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                                                  PAL




                              PAL RESOURCE PACK




PAL resource pack                                                                                                 Page 1 of 69
Written by Subgroup members      Approved by Scottish PAL implementation group
Date of approval March 2010      Date of implementation September 2010           Date of review September 2012
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                                               PAL
IInttroducttiion tto C pllacementt Pack
  n roduc on o C p acemen Pack

One of the aims of the PAL implementation group was to develop model
programmes and paperwork to support practice educators in Scotland,
to adopt the PAL model. A lack of PAL resources was identified and a
short life working group was set up to develop these, with dietetic
representation from Lothian, Ayrshire and Arran, Grampian and Forth
Valley Health Boards.

The PAL Resource Pack has been developed following review of
existing resources locally and nationally. The pack is divided into 3
sections:

 Introduction to PAL and practical guidance for Dietitians and students.

 Induction PAL activities.

 Clinical PAL activities.


Practice educators can use any activities relevant to their programme
and localise them as required. Although these resources were
developed with the C placement in mind, elements of them may also be
used within the B clinical placement.

Each PAL activity takes the same format and includes a worksheet for
the students and an overview for the supervising dietitian, which will
assist the dietitian in the preparation for and feedback from the activity.

All of the resources are due to be added to the Scottish Cluster website
in August 2010. Practice educators can use these as a pick list and can
download some or all of these resources.

The PAL Resource Pack will be formally launched at the Student
Training Forum on 2nd September 2010.




PAL resource pack                                                                                              Page 2 of 69
Written by Subgroup members   Approved by Scottish PAL implementation group
Date of approval March 2010   Date of implementation September 2010           Date of review September 2012
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                                                     PAL
     INDEX OF CONTENTS                                                                                             Page

     Introduction to PAL Resource Pack.                                  ..         ..          ..           ..       2

     Introduction to Peer Assisted Learning
      Theory of PAL.
                            ..      ..    ..      ..    ..                                     ..           ..      4
      Practice Placement Overview of PAL. ..
                                                        ..                                     ..           ..      5
      Peer Assisted Learning - Student Information. ..
                                                                                               ..           ..      7
      Peer Assisted Learning – Supervising Dietitian ..
                                                                                               ..           ..      8
      Student Led Feedback Session ..
                                                  ..    ..                                     ..           ..      9
      Checklist for participation in student led discussions
                                                                                                                    10
      Sample timetable ..
                                    ..    ..      ..  . ..                                     ..           ..      12

     Induction – PAL Activities.
      Introductions.
                           ..    ..   ..                                ..         ..          ..           ..       16
      Dietetic Shadowing. ..
                                 ..   ..                                ..         ..          ..           ..       18
      Health Hunt. ..
                           ..    ..   ..                                ..         ..          ..           ..       20
      Orientation to Acute Services.
                                      ..                                ..         ..          ..           ..       22
      Orientation to Community Services.
                                                                        ..         ..          ..           ..       24
      Menu Clerk/Catering Systems. ..
                                                                        ..         ..          ..           ..       26
      Diet Bay / Catering Systems.
                                      ..                                ..         ..          ..           ..       28
      Policies and Procedures. ..
                                      ..                                ..         ..          ..           ..       30
      Records. .. ..
                           ..    ..   ..                                ..         ..          ..           ..       32

     Clinical – PAL.
      Anthropometry.
                           ..    ..                        ..           ..         ..          ..           ..       36
      Care Homes. ..
                           ..    ..                        ..           ..         ..          ..           ..       39
      Dietetic Assistant/Food Workers.
                                                           ..           ..         ..          ..           ..       41
      Enteral Feeding.
                           ..    ..                        ..           ..         ..          ..           ..       43
      Health Promotion Project. ..
                                                           ..           ..         ..          ..           ..       47
      Home Visits. ..
                           ..    ..                        ..           ..         ..          ..           ..       48
      Nutritional Screening.
                                 ..                        ..           ..         ..          ..           ..       51
      Oral Nutritional Support (ONS).
                                                           ..           ..         ..          ..           ..       53
      Patient Interviews. ..
                                 ..                        ..           ..         ..          ..           ..       57
      Texture Modifications.
                                 ..                        ..           ..         ..          ..           ..       62


     Acknowledgements. ..                       ..          ..           ..         ..          ..           ..       64
     Know Can Do. ..               ..           ..          ..           ..         ..          ..           ..       65
     References.              ..   ..           ..          ..           ..         ..          ..           ..       67




PAL resource pack                                                                                                         Page 3 of 69
Written by Subgroup members        Approved by Scottish PAL implementation group
Date of approval March 2010        Date of implementation September 2010           Date of review September 2012
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                                                PAL

     INTRODUCTION TO PEER ASSISTED LEARNING (PAL)


THEORY OF PAL
The literature suggests that PAL is a robust strategy for improving educational outcomes
especially developing competencies in motor performance, verbal and spatial problem
solving. Similarly, educational benefits in communication, facilitation skills and in group work
have been reported.

Due to evolving healthcare, clinical education has altered from the traditional one-on-one
teaching i.e. the apprentice and teacher model into a more student centred approach using
group or PAL 2:1 based models specifically since the 1990‟s.

The term 2:1 refers to two students being supervised by a single practice educator offering
an interactive learning environment at a time of increased student numbers and limited
resources.

(Adapted from Implementation of PAL in Dietetic Practice Education, 2010)




PAL resource pack                                                                                               Page 4 of 69
Written by Subgroup members    Approved by Scottish PAL implementation group
Date of approval March 2010    Date of implementation September 2010           Date of review September 2012
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                                               PAL
PRACTICE PLACEMENT OVERVIEW OF PAL
What is PAL?

Definition of PAL - to get knowledge through study, experience, observation or teaching of
an equal.

The following gives examples of some of the benefits of PAL, which are referenced by real
life examples of activities/experiences used in the PAL programme.

Peers can help each other learn and learning is more effective when there is collaboration
between students. PAL is a natural way of learning/completing tasks if the same task is set
for more than one person (e.g. Health Hunt Activity –Induction).

Sharing of knowledge amongst students

Students have an increased depth of knowledge and greater confidence and reassurance
from working with a peer (evaluation of Tayside PAL activities)

Students are happy to ask the „silly‟ question of the student peer rather than a dietitian.
Students may think a question is too insignificant or irrelevant to ask a supervising dietitian
but will ask another student. (evaluation of Forth Valley (FV) PAL activities)


Students are more relaxed being observed by their peer rather than a dietitian (quote from
student doing FV PAL Patient Interviews Activity - Clinical)
Students learn from different styles of interviewing and can see how someone else copes
with different situations, which can then be applied to own situations (FV PAL Patient
Interviews Activity - Clinical)

In clinics students are able to questions of each other rather than going straight to the
dietitian, which shows greater confidence and independence (observation by FV dietitian of
2:1 model)

PAL gives exposure to different patient groups and ways of working, through the
experiences of their peer. This can create an understanding of how the nutritional care
process works in these areas. It allows an increase in knowledge e.g. by doing different
activities and sharing experiences and can reduce duplication of effort (e.g. Shadowing
Activity & Policies & Procedures Activity– Induction).

Students learn to give feedback, which is part of working within the code of conduct and also
will be an integral part of working life as a dietitian (KSF Core 2 Personal & People
Development)

Time to reflect and consolidate learning

Clinical experience alone doesn‟t guarantee learning. Reflection is an essential component.
PAL is a variation on the traditional training model of observation and replication. It allows
students to analyse and discuss work and draw on and share past experiences. (Examples
where this has been beneficial are the shadowing experiences which have been shared in




PAL resource pack                                                                                              Page 5 of 69
Written by Subgroup members   Approved by Scottish PAL implementation group
Date of approval March 2010   Date of implementation September 2010           Date of review September 2012
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                                               PAL
student led discussions). Although PAL activities are not used as evidence, student led
discussions could be included as evidence for:

C2 – Is able to communicate effectively with colleagues, other healthcare professionals and
clients at an appropriate level and pace.
C3 Is able to report accurately to relevant people on action taken.
P10 Reflects on practice at defined intervals and is able to describe how their practice has
changed.
P12 Takes the lead role in journal clubs and case discussions, to expand self and others
knowledge.
P13 demonstrates responsibility for own learning by seeking out answers to questions.
P14 Continues to demonstrate a professional attitude; listens to and respects others.


