Nutrition Education in Primary Care Adult and Family Nurse Practitioner Programs

Abstract

Background:

Educating and training clinicians to deliver nutrition interventions is critical to improve population health. However, the adequacy of nutrition education within primary care adult and family nurse practitioner (ANP/FNP) curriculums has not been addressed.

Purpose:

The purpose of this study was to describe faculty perceptions of nutrition education in ANP/FNP programs.

Methods:

We used a cross-sectional design to gather data on nutrition education. The survey was administered to a convenience sample of faculty from the US.

Results:

Our response rate was 47.8% (N=49). The mean ± SD hours of nutrition education was 14.4 ± 14.6. One-fourth of schools reported that their students received at least 25 hours of nutrition education. Most participants thought it was very or extremely important (75.6%) that their students become more educated about nutrition.

Conclusions:

There is a need and desire for more nutrition education within nursing graduate curricula. Novel strategies to implement nutrition education in nurse practitioner curriculum is needed.

Educating health care providers to deliver nutrition and lifestyle interventions is critical to improve population health. In 2017, 11 million deaths were attributed to dietary risk factors, which equates to 22% of all deaths among adults in the world.¹ The most common causes of diet-related deaths were cardiovascular disease, cancer, and type 2 diabetes.¹ Much of the morbidity and mortality could be reduced through improved nutrition, dietary, and lifestyle behaviors. Randomized controlled trials have demonstrated that nutritional and lifestyle interventions are effective for the prevention and treatment of chronic diseases such as diabetes,² hypertension,³ and cardiovascular disease.⁴ Clinical guidelines for many chronic diseases recommend nutrition and lifestyle changes as a foundational intervention.^5–8 Several Healthy People 2030 goals are directly related to nutrition such as reduced consumption of calories from added sugars and increased fruit consumption.⁹

Despite the importance of nutrition to the health and wellness of patients, this is rarely implemented in clinical practice. Less than half of patients report that health care providers counsel them to lose weight (40.4%) or reduce fat or calorie intake (38.9%).¹⁰ Sufficient nutrition knowledge is associated with providing healthy lifestyle counseling for chronic lifestyle-related diseases.¹¹ Yet, health care providers often cite insufficient nutrition knowledge and training as a barrier to providing nutrition education.^12–14 There have been large and persistent nutrition education and training gaps cited in medical education.^15,16 For example, 71% of medical schools do not meet the minimum of 25 hours of nutrition education recommended by the National Research Council.¹⁷ Implementation science frameworks often highlight education and training as an important component to delivery of evidence-based treatments in practice.^18,19 A lack of training in nutrition may be contributing to treatment gaps. However, little is known about the amount and type of nutrition education that other health care providers, such as nurse practitioners, receive.

Nurses practitioners are one of the largest growing health care groups with over 290,000 licensed practitioners in the US and accounting for approximately 1.06 billion patient visits per year.²⁰ It is critical that nurse practitioners have the skills and knowledge necessary to provide effective nutrition counseling to patients. However, the adequacy of nutrition education within primary care adult and family nurse practitioner curriculums has not been addressed. The purpose of this exploratory study was to describe faculty perceptions of nutrition education in primary care adult and family nurse practitioner (ANP/FNP) programs in the US. The primary aim was to quantify the number of hours of nutrition education required for students enrolled in ANP/FNP programs in the US. Our secondary aims were to describe the nutrition content offered in ANP/FNP programs, and to assess perceived barriers for providing nutrition education in these programs.

Methods

Study Design

We used a cross-sectional design to gather data on nutrition education provided in primary care ANP/FNP programs. The survey was administered to a convenience sample of faculty in the US using emailed surveys. This study was deemed exempt by the University of Pennsylvania’s Institutional Review Board.

Participants

The target population was faculty members from primary care ANP/FNP programs in the US. We used a multimodal recruitment strategy of individuals from the program listings on the Niche’s top 100 nursing schools²¹ and the American Association of Nurse Practitioners’ nurse practitioner web page, which included programs provided by the American Association of Colleges of Nursing as of fall 2019.²² The inclusion criteria were faculty members teaching in a primary care ANP/FNP program in the US or who were familiar with the primary care ANP/FNP curriculum at their institution. The primary exclusion criteria were: unwilling to consent to study procedures; institution does not offer a primary care ANP/FNP program; and faculty member was not familiar with the ANP/FNP curriculum.

Measures

The questionnaires were designed to take about 10 minutes to complete. The surveys were developed based on previously published measures and studies that have examined nutrition education given within medical and nursing school curricula and programs.^{14,17,23–25} Surveys were self-administered online via REDCap.²⁶

Professional and institutional information was collected from respondents, including their position, type of institution, and location of school by state. We asked whether the programs offered master’s (MSN) and/or doctor of nursing practice (DNP)-clinically focused programs and the length of time for completion for full-time students. For schools that offer both a Master’s and DNP program, we asked participants to respond to questions about their DNP-clinically focused program.

We assessed whether nutrition was offered in the curriculum and whether there was a required nutrition course for students. Participants were asked the total number of hours that could be identified as primarily concerned with nutrition across the primary care adult and family nurse practitioner curriculum, as well as who taught the course(s). We also asked the content of nutrition education provided to students. In addition, participants were asked whether they think their primary care ANP/FNP students receive adequate training in nutrition, the importance of nutrition education for primary care ANP/FNP students, and barriers to providing nutrition education.

Procedures

Procedures were created based on Dillman’s tailored design method and guidelines to maximize response rates.²⁷ Direct emails were sent to administrative leaders of schools of nursing (eg, primary care ANP/FNP program director, department chair, associate dean of graduate programs, dean). The invitation to participate explained the aims of the study and contained a link to an informed consent form and surveys. There were up to 4 emails per administration including: 1) the informed consent and survey, 2) a thank you and reminder sent approximately 5–7 days after the initial mailing, 3) a replacement link to the questionnaire to non-responders sent about 2 weeks after the thank you and reminder, and 4) a final reminder and thank you email sent approximately 2 weeks later.

