5.5.5 .”z. a . inure»: no. :1 ; 7 :1. $51.19.}... . l... 321:1}; 5.... IS; suit: 3.5.32. .. e . ‘ a . t). 1.33.51, a «uni. anti... . , :2... "has r9! 3!... ((5.15. «A 1.3535: ‘ttf. 25.491.17.32 .3. 1‘ .fizxrici‘. ¢LI ». 3. : .XS :- rsia “L... 5.. a :32}; II sun-L...» .1: 5 vuuxvu!..1nu.sL «It. {$91}? F: .i. 33.3! .7}.-. a r l.!!2l..a fund”? «v.3 x... .1!” . {ham Ii LtStJH . . A . . .4 .flfl...fi!!‘v.fnh. sflflu'." W: “vital...“ . éxtia £112.55 1 .1, up A Giulia»... I v . 3: in?! Vifinlg . .C £15.th ‘ fur-Kuhn... «Au I .215. a... ..t.1..\..\iitta.¢t...!‘. I .um......! I :9 :1 g. .11.... ... ‘54:}: . v. 41.3.. .rn'! .. . .. .. :2 . sir. .Pgtyvnfluail .2..:..;>i.. 5.x! .1 3. un‘x .2 THEEHS (1 £39; LIBRARY m .. a .. State University This is to certify that the dissertation entitled DEFINING PROFESSIONALISM FOR DIETETIC EDUCATION presented by Diane L. Golzynski has been accepted towards fulfillment of the requirements for Resources Education and Communication Systems mm Major professor IZ/M/q/ MS U is an Affirmative Action/Equal Opportunity Institution O~ 12771 PLACE IN RETURN BOX to remove this checkout from your record. TO AVOID FINES return on or before date due. MAY BE RECALLED with earlier due date if requested. DATE DUE DATE DUE DATE DUE AF’ABAPfidfi: 6/01 alCIRC/DmDuapes-ws DEFINING PROFESSIONALISM FOR DIETETIC EDUCATION BY Diane L. Golzynski A DISSERTATION Submitted to Michigan State University In partial fulfillment of the requirements For the degree of DOCTOR OF PHILOSOPHY Department of Agriculture and Natural Resources Education and Communication Systems 2001 ABSTRACT DEFINING PROFESSIONALISM FOR DIETETIC EDUCATION By Diane L. Golzynski Being professional within a field of study involves a large collection of behaviors and attitudes. Without a thorough definition of professionalism that includes specific trigger behaviors of which to be cognizant, educators attempting to address professionalism will be leaving much of their work to simple chance. This research project utilized an on-line Delphi process to gather input from a group of leaders and futurists in the field of dietetics identified through a snowball technique. This group began with an open-ended question regarding the definition of professionalism for the field of dietetics. Data were then collected and categorized, and through a series of three more Delphi rounds, the categories and behavioral definitions were further refined to encompass the larger umbrella of professionalism. This procedure yielded a final list of ten categories, each with operational definitions. Finally, the subjects were asked when professionalism became a reality in their own lives. With the knowledge that the formal educational setting is the most influential time for the development of professionalism, curriculum recommendations that address professionalism within the dietetic curriculum can be developed. Previous work by Rodriguez and colleagues (2000) was coupled with suggestions for professionalism improvement made by the subject pool to enhance behavioral objectives for the dietetic curriculum. ACKNOWLEDGEMENTS It certainly takes the entire village to complete a project like this. I’d like to thank the entire department of ANRECS for accepting me, for giving me the freedom to be passionate about what I was doing, and for showing me that a degree program can be thoroughly enjoyed. My mentor, Dr. Fred Whims, was an incredible person to have the opportunity to work with. Your knowledge, vision, and leadership will never be forgotten. My committee, Dr. Jenny Bond, Dr. Dave Krueger, and Dr. Joe Levine, allowed me to pursue an interest and develop it into something of which I can be proud. Thank you. Thanks also go to all of my friends who have encouraged and pushed me to be my best. Marci, Stephanie, Cherie, Klara, the Bon Bon Book Club, Karen, and Stella. In addition, all those who helped watch Allie during this time: Lisa, Ann, Stephanie, Trudy, Eileen, mom & dad, Kristy, Kerri, Tonya, and Dana. I most certainly couldn’t have finished without youll My love to my family, you all mean so much to me. Finally, I share this with my husband, Matt, and my daughter, Allie. You both are the sun in my days and the warmth in my nights. I couldn’t breathe without you in my life. Thank you for choosing to share your love with me. TABLE OF CONTENTS LIST OF TABLES ............................................................................. vii LIST OF FIGURES ........................................................................... viii Chapter 1 . INTRODUCTION ............................................. 1 The Problem ................................................... 1 Problem Statement .......................................... 3 Purpose of this Research ................................... 3 Research Objectives ......................................... 4 Significance of the Study ................................... 5 Limitations of the Study ..................................... 5 Definitions ...................................................... 6 2. REVIEW OF THE LITERATURE ......................... 9 Introduction ..................................................... 9 The Field of Dietetics ........................................ 10 Professionalism in Other Fields ........................... 12 Medicine ................................................ 12 Teaching ............................................... 14 Occupational Therapy .............................. 15 Teaching Professionalism Within a Curriculum ...... 15 Summary ....................................................... 20 3. METHODOLOGY ............................................. 21 Introduction ..................................................... 21 Subjects ......................................................... 22 Introduction to the Delphi Technique .................. 23 Strengths ............................................... 24 Limitations ............................................. 25 Characteristics of the Delphi Technique for this Research .......................................... 25 Round One ..................................................... 27 Data Collection and Analysis of Round One ........... 28 Round Two ..................................................... 28 Repeat of Data Analysis for Round Three ............. 29 Round Three ................................................... 30 Data Collection and Analysis of Round Three ........ 30 Round Four .................................................... 31 APPENDICES Data Collection and Analysis of Round Four .......... Final Posting of Results .................................... RESULTS ...................................................... Introduction .................................................... Objective One ................................................. Objective Two .................................................. Round One ........................................... Round Two ............................................ Round Three .......................................... Round Four ............................................ Objective Three ............................................... Objective Four ................................................ Summary ....................................................... CONCLUSIONS AND RECOMMENDATIONS ...... Introduction .................................................... Objective One Conclusions ............................... Objective Two Conclusions ............................... Objective Three Conclusions ............................ Objective Four Conclusions ............................... Recommendations for Further Research ............. Summary ....................................................... Appendix A — Human Subjects Approval ............... Appendix B — Electronic mail to potential participants during the snowball technique. Appendix C - Round One questionnaire ............... Appendix D — Skeleton of electronic mails to potential participants for Round One ............ Appendix E — Reminder electronic mail for Round One ...................................................... Appendix F — Electronic mail apology regarding the problems with Round One ........................ Appendix G - Round Two questionnaire ................ Appendix H - Electronic mail requesting participation in Round Two ........................ Appendix I - Reminder electronic mail for Round Two ...................................................... Appendix J — Independent Raters ....................... Appendix K - Round Three questionnaire .............. 32 33 34 34 34 35 35 56 57 59 63 66 67 69 69 69 72 73 76 76 78 79 80 82 34 86 89 91 93 96 98 100 102 BIBLIOGRAPHY Appendix L - Electronic mail requesting Participation in Round Three .................... Appendix M - Reminder electronic mail for Round Three ................................................... Appendix N — Round Three data ......................... Appendix 0 - Electronic mail requesting Participation in Round Four ..................... Appendix P - Round Four questionnaire ............... Appendix Q — Reminder electronic mail for Round Four .......................................... Appendix R - Round Four data ........................... Appendix S - Thank you electronic mail to final round participants ................................... Appendix T — Snowball technique response .......... vi 105 107 109 119 121 125 127 140 142 Table 03th (D‘I LIST OF TABLES Page Response rates for each stage of this research project .......... 33 Seventeen professionalism categories determined from Round One ............................................................. 36 Ten titles with operational definitions from Round One data... 57 Round Three results ...................................................... 58 Round Four results ........................................................ 60 Summary of demographic information for final group of subjects .................................................................. 62 Final definition of professionalism ..................................... 63 Comparison of the structured approach and suggestions for improvement ............................................................. 64 Awareness comments .................................................... 66 vii LIST OF FIGURES Figure Page 1 The ABCs of Professionalism .......................................... 3 2 Snowball technique used for identifying potential subjects ..... 22 3 Modified Delphi method for this research study ................... 26 viii CHAPTER 1 INTRODUCTION The Problem Professionalism is generally defined as “the conduct, aims, or qualities that characterize or mark a profession or a professional person” (Merriam- Webster, 2001 ). However, it is much more difficult to define and identify the specific conduct or qualities that outline professional behavior as it relates to professionalism. For the field of dietetics, Rodriguez, Robinson, and Martin organized the term “professional conduct" to encompass “the wide range of attitudes, behaviors and characteristics that encompass professionalism” (2000). In addition, Payne-Palacio and Canter (2000) emphasize that professionalism is “showing respect and concern for people, being knowledgeable and keeping current with the latest research in one’s area of practice, adherence to the strictest ethical standards, and commitment to the profession.” (p. 101) Many professional organizations, including The American Dietetic Association (ADA), provide their members with a Code of Ethics. These standards of professional conduct give guidance to members in terms of ethical and moral behavior, honesty, integrity, fairness, altruism, and compassion (The American Dietetic Association, 1999). Yet, the dietetic educator is still short of the ability to identify specific professional behavior and its development within the structured dietetic curriculum. These personal characteristics, albeit more specific than the general definition of professionalism presented earlier, are still difficult to assess and are only a small piece of the professionalism puzzle. Therefore, it is difficult to determine if behavior standards such as these are being taught, exhibited, and practiced within the structured educational setting where one learns how to become an entry-level Registered Dietitian (RD) or Dietetic Technician, Registered (DTR). To further compound this problem, a lack of research in this area leaves a void in the ability to specifically define what professional behaviors are in addition to exploring their development within a dietetic curriculum. An educator's own expectations for the teaching and learning of professional behaviors may not match those of his/her colleagues or those of the very students that he/she serves. Because of this, educators are left to make ungrounded assumptions on where, or even if, professional behavior development is taking place within the dietetic curriculum. Rodriguez and colleagues attempted to begin laying the foundation to define professional behavior for the field of dietetics with their article: “Teaching the ABCs of Professionalism” (2000). In this article, the authors referenced a citywide preceptor meeting that took place during spring, 2000. During this meeting, a professional conduct model and teaching guidelines were developed for the Jacksonville (Florida) Dietetic lntems based on roundtable discussions with the internship preceptors; see Figure 1 for the model. This research coupled with the work of Rodriguez et al. attempts to establish a working definition of professionalism for the field of dietetics. Attitude Development of self Behaviors ‘ > Conveyance of self Figure 1. The ABCs of Professionalism (Rodriguez, Robinson & Martin, 2000). Problem Statement Dietetic educators have access to general definitions of professionalism, a Code of Ethics, and a professional conduct model, and yet are still left with a void of information regarding specific behavior expectations. Without this specific information, curricular development efforts meant to be inclusive of professional behavior expectations can only be cursory. Purpose of this Research As a result, this research aims to define and specify professional behaviors for dietetic practitioners. In the broader context, how do the leaders and futurists in the field of dietetics define professional behavior? Is there a specific, identifiable point in one’s career where the concept of professional behavior becomes a reality for the Dietetic Practitioner? By knowing this information and further expanding upon the professionalism definition in the future, dietetic educators can better design the undergraduate curriculum and related learning experiences to encompass a nationally representative definition of professional behavior. It must be noted that professional behavior development is an extremely complex and personal issue that is difficult to identify and measure. In order to best serve the students and move them toward professional success, dietetic curricula should include specific learning modalities for professional behavior development. These curricula may best serve the student when based upon a nationally representative definition of professionalism for the field of dietetics. This psychosocial element should not be left to “chance” within any curriculum that aims to serve in the complete development of the entry-level dietitian/diet technician. Research Objectives 1. To assemble a nationally dispersed group of leaders and futurists in the field of dietetics using the snowball technique. 2. To determine if the administration of the Delphi technique via the Internet is a reasonable alternative to the traditional paper-and-pencil administration technique. 3. To utilize the newly developed definition of professionalism for specific dietetic education recommendations. 4. To include a recommendation that has a component of when the dietetic practitioner becomes aware that professional behavior is a vital component of professional activities. Significance of the Study As we begin the twenty-first century, many dietetic education programs across the country are looking for new and innovative ways to teach their curricular material. With little theoretical research in this area, the most logical starting point is to define professional behaviors required of the dietetic professional. By identifying the point in time in which professional behavior becomes a conscious reality for the dietetic practitioner, recommendations can be made that specifically target the inclusion of professional behavior development into the dietetic curriculum or internship. When educators can move beyond an era of taking professional behavior development for granted, they can better prepare their students to be the entry-level dietitians/diet technicians that they purport their students to be. Limitations of the 3mm As stated earlier, professional behavior development is an extremely complex and personal issue that is difficult to identify and measure. As a result, the defining of professionalism in this research is only the first step in a series of research projects. This one research project cannot possibly include all of the nuances that make up the broad realm of professionalism. In addition, professionalism is a subject that can take on slightly different meanings for different people, different professional areas of study, different times in a person’s life, and different events in the world surrounding the person involved. Therefore, although the aim is to provide a more specific definition than has been attempted by others, no definition can be entirely inclusive of all these aspects, at all times. In addition the subjects involved in helping to develop this definition will only be a small cross-sectional sample of the entire membership in the profession of dietetics. Definitions American Dietetic Association (ADA): The U.S.‘s largest organization of practitioners specializing in health as it relates to diet/nutrition/food. Commission on Accreditation for Dietetic Education (CADE): A subgroup of Delphi Technique: Dietetic Educator: the ADA that specializes in the accreditation of dietetic education programs. A sequential process of idea solicitation, generation, and summary through carefully designed questionnaires. All questionnaires are developed from data that have been summarized from the previous questionnaire. The number of rounds of questionnaires developed and administered to a group of subjects varies based on the research project’s objectives (Linstone & Turoff, 1975). A practitioner who specializes in the education of future dietetic practitioners, such as school faculty or internship preceptors. Dietetic Practitioner: Those working in and professionally certified as a professional within the profession of dietetics. Dietetic Technician, Registered (DTR): A practitioner who has completed an Field of Dietetics: Internship Preceptor: accredited undergraduate program, a specified number of supervised practice hours (fewer than those required of the RD), and has successfully completed the national registration examination given by the commission on dietetic registration, the credentialing agency for the American Dietetic Association. The Dietetic Technician, Registered must complete a required number of continuing education credits in order to maintain the DTR status. A specialized field of work/study involving food and health issues related to diet and nutrition. A practitioner who specializes in the education of future dietetic practitioners by supervising work hours during the supervised practice experience. Registered Dietitian (RD): A practitioner who has completed an accredited undergraduate program, a specified number of supervised practice hours, and has successfully completed the national registration examination given by the commission on dietetic registration, the credentialing agency for the American Dietetic Snowball Technique: Association. The Registered Dietitian must complete a required number of continuing education credits in order to maintain the RD status. A research method utilized to gather a group of potential subjects by requesting everyone within a smaller group to recommend others, then repeating this process with each new name added to the list of potential subjects until the desired number of subjects is reached. CHAPTER 2 REVIEW OF THE LITERATURE Introduction Without a normative definition, it is difficult to achieve productive dialogue or consensus regarding the connotations, complexities, and nuances associated with professionalism (Swick, 2000). “One needs a normative definition that is precise and inclusive, and that can be utilized by a wide variety of groups.” (p. 613) Other professions, such as medicine and dentistry, have spent more time on the issue of professionalism than has the field of dietetics, but still relatively less time compared to other issues. It is important to recognize that certain characteristics help to define professionalism for all specialties but that (Swick, 2000) the key may not be in a dictionary definition of professionalism. Regardless of the field, it is generally accepted that a profession includes a well-defined body of knowledge, completion of a structured course of study, examination and certification or licensure, and oversight by some kind of regulatory agency, which has disciplinary powers (Sallot, Cameron, and Lariscy, 1998). Other criteria include intellectualism, a code of ethics, a comprehensive self-governing organization, greater emphasis on public service than self- interests such as profits, performance of a unique and essential service based on a substantial body of knowledge, broad autonomy, and having practitioners guided by altruism (Wright as referenced in Sallot, Cameron, Lariscy, 1998). Presented here will be what is known currently about professionalism within the field of dietetics and other professions, and how professionalism is taught within such curricula. The ng of Dietetics The Commission on Accreditation for Dietetics Education (CADE) of the American Dietetic Association (ADA) mandates that all dietetic education programs undertake continuous program improvement in order to earn program accreditation (Haessig & La Potin, 2000). In addition, undergraduate programs find themselves in a constant state of flux in an effort to provide an innovative curriculum for students that meets the ADA Standards of Education. These standards set forth specific Foundation Knowledge and Skills requirements that baccalaureate dietetic education programs must meet (Commission of Accreditation/Approval for Dietetic Education, 1997). Potential dietetic practitioners gain knowledge and skills through structured didactic educational experiences, mentoring, and progression through a series of modeling experiences prior to entering the workforce (Brakke et al., 1998). At the conclusion of the appropriate undergraduate program, students who wish to become a Registered