Department can utilise the students to do collaborative pieces of work that need done

e.g. Audits/projects (such as health promotion project/ departmental audits)
Evaluation of processes on wards e.g. meal service, issuing of supplements, administration
of tube feeds, and review of MUST scores.

PAL evaluates well

If PAL is well facilitated by Dietitians, the students evaluate it well (student testaments/ FV
student stories).
Students who have completed their B placement using PAL activities have been evaluated
“as good as the majority of B students arriving for C placements” by practice placement
providers (evaluation of FV PAL programme)


Limitations of PAL

Student timetables need to reflect each other in order to allow working in pairs or larger
groups. Time needs to be allocated to immediate review and feedback after activities and
also for student led discussions. There is less flexibility to the programme as making a
change will impact on the student and their PAL partner(s).
This also impacts on start dates and time off during placements.

Dietitians need to be fully aware of the tasks they are setting. PAL has evaluated poorly
when Dietitians have been perceived to have little insight into the activity and the PAL
model. Dietitians need to have some knowledge of the activity/clinical area in order to
facilitate the feedback sessions




PAL resource pack                                                                                              Page 6 of 69
Written by Subgroup members   Approved by Scottish PAL implementation group
Date of approval March 2010   Date of implementation September 2010           Date of review September 2012
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                                               PAL
PEER ASSISTED LEARNING STUDENT INFORMATION
Peer assisted learning has been shown to be a more effective process for learning than an
individual based approach. It is seen as a natural progression from problem based learning.
You will be assigned a peer at the beginning of your placement and this will continue
throughout the duration of that placement. You will be assigned tasks that need to be
completed in conjunction with your peer but you will also be given individual tasks too. You
and your peer may have different leaning styles of learning. It is important to find this out
early in your placement and share this. You should respect your peers learning style and you
may need to adapt your way of working to accommodate this.

Some Vital Skills in Peer Assisted Learning

    Respect your peer.

    Communicate with your peer in a way they/you would like to be dealt with.

    Observe your peer during tasks and be prepared to feedback constructively.

    Reflect with both your peer and facilitator as required during and after tasks.

    Be honest and always say if you do not understand anything.

    Work with your peer at each task as agreed and contribute fairly to the task.

    During discussions with your peer and facilitator listen and acknowledge their views and
     opinions.


TASKS

PAL worksheets have been designed to help you complete specific pieces of work that will
contribute to your learning outcomes. Collaborative work cannot be used as summative
assessment but individual pieces maybe. You are expected to work together on these and
reflect on the process and outcome. There are no hard and fast rules to completing these
tasks, you should however:-


    Take it in turns to do practical tasks

    Take it in turns to lead a task.

    Be prepared and organised to feedback on any part of the task to your supervisor.

    Reflect on the issues and learning points of a particular task.

    Be prepared to answer questions at feedback sessions.

You will soon find a method/process that you both feel comfortable with.




PAL resource pack                                                                                              Page 7 of 69
Written by Subgroup members   Approved by Scottish PAL implementation group
Date of approval March 2010   Date of implementation September 2010           Date of review September 2012
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                                               PAL
PEER ASSISTED LEARNING INFORMATION: SUPERVISING DIETITIAN

Peer Assisted Learning (PAL) is a collaborative approach where pairs or small groups
engage in a reciprocal learning experience to exchange knowledge skills and ideas. This
type or learning has been shown to be more effective than the traditional one to one method.
PAL activities can be run throughout a twelve week placement although and may lend
themselves to the induction process and early clinical activities (see sample timetable).

Students are expected to work collaboratively using problem based learning, reflection,
discussion and structured feedback.
In most situations you will be supervising two students that have been paired together for the
duration of their placement. They will have been allocated targets to complete together and
then they will be required to feedback to the supervising Dietitian at a facilitated session.

TASKS

Advance planning is the key to a successful PAL task for both students and facilitators. The
facilitator should:-

 Be aware of what is required of the student in the task. This will be on the student PAL

  worksheets.
 Be aware of any pre task work that you as facilitator will need to complete e.g. patient

  identification, access to IT and organisation of practical visits.
 Discuss with the students regarding the expected outcomes and learning points from the

  task.
 Agree the timescales for completion of the task and when/where you expect

  feedback/facilitated session to take place. Ensure all aspects of the task have been
  completed to an acceptable standard.
 Agree a contact system should any issues arise during the task.

 Agree the format that the task should be presented in.





PAL resource pack                                                                                              Page 8 of 69
Written by Subgroup members   Approved by Scottish PAL implementation group
Date of approval March 2010   Date of implementation September 2010           Date of review September 2012
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                                                PAL
STUDENT LED FEEDBACK SESSION

Students should have structured feedback timetabled either immediately after the activity or
at a timetabled weekly feedback session (see sample timetable).

Students should be expected to take the lead in presenting the outcomes of their task. The
promotion of experiential learning can be done by ensuring:-

 That all aspects of the task have been completed to an acceptable standard

 That all students participate in the feedback session

 That students have understood the activity and have the achieved the learning points

  from it.

Key prompt questions may be of benefit to elicit information from the students e.g.

        “What do you think is going on with this patient”?
        What other types of information do you feel are needed”
        Why do you think the patient has been non-compliant”

The supervising Dietitian should ensure they do not offer opinion or try to guide to your
perceived correct answer e.g.

        “This is obviously a case of malabsorption”
        “Don’t the signs of weight loss and diarrhoea in the face of adequate food intake
        suggest anything to you?”


EVIDENCE
Collaborative pieces of work cannot be used towards summative assessments. Individual
pieces of work, which together make up a project or audit, can be used for evidence. In
addition, the student‟s participation in the feedback sessions can also be recorded by the
supervising Dietitian as evidence (see sample form)




PAL resource pack                                                                                               Page 9 of 69
Written by Subgroup members    Approved by Scottish PAL implementation group
Date of approval March 2010    Date of implementation September 2010           Date of review September 2012
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                                                  PAL
                      CHECKLIST – PARTICIPATION IN STUDENT LED DISCUSSIONS

This form is to be completed by the facilitator for each student for each of the student led
discussions. A copy is to be given to the student & SRI/FDRI co-ordinator.
This form may contribute to the evidence required for learning outcomes P2, P12, P13, and
P14.

Student Name:                                     Tutorial:                                                      Date:

Tick the most appropriate comment in each section
Attendance                                       Dietitian’s comment
Attended session on time
Attended but late
Missed session, tutor notified
Missed session, tutor not notified
Preparation
Evidence of extensive reading and preparation
Evidence of adequate preparation
Evidence of some preparation
No evidence of preparation
Activity
Completed all tasks required to a basic level
Completed all tasks to an advanced level
Failed to complete all tasks
Participation
Provided regular questions/comments/new
information
Provided some questions/comments/new
information
Sporadic questions/comment/new information
No meaningful participation
Communication Skills
Consistently communicated effectively
Generally communicated effectively
Did not communicate effectively
Presentation skills
Demonstrated developed presentation skills
Demonstrated developing presentation skills
Demonstrated poor presentation skills
Interpersonal Skills (GROUP)
Supported participation of others &
demonstrated respect for others opinions
Allowed others to participate and demonstrates
respect for others opinions
Provided minimal interaction or support to other
participants
Learning skills
Demonstrated self directed learning
Demonstrated some self directed learning
Did not demonstrate self directed learning




PAL resource pack                                                                                                   Page 10 of 69
Written by Subgroup members      Approved by Scottish PAL implementation group
Date of approval March 2010      Date of implementation September 2010           Date of review September 2012
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                                               PAL
Critical thinking
Regularly offered critical analysis/interpretation
of ideas
Sometimes offered critical analysis/interpretation
of ideas
Little evidence of agreement or disagreement
with ideas
No evidence of agreement or disagreement with
ideas
Other
Demonstrated reflection on discussion and own
learning and/or introduction of innovative ideas
and/or relating discussion to broader themes or
context
Facilitated the group process, actively
encouraged others to participate
Comments/Evidence                                                                                             Dietitian
                                                                                                              Signature




