence of demographic characteristics of practitioners: The various competency scales were examined in relation to the demographic characteristics of the practitioner respondents. Paired comparison (T-test statistic) was used to compare members vs. non-members of the various professional organizations in terms of their respective ratings of the various -scales of nutritionist competencies. There were few discernible differences, with the exception that members of the American Public Health Association had higher scores on the planning and communication competencies, and members of the Society for Nutrition Education rated competencies in administrative ability higher than did others. To determine the effect of place of employment, type of position held, type of academic degree held, and region in which the practitioner was working, on the responses to the scales of nutritionist competencies, one-way analysis of variance was computed. This analysis indicated that few differences could be attributed to these various characteristics, except that those employed in direct patient service and administrative positions rated the ""counseling" competency higher than did those in other types of positions. Likewise, this competency was rated higher by those employed in hospitals, medical centers, and health maintenance organizations, than by those employed in educational institutions. The planning competency was rated higher by those respondents with the MPH or doctorate degree, while the public communication competency was rated more highly by those holding Master's degrees and doctorates than by those having baccalaureate degrees. AJPH November 1979, Vol. 69, No. 11
COMPETENCIES OF PH NUTRITIONISTS TABLE 2-Personnel Performing Activities as Listed in Competency Scales
Activity Currently
Performed by Nutritionist Scale names
1. 2. 3. 4.
5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17.
Clear communication Counseling Empathic to patients Nutrition services in community health programs Interpret scientific data Program planning Communicate in teaching Prepare educational materials Perform screening In-service education Paraprofessionals Legislative activism Long-range planning Food-service management Mass media/public communication Program adniinistration Consumer advocate
Several relationships existed between the practitioners' ratings of the competency scales and their employment characteristics. Older respondents were less likely to agree with the competencies on administration, provision of nutrition services in community health programs, and screening. Those persons who spent a greater percentage of their time in administrative duties were less favorable to those competencies dealing with long-range planning efforts and food service management, while those who spent more time in direct patient service functions gave higher ratings to competencies dealing with client counseling, advocacy, legislative activism, long-range planning, inservice education, screening, preparing written materials, communicating with the public, and presenting information in a teaching/learning setting. Correlational analysis showed that there was a slightly negative relationship between the respondent's age and the amount of time spent in direct service functions and a positive relationship between the length of time in one's present position and the percentage of time in administrative duties. Thus, respondents' scale ratings may be an artifact of these findings, i.e., younger respondents tended to rank their own "specialty," of counseling, and their interest in advocacy/ legislative activities higher, while those who had been in administrative positions for a longer period of time may have believed that administrative responsibilties were inappropriate for the entry-level public health nutritionist. Personnel performing competency functions: When the clusters of competencies, as identified by the factor analysis, were examined in relation to the personnel who performed those functions, the results were of interest. As shown in Table 2, the highest ranked scales of competencies were also those in which a greater percentage of respondents reported that these functions were performed by the nutritionist, AJPH November 1979, Vol. 69, No. 11
Activity Performed by Personnel other than Nutritionist
(% of Practitioners Reporting)
98.5 89.6 96.2
35.2 44.9 36.1
88.7 94.7 92.1 93.1 92.4 83.0 92.1 75.6 63.2 75.2 67.6 65.5 71.6 47.7
38.8 29.7 38.1 25.8 30.6 58.8 25.3 43.6 38.3 46.7 43.3 41.0 57.9 48.5
while those receiving a lower ranking were those most likely to be performed by other personnel. These data indicate that while respondents were instructed to respond to the competency statements on the questionnaire in terms of what the
entry-level public health nutritionist should be able to do, they also responded in terms of what they themselves were doing. " Unnecessary" competencies: The 15 competency items described as being "'perhaps unnecessary for nutritionists in the next ten years" were rated by the practiioners (Table 3). Specific abilities to do tasks such as measuring and recording height and weight data of patients, as well as performing non-computer assisted dietary assessment were rated as competencies which will become less important in the future. Working as part of the health care team and implementing nutrition education programs were seen as activities which nutritionists should continue to perform. It is of great interest to note that all but one of the 15 competencies rated as activities which will be "unnecessary" for the public health nutritionist ten years hence were currently being performed by the nutritionist, according to 86 percent of the respondents. The remaining competency, "'accurately measure and record height and weight of clients," was currently being done by only 55.2 percent of the nutritionist respondents.