Dietitian (RD) or Dietetic Technician, Registered (DTR) must complete a required number of supervised practice hours and related instruction called the Dietetic lntemship or Dietetic Technician Program. It is during the Dietetic Internship or Dietetic Technician Program that students are expected to make the final transitions necessary to become an entry-level dietitian/diet technician. It is only upon completion of the supervised 10 practice hours that students are eligible to sit for the national registration examination to obtain the credential of RD or DTR. With these credentials, the individual is recognized as a nutrition expert who is qualified to disseminate nutrition knowledge to the public. But one could argue having attained the characteristics essential to being called a professional. Payne-Palacio and Canter (2000) assert that with the title of professional comes a defined set of expectations including showing respect, caring, and concern for people, being knowledgeable and keeping current with the latest research in one’s area of practice, being well groomed, adhering to the strictest ethical standards, and demonstrating a commitment to the profession which includes membership in professional societies. By accepting membership into a professional society such as the American Dietetic Association, credentialed practitioners agree to abide by the strict ethical standards outlined in the ADA’s Code of Ethics. Specific behaviors listed in the Code of Ethics include conducting oneself with honesty, integrity, and fairness (The American Dietetic Association, 1999). In addition, Rodriguez and colleagues (2000) encompass the following four elements into their definition of professionalism: attitude, behavior, the conveyance of self, and the development of self. Attitude and behavior deal with one’s conduct and disposition as defined by Merriam- Webster’s dictionary (2001). Conveyance of self is communication through appearance and actions, and a plan for individual self-improvement is reflected in the category, development of self. In addition to the Code of Ethics, the ADA publishes Standards of Professional Practice for Dietetics Professionals, which 11 are broad statements describing minimum expectations that a dietetic professional may choose to follow that are specific to their practice settings (Brakke et al., 1998). For all dietetic professionals, the change from structured monitoring during the formal education process should shift to self-monitoring after entrance into professional practice. Therefore the individual dietetic practitioner is the starting point of ADA’s mission to serve the public (Brakke et al.) as seen in these standards. Professionalism in Other Fields Medicine. Similar to the field of dietetics, students in medical school are believed to be taught the knowledge, skills, and attitudes required of competent physicians. But are they being taught professionalism? Professionalism is an ongoing, self- reflective process that involves habits of thinking, feeling, and proper behaviors. As a regulatory agency, the American Board of Internal Medicine (1995) defines professionalism as comprising “those attitudes and behaviors that sustain the interests of the patient above one’s own self-interest. Professionalism entails altruism, accountability, commitment to excellence, duty and commitment to service, honor, and respect for others.” (p. 9) Swick (2000) defines professionalism as having nine behaviors that must be exhibited by a physician in order to be considered a medical professional. These nine behaviors are: 1. Physicians subordinate their own interests to the interests of others. 2. Physicians adhere to high ethical and moral standards. 12 8. 9. Physicians respond to societal needs, and their behaviors reflect a social contract with the communities served. Physicians evince core humanistic values, including honesty and integrity, caring and compassion, altruism and empathy, respect for others, and trustworthiness. Physicians exercise accountability for themselves and for their colleagues. Physicians demonstrate a continuing commitment to excellence. Physicians exhibit a commitment to scholarship and to advancing their field. Physicians deal with high levels of complexity and uncertainty. Physicians reflect upon their actions and decisions. (p. 613) At the Northeastern Ohio Universities College of Medicine, a Professional Development Assessment Form was created that contained eight categories for professionalism: reliability and responsibility, honesty/integrity, maturity, respect for others, critique, altruism, interpersonal skills, and psychological/chemical impairment (Gibson, Coldwell, and Kiewit, 2000). Arnold, Blank, Race and Cipparrone (1998) identified that other than this, little research has been done within the medical literature that explores ways to measure professional attitudes and behaviors. However, Ginsburg and colleagues (2000) recognize that even the evaluation of behaviors that is done, is often inadequate. 13 Teaching. True professionalism for teachers was defined by Spady and Schwahn (1999) as a mixture of: competence and values, talent and integrity, principles and performance, contribution rather than wants, learning rather than knowing, and openness rather than opinion. “Genuine professionals never lose sight of the beliefs and principles that define how they think, who they are, and what they do.” (p. 27) Their view of professionalism involves 10 principles: connection, future focusing, inquiry, clarity, inclusiveness, accountability, improvement, win- win, alignment, and contribution. Morehead (1998) found that most teachers encounter difficulties and possibly are released from their teaching contracts — not because of an inability to teach, but rather because of a problem with meeting the professional expectations of being a teacher, such as being a role model, community activities, interpersonal relations, etc. In this discussion with 60 school administrators concerning the professionalism of teachers, the administrators found it unsettling to work with teachers who demanded certain behaviors of others but lacked the ability to demonstrate the behaviors themselves. Included with this list of professional behaviors were a positive attitude/friendliness, being a good professional teacher/role model, relationships with other professionals/non-teaching staff, attendance/punctuality and dress, and confidentiality/discretion, with the most common mistakes of beginning teachers being related to the use of inappropriate language. 14 Occupational Therapy. Fidler (1996) puts forth the following requirements for the occupational therapist exhibiting professionalism: regard for the dynamics of human relationships and interpersonal skills, an integration of attitudes, beliefs, and values that reflect personal integrity, empathetic regard for others, a sense of responsibility to contribute to the welfare of others, and a respect for different points of view. In addition, it is noted that an individual’s professional development goes beyond the discipline related knowledge and technology, and stretches into personal development of professionalism standards. Kasar & Muscari (2000) believe that professional behavior development begins during the formal educational process with specific individualized growth, development, and progression throughout this process. They provide an eight stage conceptual model for professionalism development in the Occupational Therapy student: beginning student, senior student, new graduate — orientation stage, graduate — novice stage, role identification stage, collaborative stage, proficient stage, and reflective stage. Each stage has a separate and distinct timeframe and requires learning opportunities for professional behaviors and careful nurturing by educators and clinical supervisors. Teaching Professionalism Within a Curriculum Professionalism is best not left to chance, but rather addressed within a full-spectrum curriculum that fosters students” engagement with specific content and integrated experiences all based within the knowledge, skills, and methods 15 central to medical education (Wear and Castellani, 2000). Bowman (1998) believes that professionalism is tacked on to the end of other courses, ignored entirely, or offered only as optional courses. Traditional medical residency programs have given little attention to how values, behaviors, and attitudes are cultivated (Markakis, Beckman, Suchman, & Frankel, 2000). Ginsburg and colleagues (2000) state, “There appears to be an unrealistic expectation that students will arrive at medical school lacking in knowledge and skills but with a full complement of appropriate behaviors that require no further attention.” (p. S7) The traditional approach to solving this is to identify and define the attitudes and concepts related to professionalism but the methods are so abstract and definitions are idealized to the point that discussions tend to revolve around people rather than behaviors, implying that professionalism represents a set of stable traits. Ginsburg and colleagues continue by stating “we are doing a disservice to our students by not providing explicit feedback in this domain, thereby missing valuable opportunities to bring about awareness and improvement.” (p. S6) However, it is identified that supervisors may be reluctant to provide negative feedback regarding unprofessional behavior, in addition to the difficulty inherent to identifying and verifying the behavior. Learning professional behaviors requires practice, experience, role mentorship, and evaluative feedback (Kasar and Muscari, 2000). This feedback has inherent problems when faculty are providing the assessment, but Ginsburg and colleagues assert that assessment of professional behaviors by peers may provide a solution to this problem as peer contact is often frequent and close. 16 One key way to develop professional behaviors in students identified by Crist (1986) is through modeling during the fieldwork experience. Hira (1996) challenges this by asserting that the teaching of these concepts should not be limited to vocational/business courses or to practicum/internship experiences but rather should start early (as early as middle school) and should be a part of all courses. To support this, Hira cites studies that provide evidence of the family environment in early childhood as being the most important influence on one’s moral and ethical makeup (Haberstram as referenced in Hira, 1996). “Educators must reaffirm the importance of basic values such as responsibility, honesty, promise keeping, free expression, and nonviolence” due to the fact that teachers of all courses serve as role models for their students. (p. 7) Teachers need to be moral agents that constantly role model such behaviors as honesty, a sense of justice, and caring throughout the educational process (Campbell, 1997). Campbell holds strongly to the notion that this process cannot be left to chance but must be deliberately developed during the education of teachers, specifically. In agreement with this, Odom (1997) asserts that dental faculty have an obligation to set standards for expected professional behaviors, to reward positive behaviors, and to reinforce positive behaviors in the event they are compromised. Faculty must guide and reinforce academic integrity and professional behavior as well as provide ethics instruction. Odom (1997) believes that dental schools need to consider ways to reduce stress, as this can have a direct impact on ethical and professional behaviors demonstrated by over-stressed students. It is believed that this is a long-term commitment to 17 promoting professionalism, and not something that should be set-aside after a few years. Clear expectations should be established and faculty must act as role models (Beemsterboer, 1997). With clear educational goals that are learner- centered, professionalism can support the attainment of professional values, and feedback regarding these behaviors is less likely to go unnoticed or be devalued by the stressed learner. At the University of California, San Francisco, clear criteria for assessing professionalism during clinical experiences are published that assert these attributes as being just as important as the discipline’s knowledge and skills (Loeser and Papadakis, 2000). Undergraduate dietetic education programs, Dietetic lntemships, and Dietetic Technician Programs find themselves under increasing pressure from their host institutions to achieve increased accountability with regard to student learning and conduct. Programs must assess quality by asking such questions as: “How do we know that students are learning what we think they are? And how do we know that our program is meeting community needs?” (Haessig & La Potin, 2000). Following the guidance of Rodriguez and colleagues (2000), professional behavior can be informally taught through modeling in addition to a structured approach that is designed to increase students’ sensitivity to the impact of professional behaviors, and help them identify and develop the behaviors and ethics that increase their chances for professional success. Dietetic educators need to be able to assure that the innovative curricula they are designing meet the learning needs of their students. However, educators must not forget the influence of the informal settings on the 18 culmination of student learning. Informal contact with undergraduate faculty and Dietetic Internship Directors outside of the classroom, involvement in student clubs, membership in professional associations, and attendance at professional meetings helps to enrich and balance the education and teaming experience for the student (Payne-Palacio & Canter, 2000). Within the medical curriculum, Wear and Castellani (2000) state that teaching professionalism cannot be left to chance but rather be integrated with content, significantly engaging students in the process of becoming a fully functioning professional. Curricula such as that outlined by Faulkner and McCurdy (2000) support the thought that medical schools have a duty to teach social responsibility and professionalism within their curricula. “The development of professionalism has different curricular implications, with different assumptions about how to move students from here to there. It invariably asks us to examine the curriculum in light of the following questions: What is the nature of the knowledge that all students, regardless of their career goals, are expected to learn in medical education, and what values are embedded in this knowledge? How does this knowledge relate to compassionate, communicative, and socially responsible doctoring? If it does not, what knowledge is associated with these habits, and where and how should this knowledgeable appear in the medical curriculum?” (Wear and Castellani, 2000). (p. 603) Haessig and La Potin (2000) term this as outcomes assessment and point to an important CADE mandate which asserts that dietetic educators move 19 beyond simple documentation of knowledge and competency and begin to address improvement in teaching and learning. By affirming that content and teaming experiences provide the desired impact on student learning, faculty can then suggest further changes and teaching methods to enhance that learning. “Articulating outcome measures for student expectations and making them measurable are essential components to the assessment process.” (p. 4) Summam How we handle ourselves in the workplace, including: doing your job conscientiously, fulfilling your contract or job description, coming to work on time and maintaining a business attitude and demeanor, and holding yourself to high standards of character and behavior, comprises a small part of the complex role of professionalism (Carroll, 2001). For some, professionalism traits may be easy to recognize but much more difficult to define (Swick, 2000). “Future efforts at understanding professionalism, and future methods of evaluating professionalism, must focus on behaviors rather than personality traits or vague concepts of character" (Ginsburg et al., 2000). For the profession of dietetics, a team approach is required, each member of the team being a true professional: concerned, knowledgeable, respectful, caring, ethical, committed to the profession, and active in the professional organization (Payne-Palacio and Canter, 2000). 20 CHAPTER 3 METHODOLOGY Introduction The need for this research was determined through personal reflection on teaching and learning in the undergraduate dietetic curriculum, personal communication with dietetic educators nationwide, and through a literature review that revealed a lack of significant previous research on professionalism and professional behavior development specific to the profession of dietetics. Utilizing the ideas initiated by Rodriguez and colleagues (2000) in Jacksonville (Florida), an attempt was made to conduct this research with a larger, more nationally disbursed sample of leaders and futurists within the profession of dietetics. Therefore, the research objectives were focused on defining desired professional behaviors for the dietetic professional; identifying a point in time in which professional behavior becomes a reality for many dietetic practitioners; and identifying areas within the dietetic profession where professional behavior development can be improved. In addition, the Delphi Technique would be administered via the Internet, a research method that has not been reported in the literature to date. Human subjects approval was obtained from the University Committee on Research Involving Human Subjects at Michigan State University prior to beginning this research (see Appendix A). 21 Subjects Potential participants were identified using the snowball technique, see figure 2. An electronic mail message was sent to two long-term dietetic educators at Michigan State University. These two educators, chosen because of their understanding of the field of dietetics, were each asked to identify three to four dietetic professionals that they considered to be leaders and futurists in the field of dietetics. Each of these were then sent an electronic mail that asked them to identify three to four more people with the same criteria, see Appendix B. Each request maintained a ten-day deadline for submission of names as potential participants for the study. Two long-time *— dietetic educators A B Each named three or four leaders/ 0 D E F G H ‘— futurists in the field of dietetics. Each person then I L O R U x <— named three or four more in the field. J M P S V Y I This process was repeated until a K N O T W 2 minimum pool of 150 potential subjects was collected. Figure 2. Snowball technique used for identifying potential subjects. 22 Delbecq, Van de Ven, and Gustafson (1975) report that a Delphi can be done with as few participants as 10 or as many as several hundred. It was determined that the more participants added, the better chance for an increased understanding of professionalism for the field of Dietetics and therefore no less than 150 names would be gathered via the snowball technique. Consequently, the request for submission of names was repeated with each new name submitted until the minimum of 150 was reached. However, since the 10-day deadline had not expired for all of those contacted for submission of names, new names continued to be submitted until the final deadline had passed. As a result, a total of 221 names were submitted as possible participants in this research study. Introduction to the Delphi Technigue The Delphi Technique was first used in the early 1950s to estimate the probable effects of an atomic bombing of the United States (Linstone & Turoff, 1975). The Delphi technique is primarily concerned with matching opinions from a broad “advice community” of experts. “The Delphi Technique is a method for the systematic solicitation and collation of judgments on a particular topic through a set of carefully designed sequential questionnaires interspersed with summarized information and feedback of opinions derived from earlier responses” (Delbecq, Van de Ven, & Gustafson, 1975, p. 10). The Delphi Method was chosen for this particular research study due to the broad complexity of the issue; the need to represent the collective opinions of a diverse 23 group of leaders in the field; and a lack of a formal definition and measurement parameters of professional behavior provided by previous research in this area. “The Delphi process appears to provide the individual with the greatest degree of individuality or freedom from restrictions on his expressions” (Linstone & Turoff, 1975, p. 7). This Delphi characteristic was particularly important to this research effort due to the already identified complexity associated with professionalism. It was believed that subjects needed a setting in which they would not be inhibited in saying what they wished on a topic that may contain personal issues. Delbecq and colleagues (1975) identified the following characteristics of the Delphi Technique that facilitate or inhibit the decision-making performance: Strengths. 1. Writing ideas without face-to-face contact produces a large quantity of ideas. Writing responses, versus verbal responses, forces thinking of the complexity of the problem and leads to high quality in the ideas. Respondents are blind to the responses of others allowing for freedom from conformity pressures. The technique is uniquely valuable for obtaining responses from participants who are geographically dispersed. There is inherent flexibility in that respondents can participate at a time most convenient to them. (p. 34-35) 24 Limitations. 1. Possible feeling of detachment by respondents due to the lack of social-emotional rewards. 2. Possible communication and interpretation differences due to the lack of verbal communication. 3. The majority-rule procedure that identifies group priorities does not lend itself to conflict resolution. Incompatible ideas are handled simply by pooling and are often lost within the final summaries. (p. 90) Characteristics of the Delphi Met_hod for Thisjw This work attempted to add a small, modern twist to the conventional Delphi as outlined by Linstone & Turoff (1975). The conventional Delphi Technique utilizes paper-and pencil questionnaires sent to a large respondent group. For this study questionnaires were offered via the lntemet for submission by the participant pool from August 2001 through October 2001. All respondents answered each round of the Delphi separately. See Figure 3 for a pictorial description of this research project. As a measure of reliability, all rounds of the Delphi method were pilot tested with graduate students to check for clarity and comprehension prior to beginning the next round. Feedback from the pilot testing was used to modify the questionnaires as needed. Content validity was measured through the research committee developing the content of the first questionnaire. The respondent group drove all subsequent questionnaire development. 