PAL resource pack                                                                                                Page 11 of 69
Written by Subgroup members   Approved by Scottish PAL implementation group
Date of approval March 2010   Date of implementation September 2010           Date of review September 2012
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                                                              PAL
                                                 SAMPLE TIMETABLE
Week/Date                     MONDAY                 TUESDAY                   WEDNESDAY               THURSDAY              FRIDAY

Wk 1                am        10am                   9am                       Community               PAL                   PAL
                              Induction              PAL                       Hosp                    ACTIVITY              ACTIVITY
                                                     ACTIVITY                  orientation             Health Hunt           Shadow in
                                                     Orientation in            All 4 students          ALL                   Acute hospital
                                                     Acute – all 4
                                                     students

                    pm        PAL                    2.00pm ID                 2 Dietitian/                                 Student led
                              ACTIVITY               badge – HQ                Assistant take                                discussion -
                              Policies &                                       2 students                                    Health Hunt &
                              procedures                                       each                                          shadowing
                              activity &                                                                                     feedback
                              feedback
                              session –
                              MDM

ASSESSMENT
Wk 2    am                    PAL                    PAL                       PAL                     Shadowing &           PAL
                              ACTIVITY               ACTIVITY                  ACTIVITY                1:1                   ACTIVITY
                              Health                 Menu clerk/               Shadowing in            supervision           Risk scoring
                              promotion              catering                  the acute                                     activity @
                              Project –              systems                                                                 Community
                              ALL                                                                                            Hospital
                                                                                                                             ALL

                    pm        1.30-2.00              PAL                       Wards 1:1               Wards 1:1             3pm Joint
                              p.m.                   ACTIVITY                  supervision             supervision           community/
                              Intro into             Diet bay /                                                              acute student
                              Facilitation           Catering                                                                led feedback
                                                     systems                                                                 session –
                                                                                                                             catering,
                                                                                                                             shadowing &
                                                                                                                             risk scoring

ASSESSMENT
Wk 3     am                       PAL                    PAL                     Community                  PAL              ALL
                                ACTIVITY               ACTIVITY                    Clinic                ACTIVITY            Complete
                               Domiciliary            Community                     1:1                Patient               case review &
                                 visits                 Clinic                   supervision           interviews in         present
                                                                                                       community
                                                                                                       hospital

                    1.30      pm -                                                                   Health                Student led
                    pm        Facilitation                                                             Promotion             discussion
                              session –                                                                Project
                              ALL
                              „Implementing
                                knowledge
                               into practice‟




PAL resource pack                                                                                                               Page 12 of 69
Written by Subgroup members                  Approved by Scottish PAL implementation group
Date of approval March 2010                  Date of implementation September 2010           Date of review September 2012
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                                                              PAL
Week/Date                      MONDAY              TUESDAY                  WEDNESDAY                  THURSDAY                FRIDAY

ACUTE
Wk 4                am        Wards 1:1        Clinic 1:1                  Specialist day -           PAL                   MDT meeting
                              supervision      supervision                 renal                      ACTIVITY              Wards 1:1
                                                                                                      Patient               supervision
                                                                                                      interviews –
                                                                                                      acute
                                                                                                      hospital
                    pm                        PAL                                                                         Study time
                                               ACTIVITY
                                               anthropometry


ACUTE
Wk 5                am        Wards 1:1        Complete case               Wards 1:1                  Clinic 1:1            Wards 1:1
                              supervision      review &                    supervision                supervision           supervision
                                               present


                    pm        1.30 p.m.        Complete case               PAL ACTIVITY                                     ALL
                              Facilitator      review &                    supplementation                                  Student led
                              session –        present                                                                      discussion
                              ALL
                              justify,
                              educate
                              &motivate‟

COMMUNITY
Wk 6     am                   Community        Area outreach               PAL ACTIVITY                Health Prom          Health Prom
                                 clinic        service                      Domiciliary                  Project            Project
                                  1:1          1:1                             visits
                              supervision      supervision

                    pm          PAL                                       ALL                                              3.30pm
                              ACTIVITY                                     Complete case                                    Half Way
                                Care                                       review &                                         Assessment
                               homes                                       present

COMMUNITY
Wk 7     am                    ALL             PAL                                                                          Mental Health
                               Health          ACTIVITY                                                                        Wards
                               Promotion       Community                                                                        1:1
                               Project –       Clinic                                                                        supervision
                               Delivery
                    pm                          Clinic write up                Community               Care                 Study Time
                                                and feedback                     Clinic               Pathway
                                                                                  1:1                 Audit




PAL resource pack                                                                                                              Page 13 of 69
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                                                              PAL
Week/Date                     MONDAY               TUESDAY                 WEDNESDAY                THURSDAY                     FRIDAY

COMMUNITY
Wk 8                am        Learning             Learning                     PAL
                              Disabilities        Disabilities                ACTIVITY                    HEF                      HEF
                                                  Facilitation                  HEF
                                                   session
                    pm                                                                                                   Student led
                                                                                                                             discussion




ACUTE
Wk 9                am        Wards            PAL ACTIVITY                Wards                    PAL                      Wards
                                               texture                                              ACTIVITY
                                               modification                                         Patient
                                                                                                    interviews –
                                                                                                    acute
                                                                                                    hospital
                    pm        Wards            Wards                        Wards                   Wards                    Wards


CONSOLIDATION   -                            ACUTE
Wk10     am   Wards                           Review of                    Wards                    Wards                    Head & Neck
                                              evidence then                                                                  MDT Clinic
                                              ALL
                                              Review of
                                              professional
                                              practice
                                              worksheets

                    pm        Wards            Wards                       Wards                    Wards                    Student led
                                                                                                                             discussion

CONSOLIDATION    -                           ACUTE
Wk 11    am   Wards                           Own clinic                   Wards                    Wards                    Wards

                    pm        Wards            Wards                       Wards                    Wards                    Wards


CONSOLIDATION    -                           ACUTE
Wk 12    am   Wards                           Own clinic                   Wards                    Final                    Handover to
                                                                                                    assessment               Dietitians

                    pm        Wards                                        Wards                    Wards                    Student stories




PAL resource pack                                                                                                                   Page 14 of 69
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                                                 PAL



            INDUCTION PAL
              ACTIVITIES
                               Introductions
                              
                                    Overview of Activity for Dietitian

                               Dietetic Shadowing
                              
                                    Overview of Activity for Dietitian

                               Health Hunt
                              
                                    Overview of Activity for Dietitian

                               Orientation to Acute Services
                              
                               Orientation to Community Services
                              
                                    Overview of Activity for Dietitian

                               Menu Clerk/Catering Systems
                              
                               Diet Bay/ Catering Systems
                              
                                Overview of Activity for Dietitian

                               Policies and Procedures
                              
                                Overview of Activity for Dietitian

                               Records
                              
                                Overview of Activity for Dietitian




PAL resource pack                                                                                               Page 15 of 69
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                                                       PAL
                                              INDUCTION - PAL
                                                 INTRODUCTIONS

Purpose
This task introduces the PAL group to each other and allows a forum to discuss each other‟s
key skills, which they can bring to the group.

TIME ALLOCATED: 1 hour

Key Activities:

 You will be working in pairs for this activity


 Discuss where each of you undertook your previous clinical placements


 Describe to each other within what types of settings you have undertaken patient

  contact in and any differences you observed between settings

 Discuss your strengths and areas for improvement in each of the areas of Knowledge,

  Communication and Professional Practice

 Discuss what skills you hope to develop during this clinical placement


 Discuss your learning styles and what influence this may have on your placement in

  regards to individual and PAL working

 Discuss how you may be able to assist each other


 Report back to your supervising on what you have found out about your Peer.




