PEN eNews 1(6) April 2012

Dear PEN Subscribers,

We are thrilled to have connected with so many of you through our Facebook and Twitter accounts! Now, in addition to connecting with us via email, and Contact Us on the PEN site, you can join our Facebook group, follow us on Twitter @pennutrition and soon we will have a LinkedIn group! Read this version of PEN eNews to find out about resources that can help support you as you take the leap into social media.

You will notice that this is our first issue in our new electronic template, created based on your feedback from the past year. In this issue, we have articles to enhance your skills in evidence-based practice and our regular articles to show you how to optimize your time spent in PEN, and help you get to know the PEN Team.

PEN is your Global Resource for Nutrition Practice. We value your feedback. What topics should PEN eNews cover? What is useful? What isn’t? Send your feedback and ideas to JayneThirsk, PEN Director; or Kristyn Hall, PEN eNews Editor, at eNews@pennutrition.com

Welcome to PEN eNews

We’re drowning in emails, we’re over-whelmed with the +++ different social networking sites available, and we are doing more work with less time.  There is prolific nutrition information available for consumption along with a feeling of urgency to read this report, scan this journal, evaluate this program and demonstrate our value.  We do all this while figuring out – what is for dinner, who is taking the kids to soccer, who is taking mom to her doctor’s appointment, who can pick up more milk and fresh produce.  And yes, we need to figure out when we are going to fit in our next training run or Pilates class, be ready for our next book club, and remember to take care of ourselves!!  Do things ever slow down?  

Kristyn Hall MSc, RD
Editor, PEN eNews

What's New in PEN

Wondering what is new in PEN? Here is a list of our updated content in PEN, including updated knowledge pathways, new practice questions, updated practice questions, new professional tools, updated professional tools, and new handouts available.

How do I….

Reference

PEN?

Many health professionals use the information in PEN for presentations and handouts. We are often asked “How do I reference PEN if I use information from it in a presentation?”

There are several different types of resources available through PEN and therefore different permissions apply when citing/referencing or reproducing these documents.

Referencing documents developed by PEN

Dietitians of Canada owns the copyright on all knowledge pathway questions, key practice points, evidence statements and summaries, background documents and practice guidance summaries. If a user wishes to cite or use part of the information (and not the entire PEN document) for a presentation or resource, there are 7 pieces of information needed to citing PEN appropriately:

Dietitians of Canada. 

[Insert name or title of the PEN information used]. Access only by subscription.

Here is an example of how this looks: Dietitians of Canada. Does diet have a role in preventing hypertension? In: Practice-based Evidence in Nutrition [PEN]. 2012 February 7 [cited 2012 Mar 1]. Available from: http://www.pennutrition.com/KnowledgePathway.aspx?kpid=674&pqcatid=144&pqid=668. Access only by subscription. 
Keep in mind that documents developed by PEN (e.g. practice questions, practice guidance summaries, evidence summaries, backgrounders and even complete knowledge pathways) can be downloaded for personal, non-commercial use, research or study. For example, licensed subscribers may download, duplicate and distribute copies of the PEN branded client handouts for educational use with their own clients. However, institutions must have sufficient numbers of site or group licenses in order to make multiple copies to meet client needs. Have questions about anything to do with citing or licensing? Contact us at http://www.pennutrition.com/contact.aspx

Reproducing Third Party Tools

PEN also contains tools that are from outside organizations and deemed as being consistent with the evidence. These documents include client tools, professional tools, research papers, documents and webpages and links that point to external websites from PEN. PEN has sought permission to include the links within the PEN database but since PEN does not own the copyright for these resources, you should contact these associations directly to learn about their copyright policies and permissions if you wish to do anything other than simply share the full resource with a client or colleague. This information is usually found on their website. They will provide a contact email address that will allow you to send them an email requesting permission for the specific resource you would like to use.If you have any questions about the information in this article, email me at lisa.koo@dietitians.ca.

"PEN has simplified my life in so many ways. Now, I can really focus on my areas of practice – and “outsource” my staying abreast of various topics to PEN."