Statistical Analysis

All data were assessed for missing data and out-of-range values. We calculated univariate statistics (i.e., means, standard deviations, ranges, frequencies, and proportions). Analyses were conducted using SPSS version 27.0 (IBM Corp, Armonk, NY).

Results

Participant Characteristics

Faculty members from 103 schools were contacted. Of the surveys that were emailed, the school-level response rate was 47.8% (N=49 faculty members from 49 schools in 39 different states). Respondents included the director of the program (32.7%), coordinator of the program (32.7%), associate dean of the graduate nursing program or equivalent (14.3%), faculty members (14.3%), associate director (2.0%), dean (2.0%), or “other” (2.0%). A little more than half (55.1%) of the participants taught at a public school. Both an MSN and DNP for ANP/FNPs were offered in 43.8% of schools while only an MSN was offered in 31.3%, and a DNP only in 25%. The mean ± standard deviation (SD) time for completion for an MSN degree was 25.2 ± 8.4 months and for a DNP degree was 32.5 ± 8.5 months.

Nutrition Education and Content

The mean ± SD hours of nutrition education was 14.4 ± 14.6 (range=0–55 hours). One-fourth of schools reported that their students received at least 25 hours of nutrition education. The majority of schools did not require a nutrition course (93.0%) for students. Only 2 schools required students to take 1 nutrition course and one school required students to take 2 nutrition courses. However, most schools reported that nutrition was taught as a topic within other courses (85.7%). Most nutrition content was taught by nurse practitioners (73.5%), and in some schools, nutrition content was taught by registered dietitians (8.2%), medical doctors (8.2%), registered nurses (6.1%), or clinical psychologist (2.0%). The most common nutrition topics were growth and development (75.5%), disease-related nutrition (73.5%), nutritional assessment (71.4%), and pediatric nutrition (71.4%; Figure). The least common were refeeding syndrome (4.1%), food science (6.1%), and nutritional genomics (10.2%).

Figure.

Nutrition Content in Nurse Practitioner Programs

Perceptions of Nutrition in Nursing Education

Only a third (29.3%) of respondents felt that their students received adequate training in nutrition education. Most participants thought it was very important (39.0%) or extremely important (36.6%) that ANP and/or FNP students become more educated about nutrition. Over half of respondents (51.2%) thought that it was likely that their institution will add more nutrition content to the curriculum in the next 5 years.

Barriers

The most frequently cited barriers were other content areas of higher priority (42.9%), insufficient time in curriculum (42.9%), and insufficient number of qualified faculty (12.2%). The most important resources needed to include nutritional content in ANP/FNP courses and in the curriculum at respondents’ institutions (mean ± SD; range = 1 [not at all helpful] to 5 [extremely helpful]) were case scenarios (4.3 ± 0.8), web-based tool-kit resources (4.2 ± 0.8), interprofessional education opportunities (4.1 ± 0.9), model curricula (3.9 ± 1.0), faculty training in nutrition (3.9 ± 1.0), and didactic modules (3.9 ± 0.9).

Discussion

In this national survey, faculty reported that ANP/FNP students received an average of 14.4 hours of nutrition content during their program. Similar to results from medical schools,¹⁷ few nurse practitioner programs reported that their students received ≥25 hours of nutrition education. While most participants thought it was very or extremely important (75.6%) that ANP/FNP students become more educated about nutrition, 93.0% did not require a nutrition course. Faculty noted barriers to providing nutrition content including other content areas of higher priority and insufficient time in the curriculum.

One explanation for the low level of nutrition education provided in graduate nursing education, is the level of nutrition education that they may receive as an undergraduate bachelor of science in nursing (BSN) student. BSN students in traditional, 4-year programs, receive an average of 52.6 hours of nutrition instruction.²⁵ However, most of this education was focused on nutrition as it related to acute settings such as enteral and parenteral nutrition. Many FNP and ANPs practice in primary care settings.²⁰ Providing students with the nutrition education and skills they will need for an advanced practice role in a primary care setting is crucial to improving the health of their patients. Additionally, there are multiple entry ways into nursing and NP programs. Second-degree nursing programs and accelerated-BSN programs are increasingly common, and these students may not receive the same level of nutrition education as those in 4-year BSN programs. Finding strategies to provide ANP and FNP students with more nutrition education during training and preparation on providing behavioral counseling to patients are essential.

Parallel to other disciplines, commonly cited barriers to incorporating nutrition education included other content areas of higher priority and insufficient time in the curricula.²⁸ Having more standardized guidance about essential competencies pertaining to nutrition for ANP and FNP students would help to guide curricula development. In addition, we believe that nutrition topics should also be integrated throughout ANP and FNP students’ education, including clinical care. Case scenarios and web-based toolkit resources may be helpful strategies to deliver this content.

Strengths and Limitations

Strengths of this study are the national sample of schools, survey recruitment methodology, and novelty of the survey. Limitations include the school-level response rate of 47.8%, though multiple attempts were made to contact individuals from different schools. There are challenges with calculating nutrition education across a degree program, particularly because most schools did not have a mandatory nutrition course for students. Thus, nutrition education was spread across the program and may have contributed to under or overreporting. It is also possible that there were variable understandings of what constituted nutrition education.

Conclusions

ANP and FNP students receive limited nutrition education during their program, highlighting an important training need. This is especially concerning given the high prevalence of nutrition-related diseases that our graduates will treat. These students need to have an adequate foundation to provide these patients with evidence-based clinical care.