`




                              The above activity links to Learning
                              Outcomes:
                              B:C3, P6, P7, P8, P9, P10, P11, P13
                              C: C2, C3, P6, P7, P8, P9, P10,P11, P14

                              C: C2, C3, P6, P10, P12, P13



PAL resource pack                                                                                                     Page 16 of 69
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                                                    PAL
                                           INDUCTION - PAL
                 INTRODUCTIONS - OVERVIEW OF ACTIVITY FOR DIETITIAN


Purpose
This task introduces the PAL group to each other and allows a forum to discuss each other‟s
key skills, which they can bring to the group.

In essence it acts as an icebreaker amongst students who may never have met before and
come to their placement with different clinical and educational experiences. This task would
allow them to understand their PAL group learning style better which in turn may lead to
improved PAL working.

TIME ALLOCATED FOR TASK: 1 hour


Preparation
Have space/room available for discussion and timetable student led feedback session to
supervising dietitian. Ensure learning style questionnaire has been completed


KEY PROMPT QUESTIONS: (only as required)

 Discuss your previous placement?

 Where were your Peers on placement?

 What are your key areas for improvement in relation to communication, knowledge and

  skills?
 What learning style are you and your peer group?

 What influence do you feel these learning styles will have on your PAL group working?





                              The above activity links to Learning Outcomes:
                              B:C2, C3, P6, P10, P12, P13
                              C: C2, C3, P6, P10, P12, P13

PAL resource pack                                                                                                  Page 17 of 69
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                                                PAL
                                       INDUCTION - PAL
                                    DIETETIC SHADOWING

Purpose

This activity aims to introduce students to Dietitians undertaking clinic work. The activity
introduces the student to information gathering/assessment methods and communication
systems as well as involvement of other members of MDT (if appropriate)

TIME ALLOCATED: 4 hours

Key Activities

For this activity you will be working alone and shadowing one of the Dietitians. This may be
in either a ward or clinic or domiciliary setting.

TASK 1
You will be asked to observe the Dietitians practice and for each consultation or episode you
observe you will be asked to consider the following questions.

 What were the Dietitian‟s main aims for this consultation?

 What did the patient want out of the consultation and how do you know this?

 Did the dietitian liaise with anyone before the consultation? What this helpful? Why/why

  not?
 What information did the dietitian collect?

 What strategies did they use to collect information?

 What info would have been useful, but was unavailable?

 What decision did the dietitian make in managing this patient & propose a rationale for

  this decision
 Look at the notes/record card after the dietitian has made the entry for the patient; did

  the dietitian use any abbreviations?
 Did the dietitian liaise with anyone after the consultation? Do you think this communication

  was helpful to: the other person, the patient, yourself & how do you Know?
 How did the Dietitian‟s communication with the patient differ from what you have

  observed from the nurse/doctor/other AHP?
 How would you describe the Dietitian‟s manner with the patient i.e.

  formal/chatty/serious? Was this appropriate & how do you know?
 Are you aware of any issues relating to

          1. Anti discriminatory practice.
          2. Practice in line with the Statement of Conduct
          3. Professionalism.
          4. Team working.
 Did you learn anything from the consultation? Why?

 Did anything trouble you about this consultation? Why?


Task 2
You will be required to report back your findings to your student peers at a student led
discussion at the end of the week.




                              The above activity links to Learning Outcomes:
                              B: C1, C3, P10, P11
                              C: C1, C3, P6, P10, P12, P14
PAL resource pack                                                                                              Page 18 of 69
Written by Subgroup members    Approved by Scottish PAL implementation group
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                                                       PAL
                                                     SHADOWING
                               OVERVIEW OF ACTIVITY FOR DIETITIANS
Purpose
This activity aims to introduce students to Dietitians undertaking clinic work. They will
observe patient contact in whichever clinical setting the dietitian is working but will benefit
from their peers reporting back from other clinical areas. The activity introduces the student
to information gathering/assessment methods and communication systems as well as
involvement of other members of MDT (if appropriate)
The activity has a debrief session for all students to discuss their findings. The students will
each present one of their cases in the group session, which will begin to develop their skills
in case presentation and handover.
TIME ALLOCATED: 4 hours
Preparation

 Each student should be allocated a dietitian to shadow for a morning.

 It would be beneficial if students could be allocated to Dietitians working in different

  settings and specialities.
 The students should be made aware of what information is required to be collected

  during their observation of the dietitian.

Minimum requirements should be
 Clinical setting where interview observed.

 Sources of information prior to consultation.

              1. Medical/dietetic/nursing records
              2. Bed end paperwork.
              3. Referral letters.
              4. Verbal communication with MDT.
              5.
Communication methods
    1. Prior to consultation
    2. During consultation
    3. Format – written, verbal, non verbal
    4. Style
    5.
Other issues including
   1. Practice within statement conduct
   2. Anti discriminatory practice.
   3. Professionalism
   4. Team working

C placement students may benefit from this activity to settle them in to the area and observe
local records/notes. Additionally, it may be a useful activity to use within specialist areas.
This task should allow students to identify the different skills and information required within
specialist areas.



                              The above activity links to Learning Outcomes:
                              B: C1, C3, P10, P11
                              C: C1, C3, P6, , P10, P12, P14


PAL resource pack                                                                                                     Page 19 of 69
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                                                    PAL
                                           INDUCTION - PAL
                                                 HEALTH HUNT
Purpose

The purpose of this activity is to consider the impact of the environment on health and
introduce students to local areas and facilities.

TIME ALLOCATED: 1 day

Key Activity
 For this activity you will be working in pairs.

 You will be given time to research the environment in a selected community within the

  Health Board area you are working in.
 You must use more than one source of information (internet, intranet reports,

  government reports)
 You must also visit the facilities within the area you have been allocated.

 You will write a report and present the findings of your health hunt.


Task 1
Use the internet and reports to consider the issues that impact upon your allocated
community in relation to aspects such as


    Health – life expectancy

    Social aspects i.e. deprivation, employment.

    Transport

    Leisure facilities.

    Shopping facilities

Task 2
Visit the area and compare what you have found in your factual search with the reality of
what you see. You should physically visit some of the facilities identified to describe how
these may affect individual‟s lifestyles

Task 3
 Complete a report and present to your student peers and facilitator.

 Present your findings in a logical order; this should include information regarding social,

  health, leisure, transport, facilities and any other useful facts identified.
                                             USEFUL WEBSITES

           www.isdscotland.org                              Information Services Division
           www.scrol.gov.uk                                 SCROL- Scottish Census results online.
           www.shs.gov.uk                                   Scottish neighbourhood statistics.
           www.gro-scotland.gov.uk                          General register office for Scotland.
           www.scotpho.org.uk                               Scottish public healthy observatory
Local NHS board and local authority websites will also give relevant data in relation to
local areas




                              The above activity links to Learning Outcomes:
                              B: C2, C3, P1, P2, P5, P6, P9, P10, P12, P13
                              C: C2, C3, P1, P2, P5, P6, P9, P10, P12, P13
PAL resource pack                                                                                                  Page 20 of 69
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                                                    PAL
                                           INDUCTION - PAL
                    HEALTH HUNT- OVERVIEW OF ACTIVITY FOR DIETITIAN

Purpose

The purpose of this activity is to increase the students understanding that assessment
encompasses a lot more that solely diet history taking. The activity requires the student to
consider the impact of the environment on health; In addition it introduces students to local
areas where they have been placed and the facilities that their patients encounter on a daily
basis. Students should develop information gathering skills, which are transferable to other
locations and areas of work they will undertake. They will identify useful and not so useful
websites, reports and resources that they can access throughout their placement. They
should appreciate that a single source of information e.g. internet will not always give a full
picture and more than 1 source should be used to verify accuracy. This should also include a
visit to the assigned area. This activity should encourage students to work collaboratively,
enhance research skills, identify relevant features for consultation and develop report writing
skills.

TIME ALLOCATED: 1 day

Preparation

 Students should have access to at least 1 computer terminal per pair for the duration of

  the morning and again after the visit to the area.
 A community area within the local area should be selected for each pair to research and

  report on.
 The students should consider all aspects of the environment that impact on the health

  and social wellbeing of the residents. They should also identify particular issue that exist
  within this community i.e. alcohol, drugs, transport, area of deprivation, amenities. Local
  demographics should be recorded.