Implications The results of this study have important ramifications for both practitioners and faculty in graduate programs in public health nutrition. Certain basic abilities, such as written and oral communication skills, patient/client counseling, and interpretation of scientific materials were rated as the 1103
SIMS
TABLE 3-Ranking of "Unnecessary" Competencies by Practitioners (n = 349) Competencies Deemed "Unnecessary" in Ten Years
Mean Score (1 = strongly disagree to 7 = strongly agree)
Ranking by PH Nutritionists (n = 297)
Ranking by Non-Nutritionists (n = 52)
4.377 4.289 3.600 3.192 3.134
1 2 3 4 5
1 2 4 3 5
2.942
6
8
2.872
7
6
2.734
8
9
2.627
9
7
2.508
10
10
2.446
11
13
2.409
12
14
2.326
13
15
2.322 2.244
14 15
12 11
Accurately measure and record height and weight of patients/clients Do non-computer data analysis Take, compute diet histories Maintain appropriate patient records Keep appropriate patient records Provide direct counseling services to individuals, families Assist in establishing food assistance or feeding programs Give general nutritional presentations to community groups Provide data for nutrition surveillance systems Identify individual, family nutritional needs, status Identify vulnerable groups on basis of nutritional needs Implement current legislation as directed Implement nutrition education programs for individuals and groups Participate in planning intervention programs Work as part of a health care team
most important competencies by both the practitioner and graduate faculty groups. These data remind us that nutritionists truly function as ""interpreters" or ""communicators" of nutrition knowledge from the source of that knowledge to those who must use it or apply it, i.e., clients and other health personnel. The results do not suggest that public health nutritionists should not be prepared to assume "'higher level" abilities in program planning and administration. Rather, they suggest that until other more basic abilities are mastered, one cannot expect to do well with greater managerial responsibilities. Practitioners were instructed on the questionnaire to respond to each competency statement in terms of what the entry-level nutritionist should be able to do. When their responses were compared to their own responsibilities, these nutritionists rated those competencies highest which they themselves were performing, and rated lower those which other personnel were doing. Thus, the data furnish us with a sense of the functions for which practitioners in the field are now responsible, as well as their assessment of what current and future academic programs should prepare graduate students to do. For persons responsible for the administration and planning of graduate curricula in public health nutrition, several important implications result from this study. Attention must be given to insuring that students attain competency in basic communication/service abilities, in addition to learning the elements of program planning and management. Practitioners rated highly those competencies that dealt with direct service functions of the public health nutritionist, rather than competencies dealing with planning or administrative abili1104
ties. Many faculty may assume that students possess oral and written communication skills as a result of their previous experiences and undergraduate education; this assumption may need to be re-examined. We must assess and strengthen the "communication" aspects of the academic preparation offered in the graduate program. A major difference between the faculty and the practiioner respondents revolved around the "'perform direct dietary counseling" competency. Faculty may assume that students in the graduate program already possess this ability. However, the institution of specific "'testing out" procedures may be indicated to determine whether or not students have mastered these skills before entering the field. Obviously, emphasis on public health nutrition planning, implementation and evaluation activities are appropriate in the graduate curriculum. Many entry-level public health nutritionists must function "solo" in community programs where program planning/evaluation competencies are essential. Planners of graduate programs must not think that they educate students only for "entry-level" positions; students must also be prepared for the positions of greater responsibility which they will assume five years hence. The results lay the groundwork for the development of a "competency-based" educational curriculum in public health nutrition. The basic competencies for the nutritionist have been identified. What remains now is for academic faculties to take responsibility for assessing whether or not students have mastered these sets of competencies, and to provide a series of experiences to ensure that these competencies are developed. The challenge is great, but so are the rewards. AJPH November 1979, Vol. 69, No. 11
COMPETENCIES OF PH NUTRITIONISTS
REFERENCES 1. The American Dietetic Association: Personnel in Public Health Nutrition. Chicago: The American Dietetic Association, 1976. 2. Huenemann, RL, Peck EB: Who is a public health nutritionist? J Am Dietet Assoc 58:327-330, 1971. 3. Bosley B: Nutritionists and dietitians in the seventies: Trends in education. World Rev Nutr Dietet. 20:49-64, 1975 4. Peck EB, Vermeersch J, Huenemann RK: A Study Guide for Public Health Nutritionists, unpublished. Berkeley: University of California, School of Public Health, 1976. 5. Johnson D: The dietitian-a translator of nutritional information. J Am Diet Assn 64:608-611, 1974. 6. Kocher RE: New dimensions for dietetics in today's health care. J Am Diet Assn 60:17-20, 1972. 7. Fischer FE: The dietitian in the legislative arena. J Am Diet Assn 64:621-623, 1974. 8. Dahl, T. Economics, management and public health nutrition. J Am Diet Assn 70:144-148, 1977. 9. Nichaman MZ, Collins GE: Nutrition programs in state health agencies. Nutr Rev 32:65-67, 1974. 10. Treacy LH: The nutritionist in a comprehensive health care plan. J Am Diet Assn 68:253-254, 1976. 11. Berg AD, Levinson FJ: A new need: the nutrition programmer Am J Clin Nutr 22:893-895, 1969. 12. Peck EB: The "professional self' and its relation to change processes. J Am Diet Assn 69:534-537, 1976. 13. Sims LS: The community nutritionist as change agent. Family and Community Health 1(4):83-92, 1979. 14. Bell CG: Role vs. entry-level competencies in competencybased education. J Am Diet Assn 69:133-137, 1976. 15. Segall AJ, Vanderschmidt H, Burglass R, Frostman I: Systematic Course Design for the Health Fields. New York: John Wiley & Sons, 1975.