25 After identification of potential subject pool, an electronic mail letter was sent explaining the purpose of the research, how the Delphi technique would work, and asked for their participation. l Development of an initial questionnaire to assess personal definition of professional behaviors by respondent pool was completed and pilot tested, and access was provided via the World Wide Web for electronic submission, electronic mail submission, or the US. Postal Service. I Results were summarized and a second questionnaire was developed and pilot tested for Round Two based on the results from Round One. This respondent pool was then asked to define and illustrate each of the 17 professionalism categories and give a preliminary ranking to the 10 that they felt to be most important. Due to the poor quality of responses, the data from Round One were re-analyzed and ten professionalism categories and their operational definitions were presented in Round Three. Participants were asked to rate each category in terms of high, medium, or low importance to the profession. I Finally, participants were asked to give final consideration to the results in the final round. In addition, participants were asked: . Demographic data (gender, highest formal education level completed, professional registration, approximate number of years practicing in the field of dietetics, current and primary area of practice, geographical location, and do they work directly with students?) 0 When did they believe professional behaviors became a reality in their life? The website contained a posting of the final results of the data. Figure 3. Modified Delphi method for this research study. 26 Round One An Internet Service Provider was contacted to host the website. Appropriate fees were paid and the site was functional within 24 hours. The Round One questionnaire was posted to the website www.dieteticprofessionalism.net. See Appendix C for the Round One questionnaire. Those on the list of potential subjects were contacted via personal electronic mail to ask for their participation in a study utilizing the Delphi method, see Appendix D. Participants were given 10 working days to provide their responses. A reminder electronic mail note was sent three days before the deadline, see Appendix E. Problems that occurred during Round One include: 1. Two days prior to the first deadline, the server maintained by the ISP stopped working causing the website not to work for participants, therefore the deadline was extended by one week; 2. The website remained nonfunctional for five days, however when it was working again, the ability to submit responses no longer existed; 3. Therefore, the Internet Service Provider was changed and those who had not submitted were sent an electronic mail apologizing for the inconvenience and instructing them to submit responses via electronic mail to the researcher until the new website was functional, in time for Round Two, see Appendix F. 27 Data Collection and Analysis of Round One As electronic submissions were received, the responses were printed and immediately deleted from the server. The printout of the response was then cut at the point where the participant’s name was listed. The piece of paper with the response was filed for later analysis. The piece of paper with the participant’s name was filed separately so that the respondent would be included in Round Two. Data were recorded and maintained utilizing a Microsoft Excel spreadsheet. Seventy-four responses were categorized according to similar traits and professionalism categories began to be identified. As these categories emerged, they were recorded and used to further analyze the responses as more responses were submitted. Once all responses were categorized, categories were combined as appropriate to eliminate duplication and to clarify the wording of each category. In an effort to trim time and workload for participants, categories were consolidated as much as possible without losing meaning. A total of 17 professionalism categories remained and were used for Round Two. Round Two After the first sets of responses were submitted, and the results summarized, a new questionnaire was developed for the respondent group (n=74) based upon the results, see Appendix G. The respondent group was sent an electronic mail letter requesting their assistance with Round Two and directing them to the new website www.dieteticprofessionalism2.net, see Appendix H. 28 Subjects were given the choice of an electronic submission via the lntemet, an electronic mail submission, via the Internet with an attachment, or submission via the US. Postal Service. All of the respondents chose to submit electronically via the Internet. Respondents were asked to define and illustrate each of the 17 Professionalism categories, then give a preliminary ranking to the 10 that they felt were most important. Participants were given 10 working days to provide their responses. A reminder electronic mail note was sent three days before the deadline, see Appendix I. During the data collection phase of Round Two, it became clear that the data returned were poor in quality and not appropriate for the research objectives. As a result, it was determined that the best route would be to return to the Round One data and create a new questionnaire, termed Round Three, and to disregard the data returned for Round Two. See Chapter 5 for a complete discussion regarding the reason for doing this. Repeat of Data Analvsis for Rognd Threg Responses from Round One were printed onto one side of a 4x6 inch index card. Three copies of these cards were printed and distributed to three independent raters, see Appendix J. The independent raters were instructed to categorize the cards into 10 categories and then create their own title and operational definition of each category. As the piles of cards were returned, the card piles were combined as much as possible, using the titles given as well as the similarities of the cards within each pile. The piles were then organized in 29 order of the most agreement, all three raters had a similar title and operational definition, to the least agreement. Ten categories with titles and operational definitions were created as determined by the independent raters. To compensate the independent raters for their time, each rater was given $15.00 in gift certificates to a local coffee shop or bookstore. Round Three The subsequent responding group from Round Two (n=49) was then given the opportunity to rate the ten categories and operational definitions as Round Three, see Appendix K. Respondents were asked for their participation and to rate each category as low, medium, or high in terms of their perception of importance to the profession of dietetics, see Appendix L. Respondents were also instructed to provide further comments regarding the categories as they so desired. Participants were given 10 working days to provide their responses. A reminder electronic mail note was sent three days before the deadline, see Appendix M. Data Collection and Analvsis of Round Three Data returned were maintained on a Microsoft Excel spreadsheet, see Appendix N for Round Three data. Due to the low, medium, and high rankings provided by the respondents a numerical value of 1, 2, and 3 respectively was assigned to each professionalism category and counting of responses for each category was completed. A mean value was determined. The operational 3O definitions of the categories were clarified and strengthened based on comments provided by respondents. Finally, the categories were listed in descending order of mean rankings. Two respondents sent electronic mail comments stating a concern over the “medium” category showing on the website as the category that was already checked. Although the “radio button” moved to the specific category they chose, these two respondents felt that the data would be skewed due to this initial button being present. However, due to the limitations of the web authoring program used in creating the website, Adobe PageMill 3.0, one of the radio buttons had to be checked in order for the buttons to work at all. Checkboxes were not an option because they allowed for more than one choice to be checked at one time, where radio buttons allowed for only one option to be checked. In addition, drop- down boxes were not an acceptable option as these may have caused more confusion. As a result, the radio button was the best way to collect the data and it was determined that this “auto choice” drawback was an acceptable risk. Round Four In Round Four, respondents (n=42) were asked for their participation, see Appendix 0 and to rate how well they believed the profession of dietetics is currently meeting the operational definitions for each category above expectations, on target, or below expectations, see Appendix P for the Round Four questionnaire. If the category was rated as “below expectations”, the respondent was asked to provide suggestions for improvement. 31 For this research, the final round of the Delphi method was expanded to include the gathering of demographic data: 1. 2. 8. Gender (male, female); Highest formal education level completed (bachelors, masters, doctoral); Registration (RD, DTR); Approximate number of years practicing in the field of dietetics; Current and primary area of practice (clinical, foodservice, school faculty, consultant, community/public health, other); Geographical location (Northefiastem United States (US), Southeastern U.S., Midwestern U.S., Southwestern U.S., Northwestern US, Western US, other); Do you currently work directly with students (undergraduate, graduate, or interns)? (yes, no); and When did you first become aware of professionalism in your own life? Participants were given 10 working days to provide their responses. A reminder electronic mail note was sent three days before the deadline, see Appendix Q. Data Collection and Analysis of Round Four The responses for Round Four (n=35) were maintained on a Microsoft Excel spreadsheet, see Appendix R for the data. Within two days, thank you e- mails were sent to those who completed the final round, see Appendix S. 32 Final Posting of Results Respondents were notified via electronic mail when final results of this research study were posted on the study’s website www.dieteticprofessionalism2.net. See Table 1 for a complete tabulation of response rates. Table 1. Response rates for each round of this research project. M Number Contacted Number Resgndlng Resgnse Rate 1 180 74 41.11% 2 74 49 66.22% 3 49 42 85.71% 4 42 35 83.33% 33 CHAPTER 4 RESULTS Introduction This research attempted to address the following research objectives: 1. To assemble a nationally dispersed group of leaders and futurists in the field of dietetics using the snowball technique. 2. To determine if the administration of the Delphi technique via the lntemet is a reasonable alternative to the traditional paper-and-pencil administration technique. 3. To utilize the newly developed definition of professionalism for specific dietetic education recommendations. 4. To include a recommendation that has a component of when the dietetic practitioner becomes aware that professional behavior is a vital component of professional activities. Results presented here are categorized according to the corresponding research objective and numerical results are rounded to the nearest percent. See appropriate table for exact percentages. Raw data can be found in the appendices. Objective One The snowball method was used for gathering a group of potential subjects for this research. A total of 138 identified leaders/futurists in the field of dietetics 34 were contacted requesting their participation in the snowball technique. Sixty- two responded and submitted a total of 221 names for the potential subject pool, of which 81% could be used (n=180). See Appendix T for a pictorial description of the response to the snowball technique. Objective Two Objective two involved the administration of the Delphi technique using the lntemet rather than the traditional paper-and-pencil administration method. For every Delphi round, participants were given the opportunity to submit their responses via the Internet or to print the questionnaire and submit via the US. Postal Service. All respondents chose to submit electronically. During Round One, the website became nonfunctional two days prior to the deadline. Due to the problems that occurred with the website, participants were offered the opportunity to submit their responses via electronic mail attachments to the researcher until the new website was functional, twelve (16%) took advantage of this opportunity. W Round One asked participants to define professionalism, as it relates to professional conduct for the field of dietetics. Of the 180 potential participants contacted for Round One, 74 completed the task (41%). Responses were categorized and 17 professionalism categories were determined from the data. These 17 categories were determined by the grouping of similar responses. For example, the category, adhering to ADA’s code of ethics, contained such 35 responses as “adheres to ethical and moral standards”, “adheres to the code of professional conduct for the profession”, and “adherence to the code of ethics for the profession of dietetics” whereas the category, maintains a commitment to excellence in the profession, contained such responses as “respecting and representing the profession as a whole”, “respect for the mission and values of the profession”, and “deliberate enthusiastic and passionate act of commitment and responsibility for a chosen profession”. See Table 2 for a complete listing of the categories and the associated responses. These 17 categories were provided to the subjects in Round Two. Table 2. Seventeen professionalism categories determined from Round One. Professlonalism Category Assoclated responses from Round One data 1. How one Iapproaches thelr work. low maintenance work style that results in high quality work with little supervision behaviors needed for effectiveness in a work environment if you want to be viewed as a professional, cannot work like an hourly employee and watch the clock consistency of conduct in a work/job setting which complements national accrediting body's mission/goals planning, implementimnd evaluating your work encompasses job performance conducts self in a business manner doing more than first a job conscientious adherence to the values, policies, and rules of one's workplace as well as faithfully carrying out responsibilities delineated in one's job description 36 Table 2 (cont’d). Ihardworking a career, not just a job not a 9-5 attitude, nor does it mean you sleep in your office conscientious preparation for and carrying out of one's professional duties and responsibilities taking pride in one’s work, no matter what it is a professional does not simply work a 9-5 job conduct work which is honest, reliable, accurate, and up to date values her expertise and expects fair pay for services rendered skilled in planning and organization of work and [projects Other professionals (MDs, PTs, etc) do not watch the clock and often have more respect the manner in which one presented oneself in ractice more than just doing a job and getting paid; how we roviding the service E0 the job and how we conduct ourselves while going the extra mile timeframes in work adheres to policies and procedures set forth by Iemployer Ibusiness-like manner developing a business sense 2. Adhering to ADA's Code of Ethics. moral and ethical beliefs are an indication of your rofessional integrity adhering to Iicensure requirements of the state, if applicable ethics/integrity acts in an ethical manner adheres to and ascribes to the ethical conduct code set forth by ADA and its sister organizations adhering to a code of ethics and standards of practice established by the profession as well as [personal standards 37 Table 2 (cont’dL standing up to high ethical values - doing the right thing! adherence to the Code of Ethics for the Profession of Dietetics adheres to the code of professional conduct for the rofession ethical conduct meeting the code of ethics and standards of rofessional performance of ADA [personal ethics and morals follows the ADA Code of Conduct following the Standards of Professional Practice in the performance of work, adhering to the Code of Ethics adheres to ethical and moral standards adherence to impeccable ethical constructs - especially as it applies to making profit off of nutrition based products and advice ethical work behavior conduct that complies with the ADA Code of Ethics nethical use of the proficiency and skills in our practice of dietetics abiding by the ADA Code of Ethics and Standards of Practice at all times. act ethically and with integrity adhering to the ADA Code of Ethics and scope of ractice and having integrity moral and ethical standards of practice that include honesty, loyalty, follow through, respect, and quality of effort [ethical at all costs conduct the work in an ethical and competent manner code of ethics serves as the base for defining rofessional conduct follows the Code of Ethics show good work ethics ethical 38 Table 2 (cont’d). requires one to follow the code of ethics as defined Iby the ADA and personally follow a high standard of morals and values Ethical in work practicing according to the Code of Ethics for the Profession of Dietetics as well as the guidelines outlined in the Standards of Practice ractitioners in all their work lpLersonal and work ethic adhered to by dietetics doing it all in accordance with the code of ethics of the ADA ethical, honest behavior set of conducts that ensure all member of the Pofession behave in similar and ethical ways demonstrates ethical, productive, quality practice adhering to the ADA Code of Ethics and application of other ethical standards for practice in ones field of specialization abiding by the Code of Ethics of the ADA mandates ethical behavior [re 292t- 3. Treating others with [nonjudgmental [listening and beiryq open-minded [providing service objectively and without bias recognizes and respects differences In all cases, others are treated with integrity, honesty, and respect, including self respect maintains respect and support for other nutrition professionals, allied health professional, and the consumer objectivity and fairness unbiased manner respect for individuals the respect that l have for myself, others respect for the rights and dignity of others respect is provided to all human contact respect diversity sincere acceptance of others, with regard to race, creed, sexual orientation, or economic status 39 Table 2 (cont’d). respect inclusive and not derogatory to others respecting the wisdom and experience of those who have been in the field for a long time values a science-based and a culturally competent approach Whether working with patients/clients, staff or administrators, educational and cultural diversity requires careful listening skills and honest, objective responses culturally sensitive respects others ideas and thoughts showing respect for divergent opinions and willing Fengage in uncomfortable dialogues (exploring opposing points of view can give us a greater (perspective and understanding) supports peers and patients in a respectful manner practicing with a respect for others - clients, patients, coworkers, supervisors, subordinates respect for others (clients, coworkers) recognizing nutrition diversity needs as appropriate 4. The attitude one iconveys to others. demeanor COU rteou S if there is a problem, the true professional will find a way to solve things and not just complain [providing a level of service/practice which matches what you believe to be right and ethical ability to listen and react to input conclusions are drawn based on fact and nothing else acts as coach or facilitator, not domineering or dictating to clients, not crossing the line between professional and personal relationship [being the best you can be and doing the best in all sfiuafions graciousness, good social skills, and above all good manners, which seem to be lacking in some ”professionals" today 40 Table 2 (cont’d). how you present yourself to the world and the respect you gain by your overall behavior which makes one successful dedication of spirit (a positive attitude to make things the best they can be) to the art and science of nutrition and dietetics mandates that personal food preferences and biases are not included in the presentation of the facts efficient dedicated intuitive and reflective disagreements are about ideas or facts, not ersonalities or individual needs behavior needs to conform to accepted norms both in own professions and in others similar to ours defends decisions actively searches for new opportunities, turning challenges into opportunities if work needs to be done, do it! the attitudes that l project externally, as well as Iinternally, my willingness to listen, to share The behavior may vary according to work settings, lknowledge, and confidence in oneself Ihow one thinks, feels, and acts appears approachable and helpful confident way of thinkigg way of actigg leasantness helpful leasant actions and reactions Ipositive thinker Ipositive, proactive, and constructive in attitude and behavior conduct, qualities, and goals manner in which a person behaves the way we treat others responds flpropriately under stress and to criticism courteous 41 Table 2 (cont’d). not only be concerned with own conduct, but with conduct of others in profession attitude and conduct during professional encounters 5. How one physically resents themselves. poise voice modulation appropriate business attire is essential to project a professional image to the public roper physical and moral fitness characteristics that promote credibility and build respect amonfleers appearance the visual side includes dress and how a dietitian Flesents the profession the care I give my body with my life style choices such as healthy eating and being physically active, my character, appropriateness of dress for the situation, the manner in which I carry myself [practices sound nutrition in his/her personal life setting an example by practicinuhat one preaches A professional lives a life that is exemplary of the [practices they profess while considerable discussion over what constitutes acceptable attire, hair, and body piercing; including body rings and tattoos, has been engaged in, the professional person strives for an appearance that does not make others uncomfortable meat and clean - does not cause employer, colleagues, or patient/client to be uncomfortable dress has become more casual - more home like |practicing what I preach, including maintaining my appearance so as to demonstrate this stylish lpersonal presentation that is moderated and respected by the mainstream approach toward others and your profession think and agglobally role models of good health and nutrition how you present yourself 42 Table 2 (cont’d). appropriate presentation of professional, physical, and social self and the ability to adjust such to the setting . Effectively ommunicatin with thers. work well with co-workers in both written and oral communication ability to communicate at a diversity of levels ability to articulate (orally and in writing) ideas, outcomes, clearly and in a meaningful way communicate consistently being able to communicate have good communication skills communicate with respect communicating in a thoughtful, polite, and appropriate level for the client effective communication and interpersonal skills 7. Functioning as a [part of a team. interdisciplinary team collaboration and trust assisting co-workers/peers as needed acknowledging other professionals with knowledge regardirg food and nutrition understands goals of others and works with them to meet common goals recently I have realized the importance of being non- olitical as a part of professionalism [beinlsupportive of other dietitians Hot to isolate yourself into dietetics only - but to work with other health professionals to implement nutrition standards to teach other professionals the role of dietitians cooperation is essential considers natural resources as well as human and financial resources in decisions works across disciplines collegiality attempts to work well with others 43 Table 2 (cont’d). partner fairly, justly, without wanting something in return, without desiripg selfish gain works with others to manage limited resources; creative in use of resources recognize and support other dietetic professionals in their endeavors able to work with others in difficult circumstances as well as easy situations recognize the value and contributions of each team member professional conduct is displayed by one who can participate as part of a team or group of people, coming from all different backgrounds, and can review items together for what they are I8. Acting resmnsibly. commitment to safe practice assumes responsibility for actions responsible professional behavior behaving in a responsible manner assumption of responsibility for critical tasks such as atient care and patient care outcomes accept responsibility for actions and programs practicing in a responsible fashion with the utmost integrity 9. Maintains a ommitment to xceflencelnthe rofession. attention to detail Iexcellence Isets excellence as a minimum standard and helps others achieve the same standard awareness of ones areas of expertise shows value to patients/clients deliberate enthusiastic and passionate act of commitment and responsibility for a chosen mfession supports the mission of the profession and helps the rofession achieve its vision 44 Table 2 (cont’d). dedication to the science and art of nutrition and dietetics you cannot sit by and watch the parade, you have to join in and contribute to the growth and development of the profession supportiryq the core values of the dietetics profession professional conduct considered appropriate to the situation for someone in a given profession respect for the mission and values of the profession uphold the dignity and honor of dietetics as a [profession by thoughts, words, and actions participation in public policy by exercising one's right to vote and by influencing legislation that affects the profession on dietetics form a network of alliances to support you and for whom you provide support on professional and Lpersonal issues, cannot operate in a vacuum involves a commitment to the profession respecting and representing the profession as a whole committed to the profession lhard decisions for professionals to stay in positions they do not like (and run the risk of not doing them well) and therefore lower the bar for all in the dietetics profession. This lowers the public's trust in dietetics as a credible profession. embracing the mission of ADA commitment to be an excellent representative of one's profession promotes the broader field of dietetics and nutrition science rather than personal views on controversial issues (alternative med, supplements, etc) believe in the profession and support the ADA mission to promote optimal nutrition and well-being for all people supporting standards of the profession of dietetics willingness to engage in professional service activities dedication to the highest standards of conduct, 1expression, knowledge, and volunteerism %ssion for the field credible 45 Table 2 (cont’d). my passion for dietetics, and commitment to do my part, in whatever capacity presents itself to continue to move our profession forward working within acceptable framework to change or modify the standards of the profession working to maintain a positive image for dietetic Imafessionals promoting the profession to consumers and other healthcare providers part of a profession (occupation requiring advanced training) keeping an open mind when I hear "new/latest/best ever/etc” diet/nutrition ideas espoused until I have time to evaluate them against valid research pledges allegiance to a recognized, specialized lpractice 10. Showlng Ieadershl . regarded by others as a leader and mentor being involved in formulating solutions to issues volunteering to promote the professional association which directs the practice of the profession volunteers within the professional association and within other associations/groups or provides volunteer service to promote global nutrition well- beiqu being active in some way (local, state, or national level) in professional organizations that advance the field of dietetics and the dietetic professional lbecomes a role model for the career and for students completing coursework for nutrition and nutrition- related demees articipation in professional groups ‘fiarticipating in profession at local, state, or national levels to enhance profession and keep it on cutting we lparticipating in local, state, and/or national association activities jbeing actively involved in the professional or anization involved in professional activities 46 Table 2 (cont’d). a member of the ADA contributing to professional organization in some way involvement in professional organizations works to further the profession; lbeing actively involved in our professional association, both locally and nationally by attending continuing education meetings, serving on committees, etc working to advance the profession at the local, state, national and/or international levels adding voice to others with similar interests to move [profession ahead leadership 11. Having a ustomer-centered lghflosophy. concerned for the individuals served, both from (patient/organization perspectives consideration of peers and clients needs reflects value for human and material resources prioritize to meet the needs of your clients - colleagues, students, patients, other healthcare professionals, and administration you are there to make a difference for your patients, co-workers, and administrators meets needs of client/customer lhumanistic dedication to and advocacy for your clients and atients thoughtfulness rprovide the best services we can individually not economically influenced lmplies that one puts the good and the benefits of lothers before their own self-interest [individualiziggservices as appropriate [putting responsibility ahead of ones self interest concerned about the welfare of others committed to the clients we serve thoughtful and tactful input for meetings and planning focuses on patient/client/customer needs 47 Table 2 (cont’d). act in the interest of the profession and the other rpeople we serve, rather than our individual self interest sets aside personal agendas for a bigger concept or a more important idea Iless focus on "what's in it for me“ and more on ”how can I help the patient/client" [performed in a manner to best meet the needs of the customer applying information taking into consideration the jpatient/client's situation 12. Malntalnlng confidentially. [maintainLnQ confidentiality on the job lbeing respectful of clients - complying with confidentiality respecting client confidentiality confidentiality is kept in check confidential with patient/client information 13. Belng honest. [beinLhonest but not offensive [honesty and integrity [honesty/integrity A true professional is honest, thorough, and consistent [honesty [honesty and integrity elements of character that include honesty, loyalty, tpracticiggwith honesty, integrity, and fairness understanding integrity [having integrity and being reliable integrity in which we provide service, in dealing with our clients and other healthcare providers [honest in the services provided unquestionable integrity and honesty as promote health and well beiggof people [integrity [honesty, integrity, and fairness 48 Table 2 (cont’d). in order to be acknowledged as nutrition expert and leading source of food/nutrition services, must conduct self with honesty and intggrity 14. Providing rustworth [information trustworthy reliable follow-through with commitments informed recommendations and decisions that affect uses a scientific base of information to make [gatient/client ives advice based on the best science available will do things right (accurate, fair, strong ethical code, unbiased) competent performance earns the dietetic rofessional respect from colleagues and patients rovides accurate, scientific, up to date information to ensure public health, safety, well-being, to do not harm, and to acquire and maintain public trust [provides accurate and reliable information for decision making we all ultimately are responsible for maintaining the consumer's trust and well being. decisions are objective and based on current [evidence accurate, balanced information before your desire for lplacing the professionals and consumer‘s right for monetary gain providing information/facts about food and nutrition based on scientific facts rely on scientific principles when providing information to the public and to patients/clients Iinterprets controversial issues in a nonbiased way 15. Malntalnlng urrent knowledge in an area of practice. following the principles of practice of relevance to ones position 49 Table 2 (cont’d). knowledge in your area of expertise remaining current with principles of practice keeping current with latest research and consumer trends dietetic professionals demonstrate competency in their area of practice by keeping abreast of evidence- rbased nutritional care keeping professional knowledge current and cutting [edge [uses research to advance practice [encompasses continuing education providing nutrition services that are based on upto- date scientifically based information providing current, research based state of the art nutritional care and/or food services to clients [leader in identifyi_ng new trends Esing acceptable standards of care [education/lifelogg learning Ibroad awareness of nutrition and food issues as well as external conditions that impact nutrition (labeling, reflations, science) continuous learningand skill development dedication of mind (life-long learning) [mactices continued self-development It is a person who uses their nutrition and general knowledge, skills, and judgment to support, develop, and enhance the health and well-being of others and to instigate and encourage the pursuit of new Iknowledgpand skills continues personal education for currency and relevancy of knowledge/practice professional is responsible for maintaining their own rofessional competence lgses continuous quality improvement methods in ractice knowledgeable demonstrates goals, results, outcome orientation, striving for continuous achievement and self- development staying on top of the latest technology and business skills (havingemail, web page, etc) 50 Table 2 (cont’d). basing my advise on the latest reputable medical nutrition therapy research as reported in the major medical journals constant active learner committed to continuingeducation [being knowledgeable about one's field [ensuring individual professional development and continuing education lifelong learner - continuous education to improve knowledge and skills keeps up-to-date with the latest information available daily commitment to learning, to not just keeping up with our profession, but staying one step ahead of the needs [keeping up-to-date on the science of nutrition having a professional development plan that involves keeping knowledge and skills current through lifelong learning stayingon top of the latest science behind nutrition staying abreast of current trends, issues, and thinking within the dietetics profession rmaintains current knowledge as directed by the Standards of Professional Practice [knowledge of the profession [maintains an awareness of changes in health care - responds to those changes proactively demonstrates progressive, current expertise, skills in chosen area of practice [each individuals professional development remains current on science and practice keep up with current information [keep up to date on current information [practicing using scientific principles and current information Learn the cost of doing business esp. in structured environments such as hospitals/long term care rintegrating evidenced based nutrition science with the art of counseling, educating, guiding, and/or feeding as appropriate appropriate depth of knowledge in their area of [practice 51 Table 2 (cont’d). commitment to only suggest advice that works and speaks out against quackery/fraud understanding the science of nutrition continue to truly educate ourselves in the advances in healthcare, nutrition, foodservice, dietetics - not 'ust meet continuing education requirements adherence to evidence based approaches to define appropriate interventions, recommendation and ractice includes life-long continuing education and personal development to ensure readiness to practice based on cutting edge principles, new scientific discoveries, and up to date technologies ability to evaluate and apply technical information to and in a wide range of settings practice based on scientific principles lknowledgeable capable and skilled in the field of dietetics critical thinking is essential (i.e. the ability to locate facts about a topic, evaluate their quality, and apply to new situations) trying new ways; breaking stereotypes and [paradigms [being open to new ideas and new ways of doing things there may be many ways of addressing certain rissues, which a professional can see and critique accordineg concurrent openness to the possibilities of new approaches and concepts that may eventually be accepted followingLigorous research thinking outside of the box staying current and well-informed in ones chosen area of practice endeavor to remain current in the knowledge and skills that potentates the ability of society to [understand nutrition information being as knowledgeable as possible about nutrition/mnt so that presents factuaVaccurate assessment of nutritional health to a person [expansion and refinement of skills [high level decision making 52 Table 2 (cont'd). strives to continuously improve his/her knowledge and skills make decisions/solve problems is the essence of professionalism appropriate depth of knowledge competent in your area of practice completes the required study assumes a thorough knowledge of the science (facts) and art (application) of facts and information related to nutrition and dietetics lhas content knowledge knowledge 16. Providing referrals when necessary. responsibility to the public one serves ability to admit to oneself and others when one doesn't have all the answers, knowing where to find them, or when to make appropriate referrals accepting responsibility to act in manner that is appropriate, accurate, a model for others to follow If one is not competent in an area, they will not make recommendations but refer to a subject matter expert practicing within the scope of dietetics practice and making referrals when necessary to other health care rofessionals you know what you know and what you don't know - you know when to fold them and defer to those with the knowledge/skill teach others in a non condescending way what you Iknow accountable accountability [personal responsibility and accountability for competence Iknowing when to refer on” when asked for specifics about a topic in an area that I'm not proficient in lknowing where to go for additional information refer to others when appropriate collaborates with others when needed 53 Table 2 (cont'd). knowing where the boundary lines are if working in a clinical setting recognizes the limits of her knowledge and qualifications humility in terms of what we don't know about nutrition and individual variation in responses to nutritional intake when little evidence exists, the dietitian is clear about the basis of decisions 17. Accepting the responsibility to [mentor others. [participates in the development of the next eneration of professionals r ractices service and mentorship conducts outcomes research to improve practices conducting research or disseminating knowledge through peer-review journals, professional mewsletters, or other avenues lshares with others in the profession, community and even with the media sharing of knowledge, understandings, and ideas with colleagues, students, and the public in order for [us to all advance together - not ”hoarding" ideas encompasses sharing experiences and expertise with students, colleagues, other healthcare rofessionals and clients bringing along new generations of nutrition ractitioners dedication of body (volunteering to share time and -expertise) willirmness to share ideas and experiences shares knowledg/skills with others shares academic and practice information without [personal gain provides service to others teacher - working with other dietetic professionals and students to help them achieve the knowledge and skills you possess serving as a role model not only in our profession, but in our world as a whole 54 Table 2 (cont’d). shares ideas sharing ideas and expertise with others mentoring those entering the profession encouraging new dietetics graduates to be involved participating in career fairs to promote dietetics as a career to today's youth contributing to nutrition education of public lpromotes nutrition when appropriate commitment to providing the public with thoughtful, well reasoned information that will meet the standard of ”first, do no harm" -ensuring the provision of quality, research-based services (in any area of practice) strategic in planningfor future contributes to the effective nutritional lifestyle of all clients True professionals provide critical, as well as ”nice to know” information that can potentially enhance or improve lives IOther (not Included In categories) [professionalism and being a professional is synonymous Just because JCAHO or OBRA standards exist does rnot prove our value to clients We have tremendous competition now in the field of nutrition. We need to show how we can provide more value than others some of the rules may be written in a code of ethics and others are more subjective and determined by the individuals experience and personal gals competition is inherent to business but a professional does not seek competition but looks for new and expanding business opportunities It embodies judgment, conduct, practices, habits, ethical decision making and perceptions that promote positive outcomes for all of society as well as for individuals For me, professionalism is about the total person, it can't be easily separated into catpgories respect for tangible and nontangible goods such as [property or practices/protocols 55 Table 2 (cont’d). if I can meet these standards in my daily walk, I will be offering the dietetics profession an individual who cares about life, health, people, knowledge, growth, future, at one point of practice, it seems that professionalism was more the manner in which one presented oneself in practice. There was a lot of emphasis put on getting dietitians out of the white 3/4 length sleeve nursing uniform (dress not pants) and into three piece suits in order to improve the professional [perception of the dietitian in healthcare. Did we look and act professional? which also seemed to mean [did we look more like doctors than foodservice workers? My observation is that people are only as good as their ”likes.” If they like to do something, they are good at it and this reinforces their continuance of the task/performance, and they get better at what they do best. If you do not like some task/role/function, you generally do not do it well. the customer always pays - willingly through the purchase of products and services and perhaps less willingly through taxes that support government programs and institutional research and education. The ultimate source of all funding is the same-the consumer. The channels through which the money reaches the professional practitioner may vary Round Two. Seventy-four participants were provided with the information for Round Two and asked to provide clarification for each category as well as give a preliminary ranking to the top 10 categories in terms of importance to the profession of dietetics. Forty-nine of the 74 subjects responded to Round Two (62%). Data were determined to be of poor quality and not appropriate to the identified research objectives. Therefore, these data were eliminated in all further analysis. See chapter 5 for a discussion regarding this decision. 56 Round Three. Three independent raters were asked to divide the index cards containing the round one data into ten separate categories and give each category a title and operational definition. Then, the thirty categories were combined according to similarities in titles and cards within each pile. The result was ten categories: leadership, service to the public, professional image, effective communication, subject competence, professional ethics, professional dedication, inherent work ethic, personal qualities, and working with others. See Table 3 for the operational definition related to each category title. The responding group from Round Two (n=49) was then given the opportunity to evaluate these ten categories and operational definitions in Round Three, 42 responded (86%). Table 3. Ten titles with operational definitions from Round One data. Tltle Leadership Ogrational Definition Contributing one's talents beyond simple participation when needed. Service to the Public Commitment to providing the public with thoughtful, well- reasoned information. Professional Image Portraying the appropriate physical image and demeanor to others. Effective Communication Expressing clear and concise knowledge. Subject Competence Using continuing education to maintain and provide accurate, scientific, and up-to-date information. Professional Ethics Being responsible for upholding the ADA Code of Ethics. Professional Working to further the profession by lending support to, Dedication and accepting support from, others within the profession. Inherent Work Ethic Working within the profession with disregard for monetary gpin. Personal Qualities Maintaining basic personal values (such as: courtesy, credibility, confidence, etc.) and good citizenship. Working with Others Maintaining positive relationships with others including those outside of the profession. 