ACTIVITY

 The students should be given an overview of the activity and what is required for the

  reporting back session. Each pair should be allocated approximately 15 minutes to
  feedback and 15 minutes for discussion.
 Students will work in pairs and be allocated a local area/village or community to

  research. This research must include a visit to this area as well as the office based
  research.
 Comparisons should be made between the factual internet/report based data and the

  physical visit to the allocated area.
 Each pair should then prepare a report of their findings.

 This should be shared with the supervising dietitian and their student peers at a

  feedback session.




                              The above activity links to Learning Outcomes:
                              B: C2, C3, P1, P2, P5, P6, P9, P10, P12, P13
                              C: C2, C3, P1, P2, P5, P6, P9, P10, P12, P13
PAL resource pack                                                                                                  Page 21 of 69
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                                                PAL
                                        INDUCTION - PAL
                              ORIENTATION TO ACUTE SERVICES
Purpose
To familiarise yourself with the layout and organisation of clinical & non-clinical services in
the acute and community sites

TIME ALLOCATED: 3 ½ hours
Key Activities: Acute hospital

Task 1 – Take a tour of the Acute hospital site locating each of the wards &
departments

    Post graduate library

    Pharmacy

    The catering department

    Menu analyst (if applicable)

    Main entrance & shops

    Main hospital out-patient clinic

    Dietetic out patient clinic

    Diabetes centre

    Toilets

    Wards 1, 2, & 3

    Day surgery unit

    Oncology unit

Task 2 - You will be allocated a ward in which to familiarise yourself with the ward
environment. You will need to observe activities and procedures and question staff
to complete this task.
 What types of patients are allocated to this ward?

 Identify the uniforms worn by Charge nurse, staff nurses, auxiliary nurse, domestics &

  ward clerk
 Which patients are likely to be seen by the dietitian and why?

 Is there a referral process for dietetic input?

 What is the average length of patient stay?

 Is there a discharge process? How is the dietitian informed of discharges?

 Arrangements for protected patient mealtimes

Note the location of:

    Bed plan

    Shared Care notes

    Medical notes

    MUST screening paperwork

    Equipment for measuring anthropometry

    End of bed charts

    Enteral feeding charts

    Meeting rooms or areas

    Rehab areas

    Doctor‟s book

    Computers



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                                                    PAL

 Task 3 - Locate in the dietetic dept offices and note down the following for future
reference:


    The office telephone numbers

    The Dietitians‟ page numbers

    How to use the paging system

    The phone number system of the wards

         Make a list of the journals kept in the department.
         Make a list of any books you would find useful.

         Find the location of the following


    Enteral feeding pumps

    Blank dietetic record cards

    Filed dietetic record cards

    Product information

    Data collection/stats forms

    Department diary

    Dietetic records of ongoing in-patients




                              The above activity links to Learning Outcomes:
                              B: C1, C3, P1, P11, P13, P14
                              C: C1, C3, P1, P12, P13, P14


PAL resource pack                                                                                                  Page 23 of 69
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                                                    PAL
                                           INDUCTION – PAL
                              ORIENTATION TO COMMUNITY SERVICES
TIME ALLOCATED: 3 ½ hours
Key Activities:               Community Dietetic Department

    Draw an outline of the layout of the department

    Find the following and mark on your map

    Fire exit and extinguishers

    Diet sheets

    Reference books

    Company information

    Supplements

    Mail trays

    Locate the paper maps

    Introduce yourself to the staff in the department

    Find out a little bit about what they do

    Mark their normal workspace on your map and their telephone number

    Identify what desks are available when
Key Activities:               Community Hospital

    Take a tour of the Community hospital site locating each of the wards.

    Find out what types of patients are allocated to each ward?

    Choose 1 ward to familiarise yourself with the ward environment

    What types of patients are allocated to this ward?

    Identify the uniforms worn by Charge nurse, staff nurses, auxiliary nurse,

    domestics & ward clerk

    Which patients are likely to be seen by the dietitian and why?

    Is there a referral process for dietetic input?

    What is the average length of patient stay?

    Is there a discharge process? How is the dietitian informed of discharges?

    Arrangements for medical cover

    Dining facilities for patients & staff
Location of:

    Bed plan

    Shared Care notes

    Medical notes

    MUST screening paperwork

    Equipment for measuring anthropometry

    End of bed charts

    Enteral feeding charts

    Meeting rooms or areas

    Rehab areas

    Doctor‟s book

    Computers


                                The above activity links to Learning Outcomes:
                                B: C1, C3, P1, P11, P13, P14
                                C: C1, C3, P1, P12, P13, P14


PAL resource pack                                                                                                  Page 24 of 69
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                                                        PAL
                                               INDUCTION - PAL
                              ORIENTATION – AN OVERVIEW FOR DIETITIANS

Purpose

The purpose of this activity is to allow the students to find out a great deal of important
information that they will need to help support their training. However, rather than Dietitians
„spoon feeding‟ them, they are expected to find out this information for themselves. They will
be given a list of things to find out/locate. Discussion with their student peers is acceptable.

TIME ALLOCATED: 3 1/2 hours

Preparation

The supervising dietitian must ensure that the students have appropriate visible ID. Ensure
the students know what to do in the event of an emergency e.g. fire or if they are
experiencing difficulties with their task. They should be given a contact name / number for
the supervising dietitian in case of any difficulties. In advance of the students completing
task 2 (ward environment), the dietitian should contact the nurse in charge to request
permission for the students to complete this activity and brief the nurse about what they are
expected to do.

ACTIVITY

The students will be briefed together on this activity and should all complete all tasks set.
No written work is required but it is expected that the students will create their own notes for
future reference. Feedback will be to the supervising dietitian immediately after the activity.




                                  The above activity links to Learning Outcomes:
                                  B: C1, C3, P1, P11, P13, P14
                                  C: C1, C3, P1, P12, P13, P14



PAL resource pack                                                                                                      Page 25 of 69
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                                                    PAL
                                        INDUCTION - PAL
                              MENU CLERK/CATERING SYSTEMS

Purpose

To familiarise yourselves with:

 Menu systems for both Acute & Community Hospitals

 Adaptations for therapeutic diets

 Communication systems between Dietitians, Menu clerks & Catering staff


TIME ALLOCATED: 2 hours

Key activities:

For this activity you will be working in pairs. Make notes on each of the following tasks for
the student led discussion later in week (All 4 students will be present at the student led
discussion.

You will be allocated time to spend working with the Menu Clerk in the acute hospital

Task 1
Observe Menu Clerk as she adapts menus from both Acute and primary care wards, noting:

 System for return of menus from wards to Menu clerk

 System for translating Dietitians instructions regarding patients‟ requirements onto menu

  card
 Rationale for highlighting foods on menu cards

 How Menu Clerk liaises with diet cook

 System for provision of snacks to wards


Task 2
Each student to adapt menus for at least 1 ward for 1 meal (supper) under the supervision of
the menu clerk

Task 3
Both students to travel together to a community hospital/community ward whose meals are
supplied from the Acute hospital kitchen. In the Community hospital/ward;


    Observe meal service

    Where do patients sit to eat meals?

    Who serves meals to patients?

    How are patients requiring assistance identified and whether assistance is given?

    Are meals interrupted and if so, by whom?

    Where are supplements stored in the ward?


                              The above activity links to Learning Outcomes:
                              B: C3, P2, P5, P6, P9, P10, P11, P12, P13
                              C: C3, P2, P5, P6, P9, P10, P11, P12, P14


PAL resource pack                                                                                                  Page 26 of 69
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                                               PAL
                                      INDUCTION - PAL
MENU CLERK/DIET BAY – AN OVERVIEW OF ACTIVITIES FOR THE DIETITIAN

The menu clerk & diet bay PAL activities are complimentary and cover all aspects of
Catering systems in both Acute & Community hospitals.