16. Duncan B: Are academic programs meeting the demands a public health nutritionist faces when she becomes a practicing professional? Paper presented at the Annual Meeting of the Association of Graduate Faculties of Public Health Nutrition, Atlantic City, NJ, Nov. 12, 1972. 17. Experiments in group prediction. Memorandum P-3820. Santa Monica, California: RAND Corp. March 1968. 18. Starkweather DB, Gelwicks L, Newcomer R: Delphi forecasting of health care organization, Inquiry 12:37-46, 1975. 19. Mulholland GV, Wheeler SG, Hereck JJ: Medical assessment by a Delphi group opinion technique., New Engl J Med 288:1272-1275, 1975. 20. Delbecq AK, Van de Ven AH, Gustafson DH: Group Techniques for Program Planning: A Guide to Nominal Group and Delphi Processes. Glenview, IL: Scott, Foresman, and Co., 1975. 21. U.S. Department of Health, Education, and Welfare, Public Health Service, Center for Disease Control: Nutrition Directory, State Health Agencies and Graduate Programs of Public Health Nutrition, Dec. 1975. 22. Nie NH, Hull CH, Jenkins JJ, et al: SPSS: Statistical Package for the Social Sciences. 2 ed., New York: McGraw-Hill Book Co., 1975.
ACKNOWLEDGMENTS The author acknowledges the receipt of a Research Initiation Grant from the Office of Research and Graduate Studies, The Pennsylvania State University. Susan Hicks Meyer and Elizabeth Leung provided assistance in the collection and compilation of data. Special appreciation is extended to Anita and George Owen and to Henry P. Sims, Jr., for their thoughtful review of an earlier draft of this paper.
The Nutrition of Children and the Fear of Fraud (School lunches in England-1905) t l
e must begin with the children". became the recurring theme of the increasing number of VY people only recently made aware of the importance of maintaining the health of even the most lowly of the population. It was already evident that voluntary efforts to feed the undernourished were not adequate. In some circles, however, there remained considerable reluctance to accept the feeding of the necessitous schoolchild as a public responsibility since to do so might undermine the proper discharge of parental responsibility.... An immediate remedy was the Relief (School Children) Order issued by the Poor Law Authorities in 1905. The Order empowered boards with guardians to grant relief to a child living with its father who was destitute, by providing him with free meals, on application to the local education authority or its officers. As a protection against the unscrupulous, the parent was to be pauperised by this relief, although he was not required to enter the workhouse or undertake some form of prescribed labour. If, none the less, a parent was found on investigation to be neglectful rather than destitute, the guardians were to recover the cost of the child's meals, if necessary by a court order. The Relief Order was not a success. Parents refused to allow their children to accept relief on such conditions.
Pinchbeck, Ivy and Hewitt, Margaret: Children in English Society, Vol II, London, Routledge & Kegan Paul, 1973, p 634. (contributed by Dr. Wm M Schmidt)
AJPH November 1979, Vol. 69, No. 11
1105
Abstract: The Delphi Technique was used to elicit a number of essential competencies expected of the "entry-level" public health nutritionist from members of Graduate Faculties of Programs in Public Health Nutrition. Questionnaires composed of "competency statements" were constructed from these responses and sent to practitioners in public health nutrition. The questionnaire requested evaluation of the "necessity" of each competency. Responses served as the basis for "factor analysis" procedures, employed to obtain clusters of competency functions expected of the nutritionist. From the 109 competency items originally identified, 17 competency scales were derived
from the factor analysis. A ranking from both faculties and practitioners revealed that both groups highly rated competencies to communicate, to counsel and deal with clients/patients, and to interpret scientific data in "lay language." Less important in the ranking were competencies which dealt with administrative abilities, program planning, legislative activism, and consumer advocacy. These findings have implications for the practitioner in public health nutrition as well as for academic groups who must plan and evaluate curricula in public health nutrition and in other fields of public health. (Am J Public Health 69:1099-1105, 1979.)
Introduction
tionist.1-13 These include roles as program administrator/ manager; program planner and evaluator, policy maker, community planner and facilitator, provider of direct services (in areas such as client counseling, nutrition education, training), consultant, investigator, human relations expert, change agent, consumer advocate and, finally, as liasion between the scientific and governmental communities. Such a variety of roles require a diverse array of skills and knowledge; hence, it is little wonder that nutritionists, as well as other health professionals, have been uncertain about the exact nature of the nutritionist's responsibilities within the
The nutritionist has been regarded as an important, contributing member of the public health team. The responsibilities of this position require competencies which typically are developed through a formal plan of graduate education and from field experience and training. By identifying the specific competencies required of the public health nutritionist, it may be possible to define more accurately the general responsibilities s/he may assume in the organization, or to evaluate how effectively s/he functions as a contributing member of the health care team. This study was conducted to identify specific behavioral competencies expected of the "entry-level" public health nutritionist, and to rank these specific competencies in priority order. Roles of the Public Health Nutritionist Two specialized roles distinguish the nutritionist in public health from other types of dietitians/nutritionists: 1) the community approach to the solution of nutrition problems, and 2) a special focus on the promotion of health and the prevention of disease rather than treatment and/or rehabilitation. A literature search revealed that several major responsibilities have been described for the public health nutriAddress reprint requests to Laura S. Sims, PhD, MPH, Associate Professor of Nutrition in Public Health, Division of Biological Health, College of Human Development, Pennsylvania State University, University Park, PA 16802. This paper, submitted to the Journal February 22, 1979, was revised and accepted for publication June 13, 1979. Editor's Note: See also related editorial, page 1096, this issue.