PEN Insider

Spotlight on Kristyn Hall

My role with PEN: I wear a few hats…

I have been involved with PEN since 2003 when it was first envisioned as a Professional Support Tool.  At that time, I participated in the PEN Advisory Committee.  In 2007, I did an evidence-based review for the [then-called] Calgary Health Region looking at best practices for pediatric obesity treatment.  This formed the basis of work that I continued with PEN as a Evidence Analyst contractor.  I have written content for the following PEN pathways: 

• pediatric obesity treatment, 

• safety of soy consumption throughout the lifecycle, 

• infant lactose intolerance, 

• infant colic, and 

• toddler and preschooler nutrition.

In the past year, I expanded my contract work in the PEN team to PEN communications, including being the Editor of PEN eNews, and the social media lead for the PEN team.

A day in my life with PEN:
PEN is a living and breathing support for dietetic practice 24/7 - as a result, I am too!!  As a contract evidence analyst, I:

• subscribe to electronic tables of contents, which alert me to new literature available. 
• am a part of various list-serves and electronic newsletters which help me stay abreast of practice issues relevant to dietitians, and what is in the news.  

Depending on what phase of the PEN Pathway development I am in (see article Birth of a PEN Pathway, page 4,  http://www.pennutrition.com/pdf/NewsletterFeb2012.pdf), I could be doing any of the following:

• devising a search strategy, 
• acquiring new evidence, 
• critically appraising an article, 
• writing an evidence-summary of an article, 
• doing an evidence-analysis of the literature reviewed, 
• completing the various parts of the PEN knowledge pathway template – practice question, backgrounder, practice guidance summary

As the Editor for PEN eNews, I work with the PEN team to plan and write articles about evidence-based dietetic practice, knowledge transfer, continuing education and optimizing time spent in PEN.  In my role as the social media lead, I plan and monitor our social media accounts on Facebook,Twitter and LinkedIn (new).
These are a “few of my favourite things” about PEN:  

• PEN facilitates opportunities for transition to new and evolving roles in dietetics.  The dietetics world is my oyster!
• PEN is dynamic and is set up to be responsive to new evidence.  
• PEN has simplified my life in so many ways.  Now, I can really focus on my areas of practice – and “outsource” my staying abreast of various topics to PEN.  Then, when a friend asks me “are you a dietitian?  I have a question about….”, I can go to PEN for my answer.  Phew!

Biggest learning from evidence-based practice; from taking a PEN approach? “The difference between background and foreground questions” Background questions form the foundation of nutrition and dietetics and are less likely to require constant updating.  Foreground questions highlight the complex questions that dietitians are faced with every day.  This difference helps me organize the new information I consume, as well as structure the questions I ask.

PEN in Action: Microwaves and Shifting Perspectives in Dietetic Practice

"I am 54 years old. I have spent most of my time as a professional working with the diet manual. Diet manuals are static until the next Diet Manual comes out. If the information is out-of date, you know you will have to search for new sources of information yourself. I was in the habit of reviewing the literature, usually Medline, to supplement the Diet Manual. Recently I started using PEN which enables me to access timely information efficiently.” Judith Proulx, Registered Dietitian, Algoma District Cancer Program, Ontario. What influenced Judith to start using PEN?

In 2009, Judith began working in an outpatient oncology program in Ontario, Canada. As she began counseling women with breast cancer, the question came up – after a breast cancer diagnosis, is it safe to include foods containing soy in my diet?

The consumption of soy foods in the diets of women being treated for breast cancer is controversial. The practice up until late 2009 was to automatically state – NO soy if you have had estrogen receptor breast cancer. This recommendation was based on results from animal and in vitro research. In late 2009 several Asian studies where published whose findings suggested that Asian women who consumed soy foods had lower incidence and lower recurrence of breast cancer. This created doubt about the wisdom of advising against soy food consumption amongst the health professionals at the Cancer Program. Judith wondered – what do other dietitians in this area recommend? What resources are they using to formulate their messages? To find out, she worked with interns in the Northern Ontario Dietetic Internship Program (NODIP) to conduct a survey of dietitians working in this area.

Questions were expert reviewed and pretested. The 13-item survey went out to 155 members of the Dietitians of Canada Oncology Network in April 2011, of which 25% of members responded. 