57 See Table 4 for a summary of the results of Round Three. See Appendix N for summary of all comments provided by respondents. One category title was modified (Professional Responsibility to Professional Dedication) as a result of these comments. Other definitions were further refined based on the comments. Table 4. Round Three results. 5 Title Ogratlonal Definition Mean :1: _D High Medium Low Using continuing . education to maintain 3321160: e n c e and provide accurate, 38 4 0 2.9 :I: 0.3 pe scientific, and up-to-date information. Effective Expressing clear and Communication concise knowledge. 37 5 0 2'9 i 0'3 Contributing one’s . talents beyond simple Leadershlp participation when 34 8 0 2.8 :l: 0.4 needed. . Being responsible for :{flfss'ma' upholding the ADA Code 32 10 o 2.8 a 0.4 of Ethics. Maintaining positive Working with relationships with others Others including those outside 27 14 1 2'6 t 0'5 of the profession. Commitment to providing Service to the the public with Public thoughtful, well- 26 14 2 2'6 i 0'6 reasoned information. Working to further the profession by lending Professional support to, and Dedication accepting support from, 22 19 1 2'5 i 0'6 others within the profession. 58 Table 4 (cont’d). Maintaining basic personal values (such 3323:: as: courtesy, credibility, 22 19 1 2.5 :l: 0.6 confidence, etc.) and good citizenship. Portraying the Professional appropriate physical Image image and demeanor to 13 25 3 2'3 i 0'6 others. Working within the Bueéent Work profession with disregard 8 16 18 1.8 :l: 0.8 for monetary gain. Round Four. The final categories were listed from highest mean value to lowest from Round Three data. For Round Four, 42 participants were provided with the on- line questionnaire and 35 responded (83%). The questionnaire asked respondents to rank how well they feel the Profession of Dietetics is doing for each category (above expectations, on target, below expectations). If any particular category was rated as “below expectations”, respondents were asked to suggest ways in which the profession can improve in that area (see appendix P for the complete list of suggestions/comments provided). See Table 5 for a summary of the results of Round Four regarding how the Profession of Dietetics is doing for each category. One category, Inherent Work Ethic, was eliminated from Round Four due to the low rankings from Round Three. See Chapter 5 for a discussion regarding this decision. 59 Table 5. Round Four results. Tltle Opgratlonal Definition Above Subject Comp- etence Using continuing education, both formal and informal, to maintain and provide accurate, scientific, and up-to- date information. I? .. Executions Target 28 Below Exwtations Effective Commun- ication Listening to your audience and expressing clear and concise knowledge, which is appropriate for, and understood by, the audience. 17 13 Leadership Contributing one’s talent and strengths toinfluence activities, which promote goal achievement. 22 12 Profess- ional Ethics Being responsible for upholding and behaving within the ADA Code of Ethics. 27 Working with Others Maintaining positive relationships with others including those outside of the profession. 19 1O Service to the Public Commitment to providing the public with thoughtful, well- reasoned, and scientifically accurate information. 18 60 Table 5 (cont’d). Working to further the profession by lending support to, and accepting 6 18 11 support from, others within the profession. Profess- ional Respons- ibility Maintaining basic personal values (such as: courtesy, credibility, 1 1 24 0 confidence, respect, etc.) and good citizenship. Personal Qualities Portraying to others the appropriate Profess- physical image and ional demeanor, which is 0 29 6 Image acceptable within the work environment. In addition to the Round Four information on how the Profession of Dietetics is doing, participants were asked to provide demographic data. The final group of participants (n=35) was mostly female (n=33; 94%), Registered Dietitians (n=33; 94%), with a Master’s degree (n=24; 69%), having worked in the field of dietetics for an average of 25 years (range=10-42). A variety of work settings were represented with school faculty (n=12; 34%) and other (n=8; 23%) being the most prevalent. Most (n=25; 71%) of the respondents currently work with students (either undergraduate, graduate, or interns) in their current positions. Most respondents were from the Western US. (n=15; 43%; Northwestern, n=1 (3%) and Southwestern, n=5 (14%) included) with the Midwestern U.S. (n=12; 34%) and Eastern US. (n=8; 23%; Northeastern, n=6 61 (17%) and Southeastern, n=2 (6%) combined) being well represented. See Table 6 for complete demographic information. Table 6. Summary of demographic information for final group of subjects. Category th_ions p _°/_o Male 2 5.71 Gender Female 33 94.29 Highest formal education Bachelors 2 5'71 level completed Masters 24 68.57 PhD 9 25.71 . . RD 33 94.29 Reglstratlon DTR 2 5.71 Approximate number of Range: years practicing in the Open ended Mean=25.06 10-42 field of dietetics years Clinical 6 17.14 Foodservice 2 5.71 Current and primary area School faculty 12 34.29 of practice Consultant 3 8.57 Community/public health 3 8.57 Other 8 22.86 Do you currently work Yes 25 71.43 directly with students? No 10 28.57 The final definition of professionalism defined by this group of subjects is provided in Table 7. It includes the professionalism categories subject competence, effective communication, leadership, professional ethics, working with others, service to the public, professional responsibility, personal qualities, and professional image. Each category also has an operational definition that empowers the dietetic educator to identify specific behaviors relating to professionalism for the field of dietetics. 62 Table 7. Final definition of professionalism. I312 Caratlonal Definition Sub'ect Using continuing education, both formal and informal, to COITJI tence maintain and provide accurate, scientific, and up-to-date pe information. Effective Listening to your audience and expressing clear and Communication concise knowledge, which is appropriate for, and understood by, the audience. Leadership Contrlbutlng one s talent and strengths to lnfluence activities, which promote goal achievement. Professional Ethics Being responsible for upholding and behaving within the ADA Code of Ethics. Working with Maintaining positive relationships with others including Others those outside of the profession. Service to the Commitment to providing the public with thoughtful, well- Public reasoned, and scientifically accurate information. Professional Working to further the profession by lending support to, Responsibility and accepting support from, others within the profession. Personal Qualities Maintaining basic personal values (such as: courtesy, credibility, confidence, respect, etc.) and good citizenship. Professional Image Portraying to others the appropriate physical image and demeanor, which is acceptable within the work environment. Objective Three Objective three was to utilize this final definition of professionalism to assist in making specific dietetic education recommendations. Therefore, the recommendations for improvement from Round Four were compared with the structured approach for teaching professionalism offered by Rodriguez and colleagues (2000). For example, both Rodriguez and colleagues and this research project had categories titled leadership. Under this category, Rodriguez and colleagues suggested that educators promote the benefits of membership to a professional organization and encourage participation to a professional 63 meeting whereas the suggestions for improvement obtained from this project suggested that there is a need to encourage professionals to be more giving of their time and talents to the national association. See Table 8 for the complete comparison of the structured approach to teaching professionalism and the suggestions for improvement offered by this participant group and Appendix P for the complete list of suggestions for improvement. Table 8. Comparison of the structured approach and suggestions for improvement. Structured Approach to Teaching Professionalism by Rodrlguez and This Research Project Collea ues (2000) Summag of the Toplc Context Categog Recommendations for Improvement The Professional Have students Development . update the . Portfolio helps to [3:323 Professional 3:23:19 n c e address this issue, ' Development 2001 but we need to focus document. more on the accurate and scientific part. Must provide clear, . concise, and n/a1 n/a1 (Esfiectlve. t' understandable ommunlca '0" messages while listenim the client. Promote the benefits of membership to a Need to encourage professional professionals to be . organization and . more giving of their Leadershlp. encourage Leadershlp time and talents to participation to a the national professional association. meeting. 64 Table 8 (cont’d). Introduce the ADA Code of Ethics in Basic Nutrition when Know what the code lfhgtfigg Code discussing seeing a FE’irgif‘essronal says and hold others ' nutrition professional accountable to it. for a weight loss plan. Lead roundtable Need ‘° 599"“ "we . . tlme on teamwork dlSCUSSlOI‘IS and critical analysis of . and development Of Fairness and territoriality among Working wrth relatlonshlps wrth assertiveness. the health Others others outside the professionals at a professron ln. order to specific facility promote feellngs of ' job security. Need to effectively communicate through the media n/a‘ n/a‘ Service to the and avoid the lure of Public alternative therapies for which there is not enough training and uidance. Discuss the responsibilities of Need to be more . Student Club supportive of others Sleatl‘egrznzam members and Professional within the profession dependability slgnlflcance of follow Responsrblllty and spend tlme role- ' through in the modeling desired context of the outcomes. planned activities. Have students in the Community Nutrition The elements of course list the Personal n/a‘ professionalism. characteristics of a Qualities competent nutrition professional. 1 1 Professional Dressing like a n/a n/a Image professional.2 1not applicable as no information is available for this category 2W hat is not included here are the opinions on body weight clue to a dichotomy of opinions received, some (n=2) stated a need to achieve and maintain normal or ideal body weight while others (n=2) expressed concern that physical image and size acceptance are important philosophies regarding an individual's weight that play into this definition. 65 Objective Four During Round Four, participants were asked to identify a point in time when professionalism became a reality to them. Many (n=25; 71%) identified their time in a formal educational setting (high school, college, or dietetic internship) as this critical period of professional development. Others (n=6; 17%) identified their time as a professional working in the field as this critical period. See Table 9 for a complete list of the awareness comments. Table 9. Awareness comments. I wasn't really aware of the broad picture of professionalism in my career until about 5 years into my career. I started volunteering for the local dietetic association and the leaders there influenced me and projected professionalism and the meaning of it to me. as an undergraduate student First year of college as an undergduate student as an undergraduate student in professional courses My father is a physician in a small town. His dedication to life long teaming and the compassionate caring for his patients exemplifies professionalism. As a young child, I understood that a job that was worth doing was worth doing well and that service to humanity is the best work of all. these may be cliches, but when l ggw up, they were ”house rules.” during baccalaureate training senior year of High School as soon as I started to volunteer where I work. As a child, observing my father WHATl?! When I got divorced and realized I needed to upgrade my work to support myself and 3 children. This is when I took professionalism seriously. from the time I was in college. Duringmy internship. Duripg my internship. 66 Table 9 (cont’d). From Dr. Karen Kubena, RD at Texas A&M University. Dr. Kubena was and has been the most professional individual I've met in our Dietetics Profession. In my undergraduate program this was stressed. The way you present yourself is the way you will be perceived. My graduate advisor was wonderful in promoting local dietetic association membership. As a dietetic trainee This was ingrained in me in my dietetic internship over 35 years ago. I think over the past 15 years when I began doinflnore public presentations In graduate school, 1965! In high school - through the example of several women who were role models (home economics teacher; chemistry teacher; dietitian at local hospital; dietitian at a university. They showcased what/who I wanted to be. in school The first day on my job after coll_ege. When I was an undergraduate; it was included throughout our curriculum. During my internship. During my internship. My internship director was an excellent professional role model. Graduate school-a very dynamic and supportive Masters Advisor who pushed rofessional responsibility. When I entered the field of dietetics. As a student, when I received a scholarship from my professional group. duringmy undergraduate education It has been a gradual evolution, which probably began in undergraduate classes and continued through my internship, work experience, masters degree, & volunteer experiences with ADA nationally, statewide and locally. Growing up as a child During my internship, l was first exposed to professionalism. However, it wasn't until my second job with the Dairy Council of California that professionalism became ingrained. 62mm The Delphi method provides the researcher with an opportunity to obtain large amounts of data for the issue at hand. In this research, four Delphi rounds were administered via the lntemet to define professionalism, determine a point in 67 time in which personal professional behavior becomes a reality, and to make recommendations for future curricular development to include professionalism education. Round Two was unsuccessful at meeting the aforementioned research objectives and was, therefore, eliminated from any data analysis. Further discussion regarding this decision can be found in Chapter 5. Data from Rounds Three and Four provided a rich beginning to exploring a point in time in which professionalism becomes a conscious reality for the practicing RD or DTR and for looking at suggestions for future improvement. In addition, the demographic data regarding this sample of respondents indicate a group of long- term dietetic educators, which may be used to further refine any future curriculum recommendations regarding the inclusion of professionalism in the dietetic curriculum. 68 CHAPTER 5 CONCLUSIONS AND RECOMMENDATIONS Introduction This research project attempted to define professionalism, identify a point in time in which personal professional behavior becomes a reality, and make curricular recommendations for addressing professionalism within the structured dietetic curriculum by using an on-line Delphi Technique. Four on-line surveys were developed using the research committee (first questionnaire) and the data provided by the respondent group (second, third, and fourth questionnaires). Conclusions and recommendations for further research are presented here according to the corresponding objective. Objective One Conclusions The snowball method and Delphi technique were useful for identifying and gathering data from a geographically dispersed group. The subjects of this research were identified by a small number of their peers as national leaders and futurists. This subjective evaluation by a small number of people has the potential to bias the results, as those chosen to participate in the research were not randomly chosen from a nationally representative population sample of the profession. Participants may also have felt obligated to participate (rather than fully choosing to participate based on one’s own accord) due to the perceived honor of being identified by a peer as a leader or futurist. 69 A total of 138 people were contacted via electronic mail during the snowball technique. Sixty-two of these responded with submission of more names of leaders and futurists in the field of dietetics. Some potential reasons for the 45% response rate include the following: 1. The snowball technique was conducted during the end of the month of July and the beginning of August, a popular time for vacations; 2. July and August are also times in which some educators are not working due to a contract that does not span 12 months; 3. Some respondents may have felt that it was unethical to provide contact information for their peers and therefore did not submit names for the potential subject list; 4. Some respondents may have been too busy to participate or submit names at that time; and 5. Some respondents may not have been interested in participating or submitting names. Forty-one names that were submitted had to be removed from the potential participant list due to the following reasons: 1. The inability to contact the person via electronic mail either due to not having an electronic mail account, the account not working at the time of contact, or the electronic mail address given not being correct; or 2. The person suggesting participants submitted more than four names. In this case, the following happened: 1. The first four names on the list were added to the master list of potential subjects; 2. If any of the first four were already on the list, that name was then replaced with the next name from the submitted list until four unique names had been submitted and accepted; 3. If any names remained on the submitted list, these names were placed on a separate list of extras, to be contacted if needed. In a two cases, the 70 request to submit names to the researcher was not followed. Instead, the person to whom the request was made forwarded the electronic mail to their potential list of subjects on their own, without contacting the researcher to do so. In this case, the first four who responded to the researcher were included in the potential subject pool and any extras were placed on the extras list. It was particularly surprising that the subject pool did not represent more of the prominent elected leaders of the national association’s membership. This may have been due to these people being “obvious” choices for inclusion, therefore those providing names through the snowball method did not include these names, or those supplying the names do not feel that these elected leaders are taking the profession of dietetics in the direction of their choice. In addition, it is possible that this could be due to the overall general membership of the American Dietetic Association not being aware of who holds elected positions or how they were elected into those positions. Delbecq and colleagues (1975) state: “Our experience indicates that few new ideas are generated within a homogeneous group once the size exceeds thirty well-chosen participants.” (p. 89) These research findings support this as the quality of responses and the overall response rate improved greatly once the group size (originally set to be 150 minimum) was trimmed to a more manageable size via self-selection of the respondents. The respondents who completed the entire project were a group of highly motivated individuals who were committed to the task. As one respondent stated, “A great project — valuable study. You are to be commended.” 71 Qbiective Two Conclusions One unique method utilized in this study was to communicate through electronic mail and provide all questionnaires to the subjects via the lntemet. Electronic mail as a primary mode of communication was effective for having asynchronous communication between the researcher and the subject, however it also removed affiliation with each other through personal interaction. This can be a positive experience for those who are busy and wish to participate only at a time in which it is convenient for their schedule. It can also be a negative if the subject is a person whose personal preference is to have face-to-face interaction when participating in a research project. For this particular project, the asynchronous communication helped to accomplish the objective that the experience be completed online. Utilizing on-line questionnaires helped to alleviate some of the monetary costs associated with traditional paper-and-pencil Delphi’s although a small amount of the cost savings were spent on paying the ISP for the Internet hosting of thewebsite. Some self-selection of subjects was likely to occur through the use of the World Wide Web for submission of each round of the Delphi due both to reliable access to the Internet and to comfort levels using the Internet, although efforts were made to minimize this by offering the ability to submit using the US. Postal Service and/or electronic mail attachments. However, it is important to note that self-selection may also occur through the paper-and-pencil process of administration. 