AJPH November 1979, Vol. 69, No. 11
agency/community setting. Educating for Competencies An increasingly popular trend in contemporary education is to rely on "competency-based" curriculum planning. Competencies may be defined as the "'minimum knowledge, skills, values, and/or attitudes a person can be certified to possess based on a specified set of criteria."114 Segall, et al,'5 concluded that the key to guaranteeing the relevancy of a particular course of study is the identification of future professional roles and performance within these roles. Duncan16 has emphasized that it is important for public health personnel in universities and in health agencies to ""plan, communicate and coordinate our efforts." To date, no systematic study has been undertaken to identify those specific competencies expected of practicing public health nutritionists or to determine whether graduate curricula are preparing students to assume those competencies actually being performed by the practitioner. This paper presents the results of research designed to answer 1 099
SIMS
these questions. Two separate phases for data collection were employed: Phase I: Identification of competencies by graduate educators in public health nutrition; and Phase II: Evaluation of these competencies by practitioners in the field. Further data analysis was performed to compare the responses of faculty with those of practitioners, and to compare public health nutritionists' responses with those of nonpublic health nutritionist practitioners. In addition, the differences in the ratings of these competency scales were examined in relation to selected demographic characteristics of the practitioners.
Method and Results Phase I: Identification of Competencies The initial phase of the research involved the identification of specific behavioral competencies expected of the "'entry-level"* nutritionist by faculty associated with graduate-level public health nutrition programs. It made use of the Delphi Technique,** a "group process utilizing written responses as a means for aggregating the judgments of a number of individuals.'"20 Respondents All program coordinators and other faculty involved in graduate-level accredited public health nutrition programs at universities listed in the Nutrition Directory, State Health Agencies and Graduate Programs of Public Health Nutrition2' were asked to participate as the group best qualified to determine baseline competencies for entry-level public health nutritionists. Of these, 18 individuals from 11 universities offering graduate programs in public health nutrition agreed to participate in the study. Procedure: For Round I, participants were instructed to respond to the following two general questions: 1) What are the behavioral competencies*** which all entry-level public *''Entry-level" nutritionist: one who has completed a Master's
Level approved curriculum in Public Health Nutrition and who is an RD or RD-eligible. Upon assuming a first time role as nutritionist in a health agency, s/he may not be in an administrative or supervisory position, but should be educated to assume these responsibilities if and when needed. **The Delphi Technique'" is characterized by several features, including multiple iterations of responses to achieve convergence, anonymity of respondents, relatively efficient use of respondents' time, controlled feedback to participants, and statistical analysis on "'group" rather than individual responses.'81'9 The initial phase is concerned with the development of the basic question, usually openended, which deals with broad issues such as program planning, suggested solutions to identified problems or forecasting future events. Respondents are selected on the basis that they can provide expert testimony/opinion to the identified issue; the process requires that respondents have adequate time to make responses, high motivation, and skill in written communication. Responses to the first questionnaire determines construction of the second, and so forth. The iterations continue, usually to the third or fourth round, until convergence or divergence on the issue is reached.20 ***A "behavioral competency" was operationally defined for the respondents as "that specific behavior, based on appropriate knowledge, skills, values and/or attitudes deemed essential for the practicing professional." Examples of behavioral competencies for a hospital nurse and secretary were given. 1100
health nutritionists in a ""generalist" position should be expected to possess?; and 2) What are the responsibilities of the public health nutritionist today that such a person should not generally be expected to do ten years from now? Eighteen individual responses were received. Responses were condensed into a series of unduplicated competencies and included in a second questionnaire, along with 25 additional competencies which had appeared in the literature but which had not been specifically mentioned by the faculty participants. The second questionnaire asked respondents to rate, on a Likert-type format of 1 to 7, the importance of each listed competency for the entry-level public health nutritionist. Fourteen of the 18 participants responded. On the third questionnaire, 13 of the 14 second-round respondents ranked the top six competencies (from most important to least important) from among the 15 competencies rated highest on the previous round. Results: From the faculty participant's responses to the second questionnaire, a mean score for each of 109 competencies was computed. The majority of the top eight ranking competencies dealt with the provision of direct services to clients rather than with administrative/planning duties. The two highest-ranked competencies (with scores of 6.846 out of 7.000) dealt with evaluating outcomes of nutrition programs in terms of stated objectives and being able to discriminate between questionable and proven nutrition information-opinion. Conspicuously absent from this list were legislative-political functions and higher level program planning functions. t An examination of the lowest-ranked competencies is also of interest. Lowest mean scores were received by those competencies which seem to require additional education, such as ""speaking more than one language fluently" and "'ability to carry out research programs." The faculty participants may have considered these requirements too high for
"'entry-level."
Another part of the second questionnaire completed by the faculty group asked responses on a seven-point (1 = strongly disagree to 7 = strongly agree) Likert-type scale to those competencies which would be considered "'unnecessary" for the nutritionist in the next ten years. None of the 15 items received a score greater than 4.7, perhaps indicating a reluctance on the part of the educators to have nutritionists relinquish responsibility in any of these areas. However, items which dealt with direct service skills, such as the taking of diet histories and measuring and recording of anthropometric data, recieved the highest "'agreement" ratings, indicating that these competencies may become unnecessary for nutritionists. Such activities are increasingly being performed by paraprofessionals, and the evaluations of the educators seemed to indicate that this trend would continue. Activities long regarded as integral to the role of the nutritionist such as working as part of the health team and participating in the planning of programs-received the lowest scores, thus indicating that the academic group felt that these would continue to be essential for the nutritionist. able
WFurther details regarding the results of this analysis are availon
request to the author.