Purpose
Students require to have a good understanding of how patients‟ meal choices are conveyed
to the Catering Dept, how they are checked & adapted for therapeutic diets, what
adaptations are possible, how these adaptations are conveyed to the diet cook, products
used to adapt foods and how meals and snacks are delivered & served to patients at ward
level.

These task also introduce students to Protected Patient Mealtimes and the systems for
assisting patients at mealtimes

Having undertaken both activities, the students should be familiar with the following:

 Menu systems for both Acute & Community Hospitals

 Adaptations for therapeutic diets and become competent in doing this themselves

 Communication systems between Dietitians, Menu clerks & Catering staff (verbal &

  written)
 The workload of the diet bay

 The preparation of therapeutic diets

 Timing of meal service/delivery

 Differences between meal provision (and therapeutic diet adaptations) for Acute &

  Community Hospitals
 The system for delivery of supplements to patients in both Acute & Community hospitals


TIME ALLOCATED: 4 & 2 hours

Preparation for Menu Clerk PAL
Arrange with the menu clerk for the 2 students to spend part of the morning shadowing her.

Choose a community hospital or ward for the students to observe bulk meal delivery &
service. Contact the chosen ward and notify the Charge nurse of the activity.

Explain to the menu clerk that each student should be given the opportunity to adapt supper
menus for at least 1 ward. Request that the menu clerk briefs the students on meal delivery
to the chosen Community setting in order that they can follow the meal to the chosen ward.

Preparation for Diet Bay PAL
In the same week as the menu clerk activity, arrange with the diet cook for the 2 students to
spend part of the morning shadowing her/him, including observation of plating of patient
meals.

Set time aside after both activities have been completed for a student led discussion lasting
approximately 1 hour. This will take place with all 4 students present.




PAL resource pack                                                                                             Page 27 of 69
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                                                  PAL
                                         INDUCTION - PAL
                               DIET BAY / CATERING SYSTEMS

Purpose
The purpose of this activity is to familiarise yourselves with:

 The workload of the diet bay

 The preparation of therapeutic diets

 Timing of meal service/delivery

 Differences between meal provision (and therapeutic diet adaptations) for Acute &
  Community Hospitals
 The system for delivery of supplements to patients in both Acute & Community hospitals

TIME ALLOCATED: 4 hours
Key activities:
For this activity you will be working in pairs. Make notes on each of the following tasks for
the student led discussion later in week which will be attended by all 4 students.
You will be allocated time to spend working with the diet cooks, in the diet bay.

Task 1

    It is suggested that you use this time to observe and participate in the following: -

    How the menu analysts liaise with the diet cook.

    How the diet cooks‟ work is generated.

    The 3-week menu cycle and how standard recipes are adapted for diets.

    Products used for fortification (include quantities per portion) for both Acute &
     Community Hospitals

    The portion sizes of the meals.

    The time constraints posed by the meal service and how these are overcome.

    Timing of meal service

    The supply of supplements and tube feeds to Acute & Community Hospitals

    Quality Control measures e.g. temperature of trolleys, checking of trays etc

Task 2
Identify the range of dietetic products used in the hospital and their nutritional contribution.

Task 3
Each student to follow a different meal trolley up to an acute ward and note the following:

    Observe meal service

    Where do patients sit to eat meals?

    Who serves meals to patients?

    What fluids do the patients get?

    How are patients requiring assistance identified and whether assistance is given?

    Are meals interrupted and if so, by whom?

    Where are supplements stored in the ward?

    If possible speak to one patient about their meal time experiences

                              The above activity links to Learning Outcomes:
                              B: C3, P2, P5, P6, P9, P10, P11, P12, P13
                              C: C3, P2, P5, P6, P9, P10, P11, P12, P14

PAL resource pack                                                                                                Page 28 of 69
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                                                    PAL
ACTIVITY

The activities take place on 2 separate mornings of the same week, firstly the menu clerk,
then the diet bay activity.

Both students together shadow the menu clerk & diet cooks, observing catering systems,
assisting in the adaptation of menus for patients on therapeutic diets, assisting the diet cook
and observing meal service in both Acute & Community settings (Acute wards have a plated
meal system and Community Hospitals/wards have bulk meal systems)
Students take notes on their findings and feedback at a student led discussion, which is
scheduled after both PAL activities have been completed with all 4 students attending.

The dietitian will facilitate the student led discussion for all 4 students:
Ask the students to describe the system from patient completing menu cards through to the
patient receiving plated meals for patients in Acute hospitals.

How does this differ for Community hospital/wards?

What the pros & cons are of plated versus bulk meal delivery systems?

How does the meal setting affect patient‟s intake (i.e. at bedside or at dining table with
others)?

Ask students to discuss communication between patients (through menus), menu clerk, diet
cook & dietitians. Does this work & where is the potential for communication to break down?

What foods can be fortified? Is this the same for Community hospitals/wards?

How do snacks & supplements get to patients in Acute & Community wards?

Discuss the benefits of Protecting Patient mealtimes.

Discuss the system for identifying patients requiring assistance at mealtimes. Is this different
in Acute & Community?




                              The above activity links to Learning Outcomes:
                              B: C3, P2, P5, P6, P9, P10, P11, P12, P13
                              C: C3, P2, P5, P6, P9, P10, P11, P12, P14

PAL resource pack                                                                                                  Page 29 of 69
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                                                    PAL
                                           INDUCTION - PAL
                                   POLICIES AND PROCEDURES

Purpose
This activity is designed to raise awareness of the main Board policies you are expected to
comply with and have an understanding of how they relate to a practising dietitian.

TIME ALLOCATED: 2 hours

Key Activities:

 Each student to log onto department computer to ensure login working.


 Look at NHS ………………. Intranet site


 Each student Dietitian should choose at least 2 policies from the following list, ensuring

  no duplication.

           
                Disclosure Information
           
                Dignity at work
           
                Record keeping policy
           
                Hand Hygiene (Infection control)
           
                Food hygiene & safety for clinical areas (Infection control)
           
                Breast feeding policy (In relation to staff)
           
                Complaints policy & procedure
           
                Lone working
           
                Attendance management
           
                Nutritional Care Policies



          You will need to familiarise yourself with the main themes of your chosen policies


          In particular note how the policy might affect Dietitians working in the hospital
           and an out patient/community setting


          Be prepared to discuss this with the other student Dietitians and assessor on the
           policies you have selected. Make sure you give your student peers the main themes
           of the policies and include your examples of how they may apply to Dietitians


          Each of you needs to be prepared to present any of your policies at a student led
           feedback session to Dietitians.




                              The above activity links to Learning Outcomes:
                              B: C2, C3, P1, P2, P8, P9, P10, P12
                              C: C2, C3, P1, P2, P8, P9, P10, P12


PAL resource pack                                                                                                  Page 30 of 69
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                                                    PAL
                                           INDUCTION - PAL
        POLICIES & PROCEDURES - OVERVIEW OF ACTIVITY FOR DIETITIAN

Purpose
This activity is designed to form part of the students‟ induction and make them aware of the
main Board policies they are expected to comply with and have an understanding of.


Preparation
Ensure students have access to the policies on the intranet

Time Allocated: 2 hours

Activity
 Each student will choose a minimum of 2 policies from the list


They will need to familiarise themselves with the main themes of both chosen policies, in
particular how the policy might affect Dietitians working in the hospital and an out patient
setting

Each student then presents to the other students on the policies they have selected. They
should include the main themes of the policies and include examples of how they may apply
to Dietitians.

Each individual student should then be able to answer questions on the key points in relation
to any of the policies and rely on their PAL group to support their learning in this area.


Preparation
Have space/room available for discussion. Allow time for questions. The supervising
Dietitians role is to ensure the key points from each policy have been discussed and that no
key policy has been omitted.




                              The above activity links to Learning Outcomes:
                              B: C2, C3, P1, P2, P8, P9, P10, P12
                              C: C2, C3, P1, P2, P8, P9, P10, P12


PAL resource pack                                                                                                  Page 31 of 69
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                                                  PAL
                                         INDUCTION - PAL
                                                   RECORDS

Purpose

This activity aims to familiarize you with the organization of medical/shared care patient
records and the variation in organization that may occur within and between health care
providers.