Key findings:

• They found that 31% of dietitians did not make soy food recommendations to female breast cancer patients. 
• 53% felt the perceived adequacy of information available on which to base recommendations were unclear or somewhat unclear. Over half felt uncomfortable giving recommendations. Many felt they didn’t know what to say.
• Some dietitians change the amount of soy foods they recommend based on the estrogen receptor status of the patient, providing cautious advice to ER positive breast cancer patients. There was variation in recommendations 0-3 servings of soy per day. Just like the literature, dietitians surveyed had wide interpretation of soy research. 
• There was variation in the sources from which dietitians consulted to obtain the answers to their questions, including PEN, independent literature reviews, American Institute of Cancer Research and from learned colleagues and researchers who study soy. PEN was identified as a key resource used to determine advice. 

 “PEN is a living thing that you can use to help you form your critical decision making.” 

Coincidentally, two weeks before survey went out, PEN updated a client handout called Eating Guidelines for After a Breast Cancer Diagnosis, indicating that consumption of two servings of soy foods is safe after a breast cancer diagnosis.

Judith’s research study highlights the change in dietetic practice of how we know what we know. Previous recommendations were based on animal and cell research studies; published human research provided the foundation from which practice guidance could be developed in this area. “There are different levels of evidence – cell studies, in vitro, in vivo, animal studies – this distinction is important for oncology dietitians to know. We cannot just extrapolate the results from preclinical studies to humans.”

The good and bad news about nutrition and dietetics is this: “What you read last week – it might have changed. When you are busy, it is difficult to change practice, or even think about changing practice. But this is the nature of our work. Now, instead of going madly to Medline hoping to find something, I go to PEN for answers to my nutrition questions”.

What 3 things facilitated Judith’s shift in perspective from a diet manual to a PEN knowledge transfer approach?

1. Needing to save time: “There is a huge time commitment for literature reviewing. Now I can spend my time elsewhere.“ 
2. Having access to the PEN database:  "The Northern Ontario School of Medicine (NOSM) had a site license and as a dietetic intern preceptor for the NOSM affiliated NODIP there was access to a knowledge transfer database." Now, access was at Judith’s finger-tips. 
3. Diving into PEN. “I looked up a few things – and thought WOW, people have done all that work for me; I don’t have to do my own Medline research anymore! It is succinct and easy to understand. I can look at the references myself if I want, AND I can access all the resources if I want them.”

Judith describes her transition from a diet manual approach to a PEN approach using the metaphor of learning to use a microwave. Growing up, she remembers her mom as a very basic cook who only had a few staples that she felt confident preparing. But when the microwave came out, her dad bought her mom a microwave; her mom took lessons and became a fabulous cook. Her mom was still able to put a plate of food on the table – her family was still getting their dinner – but how her mom got there was different, and the results was an improved final product. It is important to note that just having the microwave did not change the quality of the family meals. It was necessary to learn how to use the microwave and to use it on a regular basis. This is the same process that Judith needed to take with respect to using PEN.

“PEN has grown in breadth and depth and is rich in what it can offer. If you haven’t subscribed to PEN recently, you need to come back and give it another try.” Says Judith. “PEN is a living thing that you can use to help you form your critical decision making.”

Applying

Health Literacy to Your Practice

Part II

How can individual health professionals help people become health literate? By presenting information in ways that can be understood and allow people to act on the information. When people are more health literate, they can:

• make informed choices
• reduce their health risks
• better navigate the health system; and 
• improve their overall wellness and quality of life². 

How can dietitians improve their health literacy practice?  The Agency for Healthcare Research and Quality Health Literacy Universal Precautions Toolkit³  provides the following suggestions:

• Be aware of spoken communication
• Use plain, non-medical language and common words when speaking to clients
• Slow down: Speak clearly and at a moderate pace; focus on what clients should do, when they do it and why it is of benefit to them. 
• Teach-back to clients: Confirm clients understand what they need to know and do by asking them to teach back directions. For example you can ask your client, “It is really important to share your eating plan with your family. How will you explain to your family what you need to do to control your diabetes? 
• It is noted that dietetic culture is holistic and focuses on patient empowerment . The style of teach-back to client needs to be integrated into this culture. 
• Improve written communication. Use/develop easy to read, clearly designed materials
• Assist clients in self-management 
• Provide supportive systems such as print material to support verbal instruction or referrals to other health professionals. 