A.JPH November 1979, Vol. 69, No. 1 1
COMPETENCIES OF PH NUTRITIONISTS
Responses to the third questionnaire dealt with the ranking of those competencies which received the highest mean scores on the second round. Results from this tabulation indicated that the direct service skills of communication with clients, the ability to translate principles into action, adjusting plans, and knowing the community referral services were rated as most important. PHASE II: Evaluation of Competencies by Practitioners Sample Selection: A nationwide sample of public health nutritionists was obtained. The sample included those American Dietetic Association members having a primary interest and responsibility in public health nutrition, members of the American Public Health Association's Food and Nutrition Section, and names of attendees at various public health nutrition conferences and workshops. Care was taken to select only those individuals who were practitioners in public health nutrition; known members of a graduate faculty were eliminated from this sample, These sources were then combined and collapsed to give the names of approximately 1,240 public health nutritionists. Using a table of random numbers, (830 individuals a two-thirds sample) were selected to receive the questionnaire. Sampling with replacement was used for those persons unwilling or unable to participate in the study. Followup reminder letters and postcards were mailed at three intervals to all non-respondents. Three-hundred forty-nine of the 830 individuals completed the questionnaire, a response rate of 42 per cent.tt All respondents signed an "'Informed Consent" form signifying their voluntary participation in the study. The Instrument: The questionnaire mailed to the 830 public health nutrition practitioners contained all 109 competencies listed on the faculty participants second questionnaire, as well as the 15 additional competency statements labeled as "'perhaps unnecessary for the nutritionist in the next ten years." Practitioner respondents were asked to preface each of the 109 competencies with the phrase, "The entry-level public health nutritionist should be able to . . .", and then rank the essentiality of each competency on a Likert scale of 1 to 7. For each item, the respondent was also asked to indicate whether this particular activity was currently being performed by the nutritionist, whether it was -desirable for it to be performed by the nutritionist, and whether or not it was performed by personnel other than the nutritionist. For this last section, in cases where the nutritionist did not perform that role, respondents were asked to identify the person who did that activity. An initial section of the questionnaire requested a self-definition of whether or not the respondent was a public health nutritionist. Data were also obtained on respondent's sex, age, current employment position, professional memberships, and educational background. The Practitioner Sample: Eighty-five per cent of the 349 respondents self-reported themselves as public health nutri-
tlComparison of respondent and non-respondent characteristics was not possible. AJPH November 1979, Vol. 69, No. 11
tionists, the largest number (35.6 per cent) being employed in positions where their principal function was to provide direct nutrition services to clients; 31.5 per cent were in administrative positions; and 25.6 per cent were employed as consultants. The respondents were employed a mean of 37.8 hours per week; the mean age was 40 years, and they had been in their present position a mean of 5.5 years. Over 97 per cent were female. More than 70 per cent of the respondents held a Master's degree (either MPH, MSPH, MS, or MA degree). Ninety per cent were Registered Dietitians. Ninety-three per cent were members of the American Dietetic Association, 54 per cent belonged to the American Public Health Association, 52 per cent to the Society for Nutrition Education, and 45 per cent to the Nutrition Today Society. The demographic characteristics of 297 respondents who reported themselves as public health nutritionists were compared to 52 respondents who did not consider themselves public health nutritionists. Significant findings were: more public health nutritionists held administrative/consultant positions rather than education/training positions; their salaries were more likely to come from federal and local funds than private funds; and they possessed a Master's or higher degree. There were no significant age differences between the two groups. Results: The 109 competency items (excluding the 15 "unnecessary" items) were first grouped on a priori basis into scales.t44 Construct validity of these a priori scales was evaluated by factor analysis (oblique rotation), using a program of the Statistical Package for the Social Sciences (SPSS).22 On the basis of these results, 48 items were dropped from the final array of scales because of low communality, and others were re-arranged into different scales.* Reliability coefficients for each scale (Cronbach alpha) ranged from .67 to .92. The individual scales were named: * ability to actively function in legislative process; * ability to perform administrative/managerial func-
tions; * ability to provide nutritional services in community health programs; * ability to communicate effectively in teaching/learning
settings; * ability to communicate clearly; * ability to carry out program planning function; * ability to interpret scientific material to lay audiences; * ability to communicate in the public/mass media; * ability to supervise paraprofessional staff; * ability to manage food service delivery system; * ability to effectively do direct counseling of clients; * ability to carry out in-service education for staff; * ability to perform and interpret nutritional screening procedures; * ability to be understanding and empathic when dealing with clients; tttResults of the analysis of the responses to the 109 individual competency items are available on request to the author. The conclusions are basically the same as those derived from the scale analysis. *The final factor matrix of the 61 individual competencies belonging to 17 scales is available on request to the author. 1101
SIMS TABLE 1-Scale Scores of Essential Entry Level Competencies of Nutritionists Mean Score
Practitioners (1 = totally unnecessary to 7 = essential)
The "entry-level" nutritionist should have the ability to:
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17.