TIME ALLOCATED: 2 hours

Key Activities:

 You will be working in pairs for this activity


 You will individually look through a set of patient notes and gather information from the

  notes that you feel are relevant to the dietetic assessment of the patient

 It may be useful to use structured headings for your information gathering e.g.

  demographics, biochemistry, clinical, social etc

 Complete a dietetic record card for the patient using info you have gathered from their

  notes

 Note down any terms that you don‟t understand so you can look them up


 After 1 hour, swap notes with your peers and repeat the activity with the new set of notes


 When you have had the opportunity to collect the information you believe to be relevant,

  compare the information you both gathered and make a note of information you or your
  peer may have missed and where that information is found in the patient‟s notes

 Compare the record cards you and your peer filled out on the same patient noting any

  differences

 Compare your record cards with the actual dietetic record cards of the patients in the

  dietetic department. How do they differ?

 What might you do differently next time?


 Ensure that you follow up on any terms/abbreviations that you don‟t understand





                              The above activity links to Learning Outcomes:
                              B: C3, P1, P2, P8, P9, P10, P12
                              C: C3, P1, P2, P8, P9, P10, P12

PAL resource pack                                                                                                Page 32 of 69
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                                                  PAL
                                            INDUCTION - PAL

                       RECORDS - OVERVIEW OF ACTIVITY FOR DIETITIANS

Purpose

This activity aims to familiarize students with the organization of medical/shared care patient
records and the variation in organization that may occur within and between health care
providers. They will also gain exposure to the different ways that entries are recorded within
and between professions, become familiar with abbreviations used (often contextual e.g. Ca
could mean cancer or calcium depending on the context), and to begin to develop skills in
identifying and collecting relevant information for dietetic assessments.

This activity also aims to provide students with an introduction to the dietetic records used by
Dietitians, and will help them to reflect on the usefulness of the information they gathered
from medical/shared care patient records. By allowing students the opportunity to complete
the dietetic record cards without seeing one already completed, you are helping them to „find
out what they need to know‟.

The activity has a debrief session for all students to discuss both medical & dietetic notes,
which provides an opportunity to go through what a „good‟ record card as compared to a „not
so good‟ card; discuss issues of confidentiality and the need to ensure information is not
easily identifiable; and to begin to develop a framework for gathering useful information for
dietetic assessment.

C placement students can progress this activity by repeating it in specialist areas to identify
what different information would be required.

TIME ALLOCATED: 2 hours

Preparation

Identify appropriate patients‟ medical records for students to review on the ward or in the
clinic. Appropriate patients should have had some dietetic input in the past.
Ensure the activity is scheduled for a time when the medical records for the identified
patients are available (e.g. not at a time when ward rounds are scheduled). The record does
not have to be a patient currently admitted, it may be more practical to request the record of
a known patient not currently admitted.
Students can undertake this activity on a ward, in a clinic environment or in the dietetic office
(depending on where the records are)
Provide the students with blank dietetic record cards.
Pull the actual dietetic record cards for the 3 patients whose medical notes students have
reviewed and give these to the students towards the end of the activity.
Allocate some time in your diary, if possible, to provide direct feedback to the students on
the record cards they have completed.




PAL resource pack                                                                                                Page 33 of 69
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                                                    PAL
           Activity
           Students will work in pairs

           Each student should have an opportunity to explore a set of patient
           notes, and gain experience trying to gather dietetically useful
           information on the patient (based on written records only). This can
           take some time for students at this stage in their training, as they are
           not familiar with language, abbreviations and organisation of medical
           notes (which may differ from ward to ward)

           After an hour, the students will swap patient notes and review the
           second set of notes. The students should then compare the
           information they each gleaned individually to highlight any
           discrepancies/ differences.




                              The above activity links to Learning Outcomes:
                              B: C3, P1, P2, P8, P9, P10, P12
                              C: C3, P1, P2, P8, P9, P10, P12




PAL resource pack                                                                                                  Page 34 of 69
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                                               PAL

                     CLINICAL PAL
                      ACTIVITIES
                               Anthropometry
                              
                                           Overview of Activity for Dietitian

                               Care Homes
                              
                                           Overview of Activity for Dietitian

                               Dietetic Assistants/Food Workers
                              
                                           Overview of Activity for Dietitian

                               Enteral Feeding
                              
                                           Overview of Activity for Dietitian

                               Health Promotion Project
                              
                                           Overview of Activity for Dietitian

                               Home Visits
                              
                                           Overview of Activity for Dietitian

                               Nutritional Screening
                              
                                           Overview of Activity for Dietitian

                               Oral Nutritional Support
                              
                                           Overview of Activity for Dietitian

                               Patient Interviews
                              
                                           Overview of Activity for Dietitian

                               Texture Modification
                              
                                  Overview of Activity for Dietitian




PAL resource pack                                                                                             Page 35 of 69
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                                                    PAL
                                             CLINICAL-PAL
                                           ANTHROPOMETRY

Purpose
This activity is designed to help you understand the practical issues and interpretation of
anthropometry in a „real‟ setting.
TIME ALLOCATED: 3 hours
Key activities:
For this activity you will be working in pairs.
You will be allocated a ward or clinic where there are patients available to practice taking
anthropometrical measurements on patients in a real setting.
 It is expected that you will undertake this activity with minimal direction from the dietitian or
ward staff. You should therefore professionally communicate with patients and attempt to
take accurate measurements, which you will need to interpret (you may wish to practice
taking the measurements on your peer prior to any patients).

If possible, look in the patients‟ medical notes before taking the measurements. You may
wish to note age, medical history and reason for admission as this may help you to interpret
the measurements you take.

 You should aim to practice taking some or all of the following measurements
(depending on the patient and/ or the patient‟s condition):


    weights, heights

    waist circumference

    skin folds

    muscle circumference

    ulna length

You and your peer may take the measurements for the same patients so you can compare
results. Alternatively if this is not possible/ the patient is not happy with this then one student
should do the measuring, with the others observing/ coaching to encourage accurate
measurements (making sure you swap roles for the next patient).

You will be asked to present on one of the patients you have obtained measurements for;
these could be patients you have measured yourself or those that your peer have measured.
It will be a brief presentation (no more than five minutes) where you will give a brief
background on the patient, the measurements you obtained and how you interpret these
measurements.
Comment on any issues you had in taking/ interpreting these and how you overcame them
(or would overcome them next time).




                              The above activity links to Learning Outcomes:
                              B: C1, C2, C3, P1, P2, P9, P10, P12
                              C: C1, C2, C3, P1, P2, P9, P10, P12

PAL resource pack                                                                                                  Page 36 of 69
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                                               PAL
                                        CLINICAL - PAL
              ANTHROPOMETRY - OVERVIEW OF ACTIVITY FOR DIETITIANS
Purpose

This activity is designed to encourage students to start to communicate with
patients and to understand the practical difficulties with anthropometry in a „real‟ setting.
They will also start to understand how this information is interpreted for individual patients,
and the limitations of both measurements and interpretations in clinical practice.

TIME ALLOCATED: 3 HOURS

Preparation

Ensure students have access to multiple patients they can use for the
measurements. This can be in a ward or clinic setting, aiming for at least two
patients per student. (E.g. oncology unit/discharge lounge/Day Medicine Unit/HIV
clinic/Older adults rehab ward)

Ideally they should also have access to patients‟ medical records so they are
able to record age, medical history and reason for admission.

You will need to check the availability of scales and provide tape measure and calipers.

Activity

Students will be working in pairs. You may wish to introduce the students to the ward staff
and/ or patients they will approach for the activity.

Allocate a ward or clinic where there are patients available for them to practice taking
anthropometrical measurements on patients in a real setting

They will be expected to practice taking some or all of the following measurements
(depending on the patient and/ or the patient‟s condition):


    weights, heights

    waist circumference

    skin folds

    muscle circumference

    ulna length

The students will approach the patients and endeavor to take the most appropriate/ practical
measurements.