Improving health literacy in the health system - 5 dietitian practice points:

1. Use a universal precautions approach where plain language and clear communications are used with ALL clients.
2. Promote health literacy in your workplace. Ensure clear messaging for staff and clients in media work, signage in clinics and on health related forms.
3. Collaborate at all levels and with many different sectors to decrease health literacy barriers: 
• local, regional and national governments and different ethno-cultural communities
• practitioners and policy-makers
• literacy and health professionals 
• researchers and practitioners 
• health care institutions and clients.
4. Advocate for health literacy education in professional education programs: 
• Align community services and resources with health literacy information
• Work with media to increase awareness of health literacy 
• Use the teach-back approach/check for understanding. 
5. Communicate clearly in all health information:
• Includes limiting the number of messages; testing with target audiences; being culturally sensitive; and providing message in diverse formats, i.e. print, video, etc.

Communicating at the level of understanding of their clients is critical to achieving behaviour change in individuals and populations. Dietitians have a central role in changing themselves, the communities and organizations that they work with.

To learn more about clear language, see Health Literacy resources listed below.

Health Literacy Resources- To learn more about clear language, the following sites provide free on-line training opportunities for health professionals:

• Canadian Medical Association Health Literacy Course 
• Centres for Disease Control and Prevention - Get Training 
• Plain Language - National Institute of Health

Guidebooks/Toolkits for Health Literacy:

• Simply Put 
• Toolkit for Making Written Materials Clear and Effective
• Writing Health Information for Patients and Families

Stay tuned for a Health Literacy Knowledge Pathway on PEN in the near future!

 Have a question about this article? Contact us at: eNews@pennutrition.com

Announcements from PEN

Include PEN in your regulatory body continuing education plans this year!

For many Canadian Dietitians, this is the time of year when they report their ongoing professional learning plans or competency attestation reports to their provincial colleges. For DAA members, this is the time for membership renewal and maintaining Continuing Professional Development logs. Remember, writing or reviewing PEN content is an accepted learning activity! Reviewing a PEN knowledge pathway for personal learning is also accepted as equivalent to reading a journal article by many. PEN is also pleased to be recognized as a content reference for the Canadian Dietetic Registration Exam. Put PEN in your plan!

UK dietitians, are you ready for the HPC audit?

Every two years, a proportion of UK dietitians will be audited by the Health Professionals Council. If you are selected, you will be contacted in April and your continuing professional development (CPD) portfolio will need to be submitted by June. Did you know that dietitians can add PEN to their CPD portfolio? If you have reviewed pathways, written PEN factsheets or developed your own factsheets for use in the clinical setting, which have been informed by PEN content; these can all be used as proof of CPD for your portfolio. Another way of using PEN in your CPD portfolio is to write reflections (an essential skill for UK dietitians in proving their CPD). How has your practise changed since being informed by the information on PEN. Add PEN in your plan.

Dietitians specializing in gastrointestinal diseases wanted!
Do you practice in the area of gastrointestinal disease? Do you want to try your hand at writing for PEN? There are a couple of pathways in PEN that require modest updating and this would provide a great introduction to the evidence-based approach that PEN takes. Topics include:

• Ostomy
• Peptic Ulcer Disease
• Gastresophageal Reflux
• Gall Bladder
• Inflammatory Bowel Disease (this pathway is quite large and might be best addressed by 2 people; possibly one focusing on questions related to adults and one on paediatric populations)

All volunteers would receive mentoring from a PEN team member and a modest honorarium to acknowledge your time and effort. Contact us at http://www.pennutrition.com/BecomeAuthor.aspx if you are interested.

We invite you to like us on Facebook, Follow us on Twitter @pennutrition and join our LinkedIn group. All three which provide forums to continue the conversation about evidence-based dietetic practice.

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