Communicate clearly-oral and written Perform direct dietary counseling Be empathic, sensitive to patients/clients' needs Provide nutritional care services in community health programs Correctly interpret scientific data Carry out planning function of programs Communicate well in teaching-learning settings Prepare educational materials/programs Perform nutritional screening procedures Do in-service education programs Supervise/direct paraprofessionals Be an active nutrition advocate in the legislative process Participate in long-range planning efforts Manage food service delivery systems Communicate in public/mass media Administer/manage programs, staff Be a consumer advocate regarding food and nutrition
Practitioners
All Respondents (n = 363)
Faculties (n = 14)
6.298 5.908 5.899 5.879 5.839 5.819 5.806 5.776 5.594 5,547 5.028 5.002 4.901 4.875 4.646 4.475 4.079
6.143(2)* 5.619(7) 5.686(5) 6.357(1) 5.857(4) 6.000(3) 5.262(13) 5.631(6)
6.305(1) 5.919(2) 5.908(3) 5.859(4) 5.839(5) 5.812(6) 5.828(7) 5.781(8)
5.429(10) 5.557(9) 5.619(8) 5.278(12) 5.071(14) 5.286(11) 4.429(16) 5.012(15) 3.929(17)
5.600(9) 5.547(10) 5.004(11) 4.990(12) 4.894(13) 4.858(14) 4.655(15) 4.453(16) 4.086(17)
(n = 349)
PH
Non-PH
Nutritionists (n = 297)
Nutritionists (n = 52)
6.298(1)
6.394(1)
5.963(2) 5.915(3) 5.891(4) 5.839(7) 5.814(8) 5.849(6) 5.854**(5) 5.647(9) 5.589(10) 5.002(11) 4.995(12) 4.901(13) 4.809(14)
5.673(7) 5.869(2) 5.679(6)
4.658(15) 4.481(16) 4.050(17)
5.833(3) 5.801(4) 5.705(5) 5.365(8) 5.337(9) 5.304(10) 5.013(12) 4.962(13) 4.853(14) 5.135(11) 4.635(15) 4.295(16) 4.289(17)
*ranking in parentheses **significant differences between groups by T-test statistic, p s .05
* ability to prepare educational materials/programs; * ability to participate in long-range planning effort; * ability to function as a consumer advocate regarding food and nutrition issues. Table 1 reports scores of the competency scales as mean responses for faculties and the two types of practitioners. The highest rated scales were those that dealt with communication abilities: the ability to do dietary counseling, being empathetic with client's needs, providing nutritional care plans in community health services, and the ability to interpret correctly scientific materials for the lay public. Those that received the lowest ratings (but still an overall slightly favorable response) were those that dealt with administrative/managerial responsibilities, supervision of paraprofessionals, as well as participation in policy issues.
Supplementary Analysis and Comparisons Faculty vs. practitioner responses: The rankings of the faculty respondents to the scales developed from items contained in their second round questionnaire were compared with the ranking of all practitioner respondents, as shown in Table 1. While the T-test statistic revealed that there were no statistically significant differences between faculties and practitioners, the practitioners consistently ranked those competencies dealing with direct service functions higher than did the faculty group. Public health vs. non-public health nutritionist responses: Analysis was also performed to determine the differences in ranking on the various competency scales according to whether the respondent was a public health nutritionist or not. Results, shown in Table 1, indicated that there 1102
were no statistically significant differences on the rankings between these two types of practitioners. Influence of demographic characteristics of practitioners: The various competency scales were examined in relation to the demographic characteristics of the practitioner respondents. Paired comparison (T-test statistic) was used to compare members vs. non-members of the various professional organizations in terms of their respective ratings of the various -scales of nutritionist competencies. There were few discernible differences, with the exception that members of the American Public Health Association had higher scores on the planning and communication competencies, and members of the Society for Nutrition Education rated competencies in administrative ability higher than did others. To determine the effect of place of employment, type of position held, type of academic degree held, and region in which the practitioner was working, on the responses to the scales of nutritionist competencies, one-way analysis of variance was computed. This analysis indicated that few differences could be attributed to these various characteristics, except that those employed in direct patient service and administrative positions rated the ""counseling" competency higher than did those in other types of positions. Likewise, this competency was rated higher by those employed in hospitals, medical centers, and health maintenance organizations, than by those employed in educational institutions. The planning competency was rated higher by those respondents with the MPH or doctorate degree, while the public communication competency was rated more highly by those holding Master's degrees and doctorates than by those having baccalaureate degrees. AJPH November 1979, Vol. 69, No. 11
COMPETENCIES OF PH NUTRITIONISTS TABLE 2-Personnel Performing Activities as Listed in Competency Scales
Activity Currently
Performed by Nutritionist Scale names
1. 2. 3. 4.
5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17.