72 The problem that occurred with the ISP is a potentially unavoidable problem that cannot be controlled. The original ISP was highly recommended as a company with quick and reliable service. The problem encountered was a result of a company-wide upgrade to equipment that coincidentally happened at the same time as this research project. During this period, the ISP posted dates and times that the migration would be complete. However the dates and times continued to change until it reached the point that the need to change lSP’s was clear. Objective Three Conclusions This research provided an initial attempt at a nationally representative definition of professionalism. The Delphi technique provides for a wealth of data from which to work. Unfortunately, due to the limitations of this being a single research project, much more work needs to be done with this definition in order to fully represent this truly complex issue. It is noted that this current definition is not representative of the entire population of dietetic professionals but rather representative of this small group of individuals who are identifiably self-selective in nature. This work does give further credence to the work of Rodriguez and colleagues (2000) and moves their work out into a more national scope. A limitation to the interpretation of the results comes from the elimination of the Round Two data. During the data collection phase of round two, it was determined that the data being returned were of poor quality and not appropriate for the research objectives. In the Round Two questionnaire, respondents were 73 being asked to describe and illustrate categories without definitions or examples of these categories. Respondent’s comments included “too many similar definitions here”, “WRONG to rate categories in this manner”, and “difficult to prioritize due to similarities in definitions”. In addition, five respondents reported that the questionnaire was taking too much time to complete, (well over 30 minutes), and therefore they chose not to continue in the study. Due to these responses, it was determined that all data from this round should be disregarded and the research should instead, move forward to round three using a new analysis of the round one data. By moving on to Round Three, it was felt that a good portion of the research objectives could still be accomplished. Another potential problem occurred when the category, Inherent Work Ethic, was removed from the final questionnaire. At the time of the questionnaire’s development, it was felt that the category should be eliminated due to the low responses regarding the category's importance. However, upon further analysis, this was determined to be an error and the category should have remained. The problems with the “without monetary gain” portion of this category should be explored further in future research. This research supported the complexity and personal nature of the professionalism issue. For example with the personal image category, it was difficult to summarize every part of this category due to the conflicting views regarding the professional’s weight. One comment stating, “nothing is more disturbing than an obese dietitian advising a person on weight control” would be negated by the next comment stating, “this statement is simply scary—given the 74 current Eating Disorder epidemic . . . why is the ADA so fixated on physical image AND is there scientific evidence to underscore a positive relationship with physical image and an ability to be a professional?” At times, it also seemed like the respondent was contradicting themselves within their own statement: “I strongly object to the “physical image” component to this statement and feel that this could be considered discriminatory. What about the “size acceptance” philosophy? I personally am of normal weight.” The words “physical appearance” were chosen by the independent raters and included Round One statements regarding dress, body piercing/tattoos, nail polish, etc. but the interpretation of “physical appearance” in subsequent rounds seemed to focus more on physical size rather than appearance. This is representative of a limiting factor of the Delphi method — the inability to fully represent all opinions and explore all discrepancies. Rodriguez and colleagues (2000) began with a small, local group of internship preceptors to identify behaviors and make curricular recommendations for teaching the expected behaviors involved with professionalism. Rather than reinventing this wheel, this research aimed to take this to the national level and create a definition that can further advance curricular recommendations. As such, recommendations came from the recommendations for improvement given in round four. These recommendations are only the first in a long line of future research that must be completed prior to the recommendations being appropriate for implementation within a dietetic curriculum. 75 Mve Fglr Conclusions Although not as complex an issue as the umbrella of professionalism, the request for a point in time in which professional behavior becomes a reality provided a variety of responses. As expected, most discovered professionalism during formal schooling, which speaks to the specific need to address professionalism within the structured dietetic curriculum. In addition, some identified specific individuals who helped shape the development of professional behaviors within the respondent. These individuals, whether parents, instructors, or mentors, all provide an important link to the development of professional behaviors for students. This research confirmed that by knowing that most of these subjects developed a professional behavior reality during their time in the formal education setting educators should be focusing on this time period for teaching professional behaviors. Recommendations for Further Research. Further research could be done on how the general membership of the ADA feels regarding the elected leadership and the direction in which the association is headed or on how familiar the general membership is with the current/immediate past elected leadership, what they stand for, and what they are specifically doing for the profession while in office. It would be interesting to know how the people who are in elected positions got elected — was it because of name recognition or proven effectiveness while in an elected position? Or was 76 it simply because so few people voted that those voting are the sole determinants of who is in the elected position? In addition, further research utilizing on-line survey instruments would benefit from the use of a web-authoring program that did not force a radio button to be checked at all times. This would help to eliminate any question regarding the skewing of final results due to the checked radio button. Additionally, it would have been beneficial to explain the reason for the radio button being checked to the subjects, something that was not done in this research project. Further research would most logically include a thorough understanding of the professional image issue. A more thorough definition — with specific examples - may help to alleviate the unsettling nature of the responses found within this research project. With that category better defined, the next step would be to attempt to further refine the definition of professionalism for the field of dietetics with a nationally representative sample of practitioners within the field. It would be interesting to explore how other segments of the profession view this same issue. As most of the respondents to this study had been in the profession for an average of 25 years, how do the younger dietitians view professionalism? How about the identified leaders in the profession? Or even the dietetic educators? Most importantly, how do these differences work together to develop a common, accepted definition that the entire profession can utilize? If future research can further build and strengthen the definition and identifiable behaviors associated with each category, then educators can begin to build behavioral objectives around the consistent exhibition of such behaviors. 77 Research would need to be conducted in order to determine how to best complete this task. Summagy The Delphi research method provided a reasonable start for examining a complex topic with little theoretically based research and opinions that are as complex as the topic itself. The loss of a productive Delphi round (two) hindered the complete progression of this research and prevented the appropriate step to curricular recommendations as originally planned. The original Round Two questionnaire may have been more appropriate had it included a Likert scale (agree/disagree) rather than ranking each category in terms of importance. In addition, the Round Two questionnaire needed to include specific examples related to each category in order to best prepare the participants for their task of illustrating each category. However, despite this “bump in the road”, this research project was successful at the first attempt to define professional behaviors for the profession of dietetics. 78 APPENDICES 79 APPENDIX A Human Subjects Approval 80 OFFICE OF RESEARCH AIID GRADUATE STUDIES orally Committee on Research Involving linen Subjects idiom Sta University Administration ammo East Lining. Mlcnlqm 48824-1046 517/355-2160 FAX? 5173534976 Mail wimedu MICHIGAN STATE UNIVERSITY July 24, 2001 TO: Frederick WHIMS 409 Agriculture Hall RE: IRB# 01-426 CATEGORY: EXEMPT l-C APPROVAL DATE: July 23, 2001 TITLE: PROFESSIONAL BEHAVIORS OF UNDERGRADUATE DIETETICS STUDENTS: CURRICULUM IMPLICATIONS The University Committee on Research Involving Human Subjects' (UCRIHS) review of this project is complete and I am pleased to advise that the rights and welfare of the human subjects appear to be adequately protected and methods to obtain informed consent are appropriate. Therefore, the UCRIHS approved this project. RENEWALS: UCRIHS approval is valid for one calendar year. beginning with the approval date shown above. Projects continuing beyond one year must be renewed vn'th the green renewal form. A maximum of four such expedited renewals possible. Investigators wishing to continue a project beyond that time need to submit it again for a complete review. REVISIONS: UCRIHS must review any changes in procedures involving human subjects, prior to initiation of the change. II this is done at the time of renewal, please use the green renewal form. To revise an approved protocol at any other time during the year. send your Mitten request to the UCRIHS Chair, requesting revised approval and referencing the project's IRBff and title. Include in your request a description of the change and any revised instruments, consent forms or advertisements that are applicable. PROBLEMS/CHANGES: Should either of the following arise during the course of the work, notify UCRIHS promptly: 1) problems (unexpected side effects, corrplalnts, etc.) Involving human subjects or 2) changes in the research environment or new 'nformation Indicating greater risk to the human subjects than existed when the protocol was previously reviewed and approved. If we can be of further assistance, please contact us at (517) 355-2180 or via email: UCRIHS@msu.edu. Please note that all UCRIHS forms are located on the web: http'levvw.msu.edu/userlucrihs Sincerely, t I '1, I vJ//\”'L‘/’q Ashlr Kumar, MD. Interim Chair, UCRIHS AK: br CC: Diane Golzynski 2100E South Anthony 81 APPENDIX B Electronic mail to potential participants during the snowball technique 82 Hello, My name is Diane Golzynski. I am a PhD candidate at Michigan State University and I currently work in the Department of Food Science and Human Nutrition. For my dissertation research, I would like to probe the question of what “Professionalism” is for the field of Dietetics. The technique that I plan to use is the Delphi Method, which will be administered via the lntemet. As a part of the methods for this study, I need to identify 150 national leaders/futurists in the field of Dietetics. [Appropriate name inserted here] identified you as someone who fits this description. I am now asking for your help in identifying other potential people to put on this list. After I have 150 names, I will ask each of you formally to participate in the Delphi study, of which participation is completely voluntary. If you would, please send me a list of 3-4 people (name, address, email, phone) who you feel are leaders/futurists in the profession. I am specifically looking for a wide variety of people who are known for their ability to be futuristic in their thinking and active in their current professional roles. Providing these names IN NO WAY commits you to participation in my research study. If you have questions, please do not hesitate to contact me. I would need these names no later than [date inserted that reflected 10 business days from the date sent]. Thank you in advance for your help. Diane L. Golzynski, MS, RD. 83 APPENDIX C Round One Questionnaire 84 By completing and submitting this form, i am indicating my voluntary agreement to participate in this research study. How do you define professionalism, as it relates to professional conduct, for the field of dietetics? In order to ensure that those who completed the first round are included in the second round, please provide gs with vgr name. Please note that all responses submitted will be separated from the names provided in order to help assure confidentiality for those who choose to participate. Name: Please submit this form by 5:00 pm. EST August 10, 2001. Submit lnforrnation 85 APPENDIX D Skeleton of electronic mails to potential participants for Round One 86 Email sent to those who had not been contacted through the snowball method Hello, My name is Diane Golzynski. I am a PhD candidate at Michigan State University and I currently work in the Department of Food Science and Human Nutrition. For my dissertation research, I would like to probe the question of what “Professionalism” is for the field of Dietetics. As a part of the methods for this study, I needed to identify over 150 national leaders/futurists in the field of Dietetics. [Appropriate name inserted here] identified you as someone who fits this description. I am requesting your participation in this research study. I will attempt to gather input from a group of leaders and futurists, such as yourself, in order to define professional behaviors for the Dietetic professional. It is my hope that consensus regarding the qualities and specific conduct associated with professionalism, the results of this research can impact future curricular development for the undergraduate dietetic students and dietetic lntems nationwide. i will use a 4-step modified Delphi technique for this study (“modified” in that it will be completed via the Internet, rather than paper-and-pencil). Following the Delphi method, I will ask you to first define professional behavior in your own words. I will then summarize the responses of all the members of the group and post them on the World Wide Web for your review. Then through a two-step process of additional submissions and summaries, I will attempt to gain consensus, from all who are participating in the research, on a definition of professional behavior for the Dietetic professional. If you are interested in impacting the future definition of professionalism for the field of Dietetics, please log onto http://www.dieteticprofessionalism.net by August 10, 2001. You indicate your voluntary agreement to participate by completing and submitting the questionnaire. The time required to complete the questionnaire is estimated at approximately 5 minutes. If you prefer to complete the questionnaire and submit via the US. Postal Service, please feel free to print the questionnaire from the website and mail to the address listed. We will make every attempt to ensure that your privacy will be protected, to the maximum extent allowable by law. Participation in this study is voluntary; you may choose not to participate at all, may refuse to participate in certain steps or answer certain questions, or may discontinue the study at any time without penalty. If you have any questions or concerns regarding your participation in this study, please contact Diane Golzynski, MS, RD. at (517) 353-9661 or lentnerd@msu.edu. You are also welcome to contact the University Committee for Research Involving Human Subjects (UCRIHS) Chair, David E. Wright at (517) 355-2180 for questions about participants’ rights as human subjects of research. Thanlgou for your time. 87 Email sent to those who had been contacted through the snowball method: Hello again! Thank you for helping me to identify over 150 national leaders and futurists in the field of Dietetics. Now that the list is complete, I am ready to begin the research. I am now formally requesting your participation in this research study. lwill attempt to gather input from a group of leaders and futurists, such as yourself, in order to define professional behaviors for the Dietetic professional. It is my hope that consensus regarding the qualities and specific conduct associated with professionalism, the results of this research can impact future curricular development for the undergraduate dietetic students and dietetic interns nationwide. I will use a 4-step modified Delphi technique for this study (“modified” in that it will be completed via the Internet, rather than paper-and-pencil). Following the Delphi method, I will ask you to first define professional behavior in your own words. I will then summarize the responses of all the members of the group and post them on the World Wide Web for your review. Then through a two-step process of additional submissions and summaries, I will attempt to gain consensus, from all who are participating in the research, on a definition of professional behavior for the Dietetic professional. if you are interested in impacting the future definition of professionalism for the field of Dietetics, please log onto http://www.dieteticprofessionalism.net by August 10, 2001. You indicate your voluntary agreement to participate by completing and submitting the questionnaire. The time required to complete the questionnaire is estimated at approximately 5 minutes. If you prefer to complete the questionnaire and submit via the US. Postal Service, please feel free to print the questionnaire from the website and mail to the address listed. We will make every attempt to ensure that your privacy will be protected, to the maximum extent allowable by law. Participation in this study is voluntary; you may choose not to participate at all, may refuse to participate in certain steps or answer certain questions, or may discontinue the study at any time without penalty. If you have any questions or concerns regarding your participation in this study, please contact Diane Golzynski, MS, RD. at (517) 353-9661 or Ientnerd@ msu.edu. You are also welcome to contact the University Committee for Research Involving Human Subjects (UCRIHS) Chair, David E. Wright at (517) 355-2180 for questions about participants” rights as human subjects of research. Thank Lou for your time. 88 APPENDIX E Reminder electronic mail for Round One 89 This is a follow-up email reminder that the deadline to submit your response for the Dietetic Professionalism Research Project is fast approaching! Please log into http://www.dieteticprofessionalism.net by Friday, August 10, 2001 at 5:00 pm. EST to do so. I greatly appreciate your help. Thank you. Diane Golzynski PS If you feel that you received this email in error, or if you did not receive the email explaining the study (sent 7/31/01), please email me at lentnerd@msu.edu and I will resolve the matter as soon as possible. 90 APPENDIX F Electronic mail apology regarding the problems with Round One 91 I am writing with great apologies to all who have tried to log in and have experienced problems. When I signed up for service from the Internet Service Provider that is hosting the site, I did not know that they were physically moving their headquarters (and hence, their servers) to a different location right before the deadline of the first round! As a result, I wanted to let you know that if you would prefer to email me your first round responses, I will gladly accept them and will treat them with the same confidentiality measures as I do the web submissions. If you prefer to wait for the website, I am told that by 5:00 pm. MST the move is to be complete and all sites are to be working again. If you prefer not to participate due to the problems experienced, I completely understand and thank you for the time you have spent. l have extended the deadline to 12:00 noon EST, Friday, August 17, 2001 to try and allow extra time due to these problems. Thank you for your patience. I knew it would be a different experience trying to administer a Delphi Technique over the Internet and l have certainly teamed a great deal already as a result! Have a wonderful weekend. Diane 92 APPENDIX G Round Two questionnaire 93 By completing and submitting this form, I am indicating my voluntary agreement to participate in this research study. Instructions: 1. Please review each category below (there are 17 total). 2. Then, describe and illustrate each professionalism category, as you would personally define it. Please limit responses to 1 or 2 sentences, as this will facilitate our analysis. 3. Finally, rank (from 1-10) the categories in terms of importance, with 1 assigned to the category with the MOST importance, 2 assigned to the category with the second highest importance, and so on until you have assigned 10 total. Categories unassigned will be termed “unimportant.” Note that this is merely a preliminary vote. You will have the opportunity to revote in Questionnaire #3. Rank top 10 Professionalism Categogy Define and Illustrate (1 to 10; 1=MOST (As identified from (Be sure to include important; Questionnaire #1) questions/comments as 2=second most needed) important; etc.) I 1 How one approaches their t I work. Adhering to ADA’s Code of I I Ethics. I J Treating others with respect. The attitude one conveys to others. How one physically presents themselves. Effectively communicating with I t F J others. Functioning as a part of a L 7 team. I I Acting responsibly. Maintaining a commitment to excellence in the profession. L t Showing leadership. I j L 1 Having a %tomer-centered I J philosophy. L ] Maintaining confidentially. t J Being honest. 94 Providing trustworthy l 1 information. Maintaining current knowledge in an area of practice. Providing referrals when necessary. I I I I t j Accepting the responsibility to mentor others. [ J In order to ensure that those who completed the second ropnd are included in the third rognd. please provide us with your name. Please note that all responses submitted will be separated from the names provided in order to help assure confidentiality for those who choose to participate. Name: Please submit this form by 5:00 pm. EST Friday, August 31, 2001. Submit lnforrnation 95 APPENDIX H Electronic mail requesting participation in Round Two 96 First, a heartfelt thank you to all of you! Despite our troubles with the website, we made it through the first round and we are now ready to begin the second round! I managed to read thoroughly through all of your responses, categorize what I felt you were saying, and narrowed these categories down to 17 “Professionalism Categories”. These categories are representative of what you defined as professionalism attributes. Now, comes the second round of the Delphi Technique. In this questionnaire, you will find all 17 categories listed. I am asking you to describe and illustrate each in 1 or 2 sentences. This will serve two purposes: 1. It will be a crosscheck for me to be sure that I interpreted your first round responses correctly; and 2. It provides a list of identifiable behaviors that might be addressed within a dietetics curriculum. Then, you are asked to give a preliminary ranking to the 10 that you feel are MOST important. This will help to see which (if any) of the categories can possibly be eliminated and/or combined with others. This is a preliminary vote and you will have an opportunity to revote in questionnaire #3. Due to the problems that some of you experienced with the first website, I have changed Internet Service Providers (ISP). Hopefully, Yahoo! does not have any plans to be physically moving their servers at any time in the near future (for those who are not aware, that happened with the last ISP and the site was down for five days, and then remained non-functional after that)! As a precautionary measure, I am also attaching the questionnaire in both Microsoft Word and the Adobe Acrobat PDF formats to this email message. If you prefer, you may print the file and submit via US. Postal Service (to the address below) or submit via email. If you need another format than Word or PDF, please email me and I will get that to you right away. This second questionnaire can be found at http://www.dieteticprofessionalism2.net and should take approximately 30 minutes to complete. Please be sure that I have your submission by 5:00 pm. EST on Friday, August 31, 2001 so that we can move on to questionnaire #3 shortly after that. Again, I thank you for your participation and incredible patience as I learn about the pitfalls of trying a new method (via the Internet) to an “old” technique (the Delphi). As always, if you have questions, please do not hesitate to ask. Have a wonderful day. Diane 97 APPENDIX I Reminder electronic mail for Round Two 98 This is a follow-up email reminder that the deadline to submit your response for the Dietetic Professionalism Research Project is fast approaching! Please log into http://www.dieteticprofessionalism.net Friday, August 31, 2001 at 5:00 pm. EST to do so. i thank you for your time. Take care. Diane Golzynski PS. If you feel that you received this email in error, or if you did not receive the email explaining the study (sent 7/31/01), please email me at lentnerd@msu.edu and I will resolve the matter as soon as possible. 99 APPENDIX J Independent Raters 100 Independent raters who completed the task of categorizing the Round One data 1. Eileen Benson, Department of Food Science and Human Nutrition undergraduate student. 2. Marci Scott, MMSc, RD, Department of Food Science and Human Nutrition graduate student. 3. Jack Kelly, PhD, Department of Horticulture retired faculty. 101 APPENDIX K Round Three questionnaire 102 By completing and submitting this form, I am indicating my voluntary agreement to participate in this research study. Instructions: Please review each category below (there are 10 total). 2. Then, rate each category on its own merits in terms of its importance to the profession of dietetics. If you have further questions or comments for any of the categories, please feel free to utilize the space provided. 1. 3. meortance to the Profession pf Professionalism Categopi and Operational Definition Further Questions and Comments Dietetics (Include as needed) High Medium Low Leadership: O O O Contributing one’s talents t I beyond simple participation when needed. High Medium Low _S_prvice to Lhe Public: O O 0 Commitment to providing the L 1 public with thoughtful, well- reasoned information. High Medium Low Professional Imaoe; O O O Portraying the appropriate I I physical image and demeanor to others. High Medium Low Effective Commgnicam O O O Expressing clear and concise I J knowledge. High Medium Low Subject Competence: O O 0 Using continuing education to I I maintain and provide accurate, scientific, and up- to-date information. High Medium Low Professional Ethics: 0 O 0 Being responsible for I 1 upholding the ADA Code of Ethics. High Medium Low Professional Dedication: O O 0 Working to further the L I profession by lending support to, and accepting support from, others within the profession. High Medium Low Inherent Work Ethic: O O 0 Working within the profession L I with disregard for monetary ain. 103 High Medium Low Personal Qpalities: O O O Maintaining basic personal values (such as: courtesy, L I credibility, confidence, etc.) and good citizenship. High Medium Low Working with Others: O O O Maintaining positive [ 1 relationships with others including those outside of the profession. In order to ensure that those who completed Whird rognd are It'lCLJded ip the @th and final round. please provide us with vogr name. Please note that all responses submitted will be separated from the names provided in order to help assure confidentiality for those who choose to participate. Name: Please submit this form by 5:00 pm. EST Thursday, September 20, 2001. Submit Information 104 APPENDIX L Electronic mail requesting participation in Round Three 105 Thank you for your continued support of this research! The end is in sight! Based on the definitions and illustrations that you provided in Round 2, I have better defined the titles and streamlined the explanations for what are now ten professionalism categories and their operational definitions. Round 3 provides the opportunity to review these categories and definitions and assign a weight (low, medium, or high) to each, based on your personal feeling of importance to the profession of dietetics. I am hoping that this ”weight“ will help me to better rank the categories, in a more appropriate ”order”. The third questionnaire can again be found at http://www.dieteticprofessionalism2.net and should take no more than 15-20 minutes to complete. Please be sure I have your submissions by 5:00 pm. EST on Thursday, September 20, 2001 so that we can move on to the final questionnaire. Again, I thank you for your participation. As always, if you have any questions, please do not hesitate to ask. Have a wonderful day. Diane 106 APPENDIX M Reminder electronic mail for Round Three 107 This is a follow-up email reminder that the deadline to submit your response for the third round of the Dietetic Professionalism Research Project is fast approaching! Please log onto httpJ/www.dieteticprofessionalism2.net by Thursday, September 20, 2001 at 5:00 pm. EST to do so. i thank you for your time. For all of those affected (both directly and indirectly) by last week's tragedy, my thoughts and prayers are with you at this time. Take care. Diane Golzynski PS. If you feel that you received this email in error, please email me at Ientnerd@msu.edu and I will resolve the matter as soon as possible. 108 APPENDIX N Round Three Data 109 nication 9.322232222320021 333223322 332333333 3 23332 00222223312229.19— 3 3 322322333132 2323 110 3 otal 1 1 8 1 08 95 1 21 Mean 2.80952381 2.571428571 2.261 904 2.880952381 SD 0.39743661 0.590281 0. 0. Prof Prof Ethics Dedication ork Ethic 3 3 3 3 3 3 3 2 2 3 ODOONNODNOJN N 111 3 otal 1 1 16 7 Mean 2.904761 2.761904762 1 .761 904 SD 0.29710175 0.431 0. orking with 112 3 3 2 2 3 3 3 2 2 3 2 3 3 3 3 1 2 2 3 3 2 2 2 3 2 2 2 2 2 3 2 3 3 2 3 2 3 3' 3 Total 105 1 10 Mean 2.5 2.619047619 SD 0.55215763 0.538850672 2.557142857 Mean (all) 1 .870297817 Mean-(2*SD) (all) 034342252 SD (all) Comments Leadership I agree with the categories, but the operational definitions are way too limiting. Leadership goes belong "participation when needed.” I struggled with this one, because every profession needs leaders. I believe all professionals need professional dedication, but they may not necessarily be leaders. This is critical if the profession is to move ahead. Individual dietitians must step up - not just wait for ADA to do it! 113 Not sure what you mean by "talents” - knowledge? Ability to integrate knowledge and apply it rationally? Problem-solving skills? Communication or teaching ability? This needs to be defined in more concrete terms. Right now, just getting simple participation from more dietetics professionals would be a real improvement! A commitment to excellence within the profession. I think there is an extremely high need for leadership in dietetics. I think your operational definition is much too restrictive, mundane, and non- inspirational. I rate this medium - because I see it balanced among our professionals. Not everyone can always be at a High level of participation - because of what's going on in one's home life - Yes - we need to be more involved - and to the best of our ability beyond ”simple” participation - however in reviewing this list of categories - see it as important - but not the most important. I like to see dietitians who are eager to participate - and do the best of their ability/life status, recognizing the natural ebb and flow of involvement. Service to the Public I think service to the public is much more than providing information - I believe providing information is the job dietitians do, providing service is community service, unpaid types of activities Providing info to public is way to limiting to define ”service.” We serve the public through policy development for example and this is way different than providing nutrition information. This is a basic assumption. Service and providing information are two different areas. ”when paid for it”. Word "service" insinuates we should all be always volunteering, which I disagree with. Absolutely the heart of our profession. This will do more for making the dietetics professional better known than anything else. But the information HAS TO BE SCIENTIFICALLY ACCURATE. No quackery - supplements, herbals, etc.ll If you know your subject area and communicate effectively as listed below, this should follow as a matter of course. But first you have to have up-to-date knowledge and evidence-based information. This may be more or less directly related to one's job. If the job is public- oriented, then I would rate this high; but in general, a medium. 114 ? This category heading is confusing - makes it should like we're a service or government organization. I don't see doctors or lawyers having this category. The commitment to thoughtful info, to me, falls under communication and subject competence. Is this category trying to reflect ”Social Good"? While I agree that it's important as a citizen (and that everyone should do, i.e. personal qualities) - l rank it low in the overall scheme of specific categories that are important to the profession. Professional Image Again, this is more than cosmetic/dressing for success etc. Northing is more disturbing than an obese dietitian advising a person on weight control. Depends on your job situation. Important, but I also know some darn good dietitians who are not at their ideal weight! Again, I'm not sure what you mean by physical image and demeanor. Are you talking about someone's looks, weight, posture, fitness level, attitude, patience, communication skills, tolerance?? Are you talking about someone's taste and wardrobe, personal grooming, hairstyle?? Dietitians and the public make this important but it should not be. Dietitians should ”practice what they preach" in terms of fitness, weight, exercise, food choices, etc. but their body image should not be the defining characteristic for them. Their knowledge should be what is irmmrtant. A positive attitude is important, but looks are not as important as content. Professional image is important but I object to the physical image component. Depends on the definition of “appropriate", which is dependent on work environment. Basically, if all the other categories are positive, then this one falls in line. Effective Communication VIP but communication has other nuances beyond expressing ”knowledge.” Being able to speak in layman's terms would be most helpful in communicating our message. Using appropriate language depending on the audience - knowledge is not the only thing we communicate; listening is a communication skill as well If you cannot communicate, the message no matter how good is lost. That which is expressed must also be understood by the intended audience. 115 Subject Competence Again, way too limiting in definition. We maintain competence in many more ways than through CE. There are other ways to maintain currency, you may be creating the new knowledge, rather than participating in continuing education. This is most important and is most often not done. Not only in dietetics but all professions. Dietitians must understand science and know what current ideas are floating around and know the quackery from the potentiajy beneficial. Credibility and effectiveness is contingent on knowing the right information for your position. Add the idea of excelling during formal education to begin with cutting- pdge knowledge and high performance in the field. Also need to recognize that dietitians are not the expert in everything - and must not be threatened when they have to refer to others. Professional Ethics Way beyond just upholding the ADA Code of Ethics. Not only for the individual. The dietetic professional must call to task other dietetic professionals who are not ethical in their practice - including those who promote non-scientific nutritional therapies - herbals, supplements, cures, etc. To me, having accurate knowledge, communicating effectively, and behaving within the ethical code, will contribute to better service to the public and each healthcarpprofessionals Professional Dedication I would term this responsibility or accountability to the profession, rather than "dedication.” Givirlg as well as receivipg. Not sure this is the right term for this definition. Not sure what this means. Working with and for others is what this profession needs. We often compete with each other for attention rather than collaborate and suppon. Inherent Work Ethic I think as a profession dominated by women this is one principle that has had an adverse effect on our ability to earn competitive salaries What is this ”with disregard for monetary gain!” We have an inherent work ethic. We should not sell our profession short (by not negotiating for salaries), but we should not sell out either to any monetary concern - whether industry or tax-supported government progams. Important as a personal rather than professional characteristic. 116 This is very important but we also need to realize that bills need to be paid. As dietitians we should form some sort of union, as the nurses did many years ago, to ensure that salaries really keep up with the market and the level of education that we all have. By accepting less we ”cheapen” our value and possibilities of being paid what we really deserve. I would have rated this medium except for "disregard for monetary gain". RDs have been sellingthemselves too short for too long! Not clear as work ethic does not mean you don't have to make money: Work ethic relates to meeting job expectations 100% but don’t take the 'ob if you are not being paid what you are worth And we wonder why we have low salaries! Usually people work for satisfaction and reward - it may not be reasonable to work with disregard for monetary gain - salary status has been an issue in the profession for many years and will likely continue to be The profession will never advance in a profit-driven culture if it tries to convince its members to be altruistic and disregard monetary gain. You work hard within the profession with the expectation that your quality of life will be enhanced in part by financial gains that you could not get otherwise. No matter you are paid when working for your profession it never matches the hours and effort expended. I don't like the monetary link with this characteristic. Unsure of the meaning. If this refers to volunteerism, I would rate it high. If it refers to working for lower salaries, I would rate it low. It would be unwise, or stupid, to work with disregard for salary and appropriate pay. Our profession has lagged behind in pay for decades, and part of being a professional dietitian entails working to obtain better pay for ourselves and all others in the profession. Maybe put this in terms of altruism which sounds more professional than disregard for monetary gain. White laudatory - not realistic in today's society. I believe the profession can prgqress without sacrificingour livelihood. Personal Qualities These are givens for being a decent human being. How about respect and collegiality? Good citizenship is hard to define and means different things to different people - can you be more specific? This is all part of the tapestry. The design is the knowledge and competence, but what makes us effective in sharing the information is our integrity and ability to build rapport with whomever we work. 117 This category also encompasses part of the professional image category. To me - these qualities should be consistently present for us to help our clients and each other. Working with Others Again, what is this - maintaining positive relations with others outside the profession - as if we shouldn't??? Why this type of distinction? Makes those outside the profession appear to be less worthy than our own colleagues???? Don't think so. This does NOT mean the profession should try to accommodate those who promote non-science based nutrition therapies. If a group is defrauding the public by pushing nutrition quackery, they should be challenged. I think Carol Gallagher calls it building alliances in her book, Going to the Top. We need to create an atmosphere of cooperation with people that touch our career and personal lives. 118 APPENDIX 0 Electronic mail requesting participation in Round Four 119 Well, here we are. Scarred and troubled, but a strong nation. My heart goes out to all who were affected, both directly and indirectly. I so appreciate each and every one of you for continuing to help me with this project (and for your kind words of encouragement along the way) - THANK YOU! This is it, the final round (yeahl). Here is a summary of what has happened . . According to your rankings, the category of "Work Ethic" has been deleted. Most voted it as medium to low importance, and many included comments that expressed concern over the "monetary gain” portion of the definition. The final rankings dropped it well over 2 standard deviations below the mean. As a result, we are left with 9 categories; all with definitions that I feel have been strengthened due to your comments! They are now listed in order of importance (high to low) according to your votes. This is not meant to imply that any one is less important than another, it just gave me guidance as to what order to list the definitions in. Now, comes the final round of the Delphi Technique. In this questionnaire, you will find the final 9 categories listed. I am asking you to tell me how you think the profession of dietetics is doing in relationship to these categories (are we on target with your expectations, are we exceeding your expectations, or are we falling below your expectations). In the case that you choose ”falling below expectations“, I am asking for you to provide suggestions that would help the profession improve in this area. Finally, you will find a few basic demographic questions at the end, designed to help me explain who participated in every round of the Delphi. The final questionnaire can again be found at htth/wwwdieteticprofessionalism2.net and should take approximately 10-15 minutes to complete. Please be sure I have your submissions by 5:00 pm. EST on Thursday, October 4, 2001. Again, I thank you for your participation. As always, if you have any questions, please do not hesitate to ask. Have a wonderful day. Take care, Diane 120 APPENDIX P Round Four Questionnaire 121 By completing and submitting this form, I am indicating my voluntary agreement to participate in this research study. Instructions: 1. Please rate how well the Profession of Dietetics is currently meeting the Operational Definitions (there are 9 in all). 2. If you rate the Operational Definition “Below Expectations”, please indicate suggestions for improvement. 3. Finally, answer the demographic questions at the end. Professionalism How well the Profession of _Dietetics is If vogchose Category and c_urrentlv meeting the Operational “Below Opefitjpnal Definition Definitions Expectations”, then what would you W W Subject Competence: Above m Below Using continuing Expectations Tar et Expectations education, both format 0 . O I I and informal, to maintain and provide accurate, scientific, and up-to-date information. Effective Above Q_n Below Eoi'nmunifation: Expectations Tar et Expectations r t is enan 0 your audience and O . O expressing clear and concise knowledge, which is appropriate for, and understood by, the audience. Leadership: Above Qp Below Contributing one’s Expectations Tar et Expectations talent and strengths to t l influence activities, 0 . O which promote goal achievement. Professional Ethics: Above Qp Below Being responsible for Expectations Tar et Expectations upholding and O . O f TI behaving within the ADA Code of Ethics. 122 Working with Others: Above Q Below Maintaining positive Expectations Targ_e_t Expectations relationships with O . O others including those F outside of the profession. Service to the Public: Above @ Below Commitment to Qpectations Targ_e_t Expectations t providing the public 0 . O with thoughtful, well- reasoned, and scientifically accurate information. Professional Above g1 Below Responsibility: Expectations Tar et Expectations Working to further the O . O profession by lending I support to, and accepting support from, others within the profession. Personal Qualities: Above Q_n_ Below Maintaining basic Expectations Tar et Expectations personal values (such as: courtesy, O . O t credibility, confidence, respect, etc.) and good citizenship. Professional lmagg Above 91; Below Portraying to others the Expectations Tar et Expectations appropriate physical O . O t image and demeanor, which is acceptable within the work environment. Gender Male CI Female CI gigaglttggrmal Education Level BACHELORS MASTERS DOCTORAL Registration RD E] DTRD Approximate number of years practicingin the field of dietetics I I 123 Clinical El Foodservice [:1 Current and primary area of practice School Faculty CI Consultant CI Community/Public Health El Other I j Geographical Location NORTHEASTERN us. I SOUTHEASTERN u.s. MIDWESTERN us. SOUTHWESTERN u.s. NORTHWESTERN u.s. WESTERN U.S. OTHER Do you currently work directly with Yes [:1 students (undergraduate, graduate, or No C] interns)? When did you first become aware of t l professionalism in your own life? In orper to ensure that those who completed final round, please provide us with your name. Please note that all responses submitted will be separated from the names provided in order to help assure confidentiality for those who choose to participate. Name: Please submit this form by 5:00 pm. EST Thursday, October 3, 2001. Submit lnforrnation 124 APPENDIX Q Reminder electronic mail for Round Four 125 This is a follow-up email reminder that the deadline to submit your response for the final round of the Dietetic Professionalism Research Project is fast approaching! Please log onto http://www.dieteticprofessionalism2.net by Thursday, October 4, 2001 at 5:00 pm. EST to do so. I thank you for your time. Take care. Diane Golzynski PS. If you feel that you received this email in error, please email me at lentnerd@msu.edu and I will resolve the matter as soon as possible. 