Clear communication Counseling Empathic to patients Nutrition services in community health programs Interpret scientific data Program planning Communicate in teaching Prepare educational materials Perform screening In-service education Paraprofessionals Legislative activism Long-range planning Food-service management Mass media/public communication Program adniinistration Consumer advocate
Several relationships existed between the practitioners' ratings of the competency scales and their employment characteristics. Older respondents were less likely to agree with the competencies on administration, provision of nutrition services in community health programs, and screening. Those persons who spent a greater percentage of their time in administrative duties were less favorable to those competencies dealing with long-range planning efforts and food service management, while those who spent more time in direct patient service functions gave higher ratings to competencies dealing with client counseling, advocacy, legislative activism, long-range planning, inservice education, screening, preparing written materials, communicating with the public, and presenting information in a teaching/learning setting. Correlational analysis showed that there was a slightly negative relationship between the respondent's age and the amount of time spent in direct service functions and a positive relationship between the length of time in one's present position and the percentage of time in administrative duties. Thus, respondents' scale ratings may be an artifact of these findings, i.e., younger respondents tended to rank their own "specialty," of counseling, and their interest in advocacy/ legislative activities higher, while those who had been in administrative positions for a longer period of time may have believed that administrative responsibilties were inappropriate for the entry-level public health nutritionist. Personnel performing competency functions: When the clusters of competencies, as identified by the factor analysis, were examined in relation to the personnel who performed those functions, the results were of interest. As shown in Table 2, the highest ranked scales of competencies were also those in which a greater percentage of respondents reported that these functions were performed by the nutritionist, AJPH November 1979, Vol. 69, No. 11
Activity Performed by Personnel other than Nutritionist
(% of Practitioners Reporting)
98.5 89.6 96.2
35.2 44.9 36.1
88.7 94.7 92.1 93.1 92.4 83.0 92.1 75.6 63.2 75.2 67.6 65.5 71.6 47.7
38.8 29.7 38.1 25.8 30.6 58.8 25.3 43.6 38.3 46.7 43.3 41.0 57.9 48.5
while those receiving a lower ranking were those most likely to be performed by other personnel. These data indicate that while respondents were instructed to respond to the competency statements on the questionnaire in terms of what the
entry-level public health nutritionist should be able to do, they also responded in terms of what they themselves were doing. " Unnecessary" competencies: The 15 competency items described as being "'perhaps unnecessary for nutritionists in the next ten years" were rated by the practiioners (Table 3). Specific abilities to do tasks such as measuring and recording height and weight data of patients, as well as performing non-computer assisted dietary assessment were rated as competencies which will become less important in the future. Working as part of the health care team and implementing nutrition education programs were seen as activities which nutritionists should continue to perform. It is of great interest to note that all but one of the 15 competencies rated as activities which will be "unnecessary" for the public health nutritionist ten years hence were currently being performed by the nutritionist, according to 86 percent of the respondents. The remaining competency, "'accurately measure and record height and weight of clients," was currently being done by only 55.2 percent of the nutritionist respondents.
Implications The results of this study have important ramifications for both practitioners and faculty in graduate programs in public health nutrition. Certain basic abilities, such as written and oral communication skills, patient/client counseling, and interpretation of scientific materials were rated as the 1103
SIMS
TABLE 3-Ranking of "Unnecessary" Competencies by Practitioners (n = 349) Competencies Deemed "Unnecessary" in Ten Years
Mean Score (1 = strongly disagree to 7 = strongly agree)
Ranking by PH Nutritionists (n = 297)
Ranking by Non-Nutritionists (n = 52)
4.377 4.289 3.600 3.192 3.134
1 2 3 4 5
1 2 4 3 5
2.942
6
8
2.872
7
6
2.734
8
9
2.627
9
7
2.508
10
10
2.446
11
13
2.409
12
14
2.326
13
15
2.322 2.244
14 15
12 11
Accurately measure and record height and weight of patients/clients Do non-computer data analysis Take, compute diet histories Maintain appropriate patient records Keep appropriate patient records Provide direct counseling services to individuals, families Assist in establishing food assistance or feeding programs Give general nutritional presentations to community groups Provide data for nutrition surveillance systems Identify individual, family nutritional needs, status Identify vulnerable groups on basis of nutritional needs Implement current legislation as directed Implement nutrition education programs for individuals and groups Participate in planning intervention programs Work as part of a health care team
most important competencies by both the practitioner and graduate faculty groups. These data remind us that nutritionists truly function as ""interpreters" or ""communicators" of nutrition knowledge from the source of that knowledge to those who must use it or apply it, i.e., clients and other health personnel. The results do not suggest that public health nutritionists should not be prepared to assume "'higher level" abilities in program planning and administration. Rather, they suggest that until other more basic abilities are mastered, one cannot expect to do well with greater managerial responsibilities. Practitioners were instructed on the questionnaire to respond to each competency statement in terms of what the entry-level nutritionist should be able to do. When their responses were compared to their own responsibilities, these nutritionists rated those competencies highest which they themselves were performing, and rated lower those which other personnel were doing. Thus, the data furnish us with a sense of the functions for which practitioners in the field are now responsible, as well as their assessment of what current and future academic programs should prepare graduate students to do. For persons responsible for the administration and planning of graduate curricula in public health nutrition, several important implications result from this study. Attention must be given to insuring that students attain competency in basic communication/service abilities, in addition to learning the elements of program planning and management. Practitioners rated highly those competencies that dealt with direct service functions of the public health nutritionist, rather than competencies dealing with planning or administrative abili1104
ties. Many faculty may assume that students possess oral and written communication skills as a result of their previous experiences and undergraduate education; this assumption may need to be re-examined. We must assess and strengthen the "communication" aspects of the academic preparation offered in the graduate program. A major difference between the faculty and the practiioner respondents revolved around the "'perform direct dietary counseling" competency. Faculty may assume that students in the graduate program already possess this ability. However, the institution of specific "'testing out" procedures may be indicated to determine whether or not students have mastered these skills before entering the field. Obviously, emphasis on public health nutrition planning, implementation and evaluation activities are appropriate in the graduate curriculum. Many entry-level public health nutritionists must function "solo" in community programs where program planning/evaluation competencies are essential. Planners of graduate programs must not think that they educate students only for "entry-level" positions; students must also be prepared for the positions of greater responsibility which they will assume five years hence. The results lay the groundwork for the development of a "competency-based" educational curriculum in public health nutrition. The basic competencies for the nutritionist have been identified. What remains now is for academic faculties to take responsibility for assessing whether or not students have mastered these sets of competencies, and to provide a series of experiences to ensure that these competencies are developed. The challenge is great, but so are the rewards. AJPH November 1979, Vol. 69, No. 11
COMPETENCIES OF PH NUTRITIONISTS
REFERENCES 1. The American Dietetic Association: Personnel in Public Health Nutrition. Chicago: The American Dietetic Association, 1976. 2. Huenemann, RL, Peck EB: Who is a public health nutritionist? J Am Dietet Assoc 58:327-330, 1971. 3. Bosley B: Nutritionists and dietitians in the seventies: Trends in education. World Rev Nutr Dietet. 20:49-64, 1975 4. Peck EB, Vermeersch J, Huenemann RK: A Study Guide for Public Health Nutritionists, unpublished. Berkeley: University of California, School of Public Health, 1976. 5. Johnson D: The dietitian-a translator of nutritional information. J Am Diet Assn 64:608-611, 1974. 6. Kocher RE: New dimensions for dietetics in today's health care. J Am Diet Assn 60:17-20, 1972. 7. Fischer FE: The dietitian in the legislative arena. J Am Diet Assn 64:621-623, 1974. 8. Dahl, T. Economics, management and public health nutrition. J Am Diet Assn 70:144-148, 1977. 9. Nichaman MZ, Collins GE: Nutrition programs in state health agencies. Nutr Rev 32:65-67, 1974. 10. Treacy LH: The nutritionist in a comprehensive health care plan. J Am Diet Assn 68:253-254, 1976. 11. Berg AD, Levinson FJ: A new need: the nutrition programmer Am J Clin Nutr 22:893-895, 1969. 12. Peck EB: The "professional self' and its relation to change processes. J Am Diet Assn 69:534-537, 1976. 13. Sims LS: The community nutritionist as change agent. Family and Community Health 1(4):83-92, 1979. 14. Bell CG: Role vs. entry-level competencies in competencybased education. J Am Diet Assn 69:133-137, 1976. 15. Segall AJ, Vanderschmidt H, Burglass R, Frostman I: Systematic Course Design for the Health Fields. New York: John Wiley & Sons, 1975.
16. Duncan B: Are academic programs meeting the demands a public health nutritionist faces when she becomes a practicing professional? Paper presented at the Annual Meeting of the Association of Graduate Faculties of Public Health Nutrition, Atlantic City, NJ, Nov. 12, 1972. 17. Experiments in group prediction. Memorandum P-3820. Santa Monica, California: RAND Corp. March 1968. 18. Starkweather DB, Gelwicks L, Newcomer R: Delphi forecasting of health care organization, Inquiry 12:37-46, 1975. 19. Mulholland GV, Wheeler SG, Hereck JJ: Medical assessment by a Delphi group opinion technique., New Engl J Med 288:1272-1275, 1975. 20. Delbecq AK, Van de Ven AH, Gustafson DH: Group Techniques for Program Planning: A Guide to Nominal Group and Delphi Processes. Glenview, IL: Scott, Foresman, and Co., 1975. 21. U.S. Department of Health, Education, and Welfare, Public Health Service, Center for Disease Control: Nutrition Directory, State Health Agencies and Graduate Programs of Public Health Nutrition, Dec. 1975. 22. Nie NH, Hull CH, Jenkins JJ, et al: SPSS: Statistical Package for the Social Sciences. 2 ed., New York: McGraw-Hill Book Co., 1975.
ACKNOWLEDGMENTS The author acknowledges the receipt of a Research Initiation Grant from the Office of Research and Graduate Studies, The Pennsylvania State University. Susan Hicks Meyer and Elizabeth Leung provided assistance in the collection and compilation of data. Special appreciation is extended to Anita and George Owen and to Henry P. Sims, Jr., for their thoughtful review of an earlier draft of this paper.
The Nutrition of Children and the Fear of Fraud (School lunches in England-1905) t l
e must begin with the children". became the recurring theme of the increasing number of VY people only recently made aware of the importance of maintaining the health of even the most lowly of the population. It was already evident that voluntary efforts to feed the undernourished were not adequate. In some circles, however, there remained considerable reluctance to accept the feeding of the necessitous schoolchild as a public responsibility since to do so might undermine the proper discharge of parental responsibility.... An immediate remedy was the Relief (School Children) Order issued by the Poor Law Authorities in 1905. The Order empowered boards with guardians to grant relief to a child living with its father who was destitute, by providing him with free meals, on application to the local education authority or its officers. As a protection against the unscrupulous, the parent was to be pauperised by this relief, although he was not required to enter the workhouse or undertake some form of prescribed labour. If, none the less, a parent was found on investigation to be neglectful rather than destitute, the guardians were to recover the cost of the child's meals, if necessary by a court order. The Relief Order was not a success. Parents refused to allow their children to accept relief on such conditions.
Pinchbeck, Ivy and Hewitt, Margaret: Children in English Society, Vol II, London, Routledge & Kegan Paul, 1973, p 634. (contributed by Dr. Wm M Schmidt)
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