126 APPENDIX R Round Four Data 127 1 Communication Ethics w/ Others to Public 128 Dedication Qualities 129 rs Pract 1 130 Female Resource ist for educ rat Clinical Research center 131 faculty [MW es consultant INE no [Business W [no Education and Consultant INE as faculty W yes Program administration and graduate Education SW es Private practice NE es consultant SW es |Dietetic Internship Director-hospital based W es Research and Education SW es clinical SW es consultant W [no Business [MW no clinical IMW yes Foodservice SW no clinical/faculty [NW yes acuity IMW es clinical/foodservice W es Community W yes clinical [MW es IHealth Care Marggement paw es Training business [NE no Clinical [MW es Community NE no Renal nutrition support/home infusion pharmacy W es Comments Subject Competence I would say ”on target.” This is such an individual issue. I do believe ADA's professional development portfolio helps address this issue, however, I still see ractitioners who have not necessarily kept up with the scientific literature. 6 are getting more diverse in out methods of disseminating information to dietetics professionals, but there are many within our profession who continue to lag behind on current, evidence-based research. Many are still doing things the same way they did 10-20 years ago. we need to institute competency standards, MNT processes/guidelines, encouragement and support to those in the profession who are change-agents. personally, I think we should have to take a competency exam in our area of practice every 5 years. We should focus more on the "accurate, scientific” part of information. Not the “current and popular" part. Not all information is scientific. The majority of dietetic professionals do not work in a clinical setting and their continuingducation needs are not being met. 132 Peel there is a lacking of application in the clinical setting of perhaps what is learned both formally and informally. I think by having continuing education situations that deal with realistic application, such as in an 1:1 counseling session either taping it (audio or video) with permission or role playirLg, etc.. On target for many but also below expectations for others. I'm amazed by the uestions that come into our listserve. The just initiated PDP 2001 (ProfessionalDevelopment Portfolio) will/has greatly ienhance the subject competence ofthe members. If this were not in place - l WOUId have checked ”belowexpectations.” While the program results/impact is still not known, I seethis as the right step for our members and the profession in ensuring theyare current and competent in the areas they practice. Even though I marked ”on target” we must do a better job of promoting evidenced based nutrition. This is essential to our credibility as nutrition professionals and what separates us out from other practitioners and providers of nutrition information. o a go. The Assoc is addressing this. it is my hope for a brighter future that makes me rank this as ”on target“ because I think we continually need to reach fonivard to the targe_t. l‘l'm biased, I believe that ADA, as the leading org for the profession, has a ways Effective Communication Overall, I think the profession does not step up to the plate and communicate as well as it should. A lot of this is directly related to competency. Too often dietitians enter a patient's room with the handouts completed before they even [talk to the patient to find out what the patient wants or needs. we need to provide communication skills training as well as assertiveness training for dietitians. [Need more training on working with diverse and low literacy audiences. Many dieticians still "preach" nutrition messages to their audience. Although we have improved tremendously over the past 10 years to make our messages more customized and realistic to the intended audience, we must continue to improve in providing clear, concise and understandable messages. also we must avoid jumping on bandwagons and then later having to modify or refute messages previously given to our patients or consumers. RD's are out of touch with the knowledge of consumers. They need to practice their talk in front of friends before presenting to an audience. Research done by IFIC strongly identifies that the dietetic professional is not able to communicate in a fashion that receives a positive response from recipients of the information. Too often out language is oversimplified...our audience (the public) is more sophisticated than ever and is bored by simple explanations. Courses, workshops, interactive video training in communication skills. Based on information I obtain from my clients some of our colleagues are not listening to the client. The best way to resolve is to begin to ask oneself, what is the client/audience askingfor? Am I fulfillipq their need? 133 More exposure to the media from the ADA Ambassadors especially on nationwide daily news programs. Whis varies so much. As a profession, perhaps we are below expectation [because the public still doesn't recognize the profession as the leading source of food and nutrition information. Communications are such a key to impacting behavior and change (both in the clinical and practical settings). I think we need to do more at the undergraduate level to help our members become better listeners and communicators. This could be in the form of lessons; practical applications in a variety of settings; cross functional liraining/experiences with other professionals (i.e. pharmacy; nursing; insurance agents) Overall I do not believe most dietitianscommunicate well to their respective audiences. We often get tied up with"protocol" and miss the big picture. For example, if we are working withMDs we need to speak like they do. We do this very well for the selected spokesperson group, however our lresources are very concentrated in this arena. Could improve by developing training programs for a broader spectrum of our membership. [Do a better job of balancipg knowledge skills and comm. skills However, some professionals' skills need improvement in communications with diverse individuals and groups, as well as being able to separate personal references and emotions duringcounseligg and education. Leadership More format leadership training provided. The new Professional Development Portfolio system should help. It would be nice if everyone was more active, but overall, I think we have many members who are willing to give their time and talents. WE need to do a much better and consistent job of demonstrating our leadership and expertise in nutrition and food. We must become recognized as the experts in these areas in the minds of our colleagues, consumers and media. There seems to be a problem with sharing your talent. I don't know why. We lneed to convince RD's that the more we share, the better we do. We need to encourage those dietetic professionals who think out of the box to lspeak to their ideas. Most of our leaders are developing their own businesses or working hard for others and do not have the time not the inclination to try to influence an association that is behind the times and not meeting member needs. I think the leadership aspect is lacking because many think they do not have ime to get involved in leadership or do not want to be bothered. They see this as ”someone else's job." how we fix this is something I am, as an internship director, trying to explore. we need somehow to show people that leadership is a professional responsibility. I do not, at this time have a better answer. 134 Too many people do not see the bigger picture, don’t know the history and development of the profession and need to feel part of something bigger than their own ambitions. Profession does little to offer this-again, self-study lmodules, workshops with small group discussion on leadership-how, why, who ”they” are. I feel many new RDs do not want to share their time to volunteer for our [professional assoc. They do not seem to be committed to the profession? A simple word to explain it the way! see it is they are "selfish". Sad to say this. This is borderline between on target and below expectation. I base this on what appears to be a falling off of young professionals interested in leadership ositions. As a whole, most RDs fail miserably in this area. It is important to go beyond the 8 hour day and normal routine. In general, I think dietetic practitioners in general do not display expected levels of leadership. Many are dependent on others to take the lead. They sit back and wait for good things to happen to them. They blame ADA for ”inadequate” lsalaries. They expect others to get insurance coverage for them. Many maintain the status go in health care even though systems are changi_ng dramatically. Moving in this direction by streamlining ADA'sgovemance process. However, have seen a strong focus on processes vs.outcomes, achieving compliance with standards rather than taking the lead onchanging outdated standards, focus on lindividual practice groups but not oncombining , collaborating the efforts of these ”ups. national Leadership Development Program Again, as professionals move forward in their careers, the bar must be continually raised. 'Professional Ethics The Code is published but I don't think the average practitioner has a clue about what it says. Somehow we need to make this document and what it means come alive by showipg how it can be used. Stronger lobbyist, stronger links to nutrition research leaders, stronger public identity. WE have become afraid to call to task dietitians who act unethically by promoting nutrition quackery through the sales of alternative medicines, supplements, herbals, etc.. This is not emphasized enough in writings, lectures, journal articles. INot addressing members that blatantly disregard the Code of Ethics. When violations are pointed out ignore and do not take action for fear of legal action by filly party- Working w/ Others 135 I think we do ok with working with each other, but reaching outside the profession and teaming to collaborate and be a team player needs help. Need to focus on this more in undergraduate education as well as on the job. There is a movement to expand beyond our own pod-individually and grganizationally. We need more training on working in teams and taking initiative and finding creative ways to initiate collaboration with other. Rd's are shy and introverted, not only in the US but worldwide. They need to ggin confidence to say what they think. [Based on recent comments I read on the proposed new membership categories for ADA I feel many RDs are insecure about their jobs and afraid others will take their jobs i.e. chefs. I think many are too narrow minded and not open for needed change. Although strides have been made in this area, I still find that dietitians are easily threatened by other professions and fail to recognize that others can not know his if we do not become their colleagues. That means we must respect what hey do if we want respect in turn. [Dietetics sometimes seems isolated - we need toencourage joint teaming among our undergraduates and interns. More jointexperiences (i.e. working to pass dietary supplement legislation) mightyield long-term tangible and intangible lresults. Spending more time out side profession than working with current members. I think there is still a lot of tension between nurses and R05, especially in health care institutions. Dietetics is still viewed as a ”lowly” profession. More promotion and encouragement (professional credit for working on issues and teams with other professions. Service to Public I was truly disappointed when an ADA media rep goes on TV and tells everyone hat a low albumin means they need to eat more protein. We need to educate dietitians and keep them current so that science and practical application work synergistically. RD's don't know enough about complementary and alternative medicine therapies to make recommendations for clients. we need more raining and glidance. We need to learn how to take initiative and effectively communicate information Ito the public through mass media. We need stronger links to science community, public policy, and community service orgs. [see comments for effective communication questions The profession has become too willing to become part of the nutrition quackery foisted off on the public by alt med and supplement/herbal hucksters. We need to get back to making people understand how nutrition relates to health. The Lure of profit is eroding our ethics. 136 [More newspapers and magazine articles outside of professional journals and the NY Times. AT times we may be too conservative. I think the profession is still too inwardly focused. Unless there is consumer/public demand for our service, there is no need to have educational | rograms to prepargprofessionals. Take stand of those that provide money to association rather than an unbiased information. this has improved, but we could take more initiative in working with other health care professionals, educators, and policy makers. see comments under communication Professional Dedication This is improving with development of mentoring programs, but in the workplace lmany dietitians don’t support each other's accomplishments or ideas. We often do not play well together”. We need to continue to foster each other. The [mentoringgroups are a great start-let's see how they do. [Many persons precept others without remuneration. WE are committed to service to the public but need to increase our forum. At times the information the public gets is confusing to them. We need to use [simpler language and be clearer about the message we want to convey. 0 share and try to advance the associations membership. It is a very Fltany dietetic professionals are jealous of others success and do not reach out unfortunate situation. [Many do not understand this concept and do not see their role as lending support as preceptors, as mentors, or as active participants in professional associations. l have always told people that I do not want to be ”paid back” for Lwhat l have done for them, I want them to do the same for someone else. Role modeling may help, but that is not the complete answer. People have to be shown where they fit in with specific talents and be taught what professionalism [is all about. From my experiences both being on the boardof DPG and requesting information of colleagues, the profession seems ratherterritorial and not willing to share. In order for the profession to bebetter recognized by other disciplines we [need support each other in any waywe can. We need to help our members better understand ”group processes” and how [just because someone questions - no need to take it personally. How do we 'desensitize” the members when working toward common goals - so that they can accept input from everyone. We are too self centered. We need to be more involved with other organizations and other professions [But honestly can't think of examples of how we are tangibly doing this... Promotion of professional responsibility to the profession through basic [education 137 Although many dietetic professionals take theinitiative to volunteer their services to the profession, the professionoften does not reach out to lend support or rguest support from otherswithin and outside of the profession. [national Leadership development program I personally believe (and observe) that many dietetics professionals could add some level of volunteerism to their career and life. Personal Qualities We have come a long way from the ”whites” and sensible shoes. Overall I think our energy, confidence, and appearance are ok. [Did not rate below expectations, but we can do better at networking with other professions and teaming from them how to be more effective in our messages and goals. Professional Image We have come a long way from the ”whites' and sensible shoes. Overall I think our energy, confidence, and appearance are ok. There is a need to get away from the drift toward “image is everything” kind of thinking. We have to convince people that dietetics is a knowledgeable Dull and frumpy comes to mind. Being stylish can open doors and lead to rofession, not an attractive, well-dressed profession. romotions and better acceptance. That statement is simply scary--given the current Eating Disorder epidemic...why is the ADA so fixated on physical image AND is there scientific evidence to underscore a positive relationship with physical image and an ability to be a professional? Hopefully! Most of the time. There are many RD's who are ovenNeight andobviously do not practice healthy Ihabits. This turns many people off. Inhospitals, I often see RD's dressed in scrubs, which is fine for those whowork in intensive care units perhaps, but not for all of them. We areusually paid well enough to dress so that we will be recognized asprofessionals, not that I believe there is a need to wear a suit every day!And certainly we need to be at a normal weight, not 30# overweight! This could be border below expectation because this definition is still unclear to me. Hate to say this - but we need to teach dietitians how to always present a professional front. One colleague mentioned how the Hotel and Restaurant management program at her university instilled this ”spirit of professional” look and style into all its students... the dietetic program could team a few things.” Again - we should reach but and cross pollinate with other programs/professions that we benchmark ourselves against. 138 ' I do not believe most dietitians present a very professional image. This may mean achieving and maintaining IBW as well as speaking in a more professional manner. I strongly object to the ”physical image” component to this statement and feel that this could be considered discriminatory. What about the "size acceptance” philosophy? I personally am of normal weight. Still opportunity for improvement, tend to portray the support vs. the professional image. 139 APPENDIX S Thank you electronic mail to final round participants 140 Hi [appropriate name inserted here]! I just wanted to take a moment and say thank you for participating in my study. I really appreciate the time and thought that you put into this project. If, by chance, you are going to FNCE, I'll be at the Product MarketPlace, booth #15. I'd love it if you could stop by so I can thank you in person. Take care, Diane 141 APPENDIX T Snowball Technique Response 142 i; x [II If XXX XX XX [I X kl X t1 XXXXXX X XX Ff fix XX X XXXiX X XX X Xi X X X XXX XXX XXXXX X X 1K- ! X . | I | Legend- . . xxxxxxxo O=Respondent who provrded additional names to add to the list of potential subjects. [3 X=Nonrespondent. I; XI E X X 143 BIBLIOGRAPHY 144 BIBLIOGRAPHY The American Board of Internal Medicine. (1995). Committee on Evaluation of Clinical Competence. Project Professionalism. ABIM, Philadelphia. The American Dietetic Association. (1999). Code of Ethics for the Profession of Dietetics. Journal of the American [fistetic Association 99 109-113. Arnold, E.L., Blank, L.L., Race, K.E.H., & Cipparrone, N. (1998). Can Professionalism Be Measured? The Development of a Scale for Use in the Medical Environment. Academic Me_djcine. 7C; 11 19-1 121. Beemsterboer, PL (1997). Academic Integrity: What kind of students are we getting, and how do we handle them once we get them? Journal of Dental Education 61 686-688. Bowman, J.S. (1998). The Lost World of Public Administration Education: Rediscovering the meaning of professionalism. Journal of Public Affairs Education 1, 27-31. Brakke, D.R., Escott-Stump, S., McCoy, B., Flynn, C., Babjak, P., & Dougherty, D. (1998). Standards of Professional Practice for Dietetics Professionals. Chicago, IL: American Dietetic Association. Retrieved March 3, 2001, from the World Wide Web: httpzllwww.eatright.com/qm/standards.html. Campbell, E. (1997). Connecting the ethics of teaching and moral education. Journal of Teacher Education 48 255-263. Carroll, J. (2001). Being professional in an unprofessional climate. Th_e Chrgnicle of Higher Education. Retrieved October 5, 2001, from the World Wide Web: http'J/chronicle.com/joba/2001/2001 100501 c.htm. Commission on Accreditation/Approval for Dietetics Education. (1997). Accreditation/Approval Mangal for Dietetic Education Programs (4th ed.). Chicago, IL: The American Dietetic Association. Crist, PH. (1986). Contemporapi Issues In Clinical Education. Thorofare, NJ: Slack. Delbecq, A.L., Van de Ven, A.H., & Gustafson, DH. (1975). Group Technigues for Prmram Pis_nning. A guide to nominal group and Delphi processes. Glenview, IL: Scott, Foresman and Company. Faulkner, L.R., & McCurdy, R.L. (2000). Teaching medical students social responsibility: The right thing to do. Academic Medicine, 75. 346-350. 145 Fidler, G. (1996). Developing a repertoire of professional behaviors. American Journal of Occupatiorgl Therapy, 50, 583-587. Gibson, D.D., Coldwell, L.L., & Kiewit, SF. (2000). Creating a culture of professionalism: An integrated approach. Academic MedLicine. L5, 509. Ginsburg, S., Regehr, G., Hatala, R., McNaughton, A.F., Hodges, B., Lingrd, L., & Stern, D. (2000). Context, Conflict, and Resolution: A new conceptual framework for evaluating professionalism. Academic Medicine, 75, 86-311. Haessig, C.J., & La Potin, AS. (2000). Outcomes Assessment for Dietetics Educators. Chicago, IL: The American Dietetic Association. Hira, T.K. (1996). Ethics: Personal and Professional Implications. Journal of fimilv and Consumer Sciences. 88. 6-9. Kasar, J., & Muscari, ME. (2000). A conceptual model for the development of professional behaviours in occupational therapists. Canadian Journal of Occupational Therapy, 67, 42-50. Linstone, H.A., &Turoff, M. (Eds.). (1975). The Delphi Method: Techniwesspd Applications. Reading, MA: Addison-Wesley. Loeser, H., & Papadakis, M. (2000). Promoting and assessing professionalism in the first two years of medical school. Acad_emic Medicine. 75. 509-510. Markakis, K.M., Beckman, H.B., Suchman, A.L., & Frankel, RM. (2000). The path to professionalism: Cultivating humanistic values and attitudes in residency training. Academic Medicine 75 141-150. Merriam-VLebster’s collegiate dictionary. (2001). Retrieved April 7, 2001, from the World Wide Web: httpzllwww.m-w.com/cgi-bin/dictionary. Morehead, MA. (1998). Professional Behaviors for the Beginning Teacher. American Secondary Education, 26, 22-26. Odom, J.G. (1997). Academic and Clinical Ramifications of Integrity and Cheating. Journal of Dental Education 55 272-275. Payne-Palacio, J., & Canter, DD. (2000). Professionalism. In N.W. Marquardt (Ed.), The profession of pietetjcs: A team approach (pp. 101-129). Upper Saddle River, NJ: Prentice-Hall, Inc. Rodriguez, J.C., Robinson, N., & Martin, T. (2000, Fall). Teaching the ABCs of Professionalism. DEP-LINE, 21, 1, 4-8. 146 Sallot, L.M., Cameron, G.T., & Weaver Lariscy, RA. (1998). Pluralistic Ignorance and Professional Standards: Underestimating professionalism of our peers in public relations. P_uplic Relafigns Review. 251, 1-19. Spady,W.G., &Schwahn, C.J. (1999). Keys to Professionalism. American School Board Journal 186 26-30. Swick, HM. (2000). Toward a normative definition of medical professionalism. Academic Medicine. 75. 612-616. Wear, D., & Castellani, B. (2000). The development of professionalism: Curriculum matters. Academic Medicine. 75. 602-611. 147 IF. ..