Ideally each student should take the measurements for the same patients so they can
compare results. Alternatively one student can do the measuring, with the others observing/
coaching to encourage accurate measurements (with the students swapping roles for the
next patient).

Allow the students to undertake this activity autonomously if possible.




PAL resource pack                                                                                             Page 37 of 69
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                                                    PAL
Students will be expected to present on one of the patients they have obtained
measurements for; this could be a patient the student measured themselves or one of those
that one of their peers measured.

It will be a brief presentation (no more than five minutes). Check that it covers the following:

 a brief background on the patient

 the measurements obtained and how these have been interpreted

 any difficulties in taking/ interpreting these measurements and how these were overcome

  (or would overcome them the next time).




                              The above activity links to Learning Outcomes:
                              B: C1, C2, C3, P1, P2, P9, P10, P12
                              C: C1, C2, C3, P1, P2, P9, P10, P12




PAL resource pack                                                                                                  Page 38 of 69
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                                                    PAL
                                             CLINICAL - PAL
                                                 CARE HOMES
Purpose:
This activity aims to allow you to build confidence in assessment and care planning skills
within the care home setting. It also allows you to consider how delivery of the service may
be different from a hospital or out patient setting.
TIME ALLOCATED: 1 DAY

Key Activity
For this activity you will be working in pairs and reporting back to your supervising dietitian.
These tasks will allow you to consider what information is provided by care homes to the
dietetic service on referral of a patient and how this will impact on assessment and care
planning. You will also be given the opportunity to carry this process through by reviewing a
referred patient. You will also be required to ascertain what dietetic resources, guidelines
and procedures have been agreed for use within the Care Home setting.
Task 1
You will be given a copy of the referral information for 4 current patients within care homes.
You must:-
 Consider, comment and document on the quality of the information provided to the

   dietetic service on referral of a patient within the Care Home setting.
 Whether the information provided is in line with what is required within the departmental

   referral guidelines. If not, how can this be addressed?
 How the information can aid the dietitian prior to and during assessment of the patient.

 How the referral may impact upon the care planning process for this patient?

Task 2
You will now be given the opportunity to review 2 patients each within the Care Home
setting. One student should lead the interview, while the other observes and documents
feedback for discussion with your peer and dietetic supervisor.
You should:-
 Review the case notes within the care home.

 Discuss any relevant information with care home staff.

 Obtain a typical days intake from the patient land/or staff.

 Assess whether the existing care plan is being followed through by the patient and staff.

 Consider what steps the dietitian has previously taken to ensure that the care plan is

    being followed.
 Consider any further action that you feel may be necessary to ensure this patient‟s

    dietetic needs are being met.
 Compare your assessment with the dietetic case notes of your supervising dietitian.

 Finally document any barriers that you have observed or thought about in relation to the

    dietetic care plan being observed.
Task 3
You and your peer should investigate what nutrition and dietetic resources, guidelines and
procedures are in use within the care home setting. In pairs consider the impact of these for
both patients and individual staff groups i.e. nursing, care staff, catering staff, Dietitians, care
home managers.
You will be asked to discuss your findings and feedback to your dietetic supervisor.
                              The above activity links to Learning Outcomes:
                              B: K1, C1, C3, P2, P4, P5, P6, P9, P10, P11
                              C: K1, C1, C3, P2, P4, P5, P6, P9, P10, P11

PAL resource pack                                                                                                  Page 39 of 69
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                                                    PAL
                                                CLINICAL - PAL

                   CARE HOMES – OVERVIEW OF ACTIVITY FOR DIETITIANS

Purpose
This activity aims to allow the student to build confidence in assessment and care planning
skills within the care home setting, It also allows them to consider how delivery of the service
may be different from a hospital or out patient setting. They will also need to consider the
impact of any agreed procedures, resources and guidelines within the Care Home setting,
and their success in facilitating dietetic interventions. Patients in these settings are often
more complex and this allows them to build upon the skills and communication methods that
have been developed during B placement.
TIME ALLOCATED: 1 DAY
Preparation
Identify 4 current patients that the student can review within the care home setting. It does
not need to be within the same care home and their needs and level of communication skills
can be variable. Ensure that the care homes you will be visiting are aware that the students
will be undertaking this activity and are happy for them to do so. The students should be
made aware of health and safety aspects within the care home e.g. what to do in the event
of a fire. Students should also have access to dietetic policies, procedures, guidelines and
resources provided to the care homes.
Activity
The students should be given the 4 referrals prior to the visit to:-

 Allow the students to assess the quality of information provided for each of these

  patients.
 Consider whether this is in line with the referral guidelines.

 Consider the usefulness of this in relation to assessment and care planning process for

  the identified patients.

The students should then visit the care home and both lead 2 interviews and observe 2
interviews by their peer. From task 2 they should be consolidating and beginning to enhance
information gathering skills previously learned. They should consult both written notes and
discuss each patient with appropriate care home staff. They will require to develop
communication skills with patients and staff by obtaining a typical day‟s food intake and
checking if previous dietetic interventions would be in relation to these patients and how
these would be followed through. They will also need to consider any barriers to the care
plan being completed. Both students should be prepared to discuss the outcomes of the 4
interviews and learning points from Tasks 1 & 2.

Finally the students should discuss the dietetic resources packs, guidelines, procedures that
are available to the care homes. They must consider the impact of these and patients, staff
within the care home and the dietitians.


                              The above activity links to Learning Outcomes:
                              B: K1, C1, C3, P2, P4, P5, P6, P9, P10, P11
                              C: K1, C1, C3, P2, P4, P5, P6, P9, P10, P11


                              C:
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                                                        PAL
                                                 CLINICAL - PAL
                              DIETETIC ASSISTANTS/ FOOD WORKERS – PAL

Purpose

This activity is intended to give you the opportunity to find out about the roles and
responsibilities of dietetic assistants/community food workers in your area.

Time Allocated: 1 day

Key Activities

This activity will be issued to you as a group. It is up to you how you go about completing
the task i.e. in a group, in pairs or individually.

The dietetic profession routinely employs and trains dietetic assistants and food workers to
carry out a wide range of duties in the acute hospitals and in the community.

Task 1

You will find out who the dietetic assistants and food workers are, where they are based and
what their hours of work are.

Task 2

You will be expected to speak with the assistants /food workers or their colleagues to
determine what their individual job outlines are.


    What are their day to day duties?

    Do they have any unique aspects to their jobs?

    What training did they have to provide this?

    How does this contrast with the work of a dietitian?

    How do they interact with the Dietitians and with each other?

    If you have the opportunity shadow a dietetic assistant/community food worker in your
     area for part of the day.

Task 3

Compare and contrast the roles of the assistants /food workers in the acute hospitals and
the community.

Include any experience of assistants/food workers that you may have from your A or B
placement.

As a group, be prepared to feedback your findings to your supervising dietetic assistant/food
worker/dietitian.



                                  The above activity links to Learning Outcomes:
                                  B: K1, C2, C3, P5, P6, P7, P8, P9, P10, P11
                                  C: K1, C2, C3, P5, P6, P7, P8, P9, P10, P12



PAL resource pack                                                                                                      Page 41 of 69
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                                                    PAL
                                             CLINICAL - PAL
                     OVERVIEW OF DIETETIC ASSISTANTS/FOOD WORKER
                              PAL ACTIVITY FOR DIETITIANS

General aims:
 To enable the student to contribute towards dietetic team working

 To demonstrate an enquiring mind and share knowledge and experience with others


Purpose

This activity is intended to focus the students on the wide range of activities and abilities that
a dietetic assistant and food worker has to offer. They will be expected to find out who these
people are and to make contact with them to discuss their roles and responsibilities. If time
allows, it may even be appropriate for a student to shadow an assistant/food worker for a
short time. Each student may focus on one assistant/food worker and all students pull the
information together at the end of the session but as long as they have completed the task
appropriately it doesn‟t matter how they have split it up. If one of the assistants/food workers
is unavailable then it is expected that the students would seek out as much information from
their colleagues.

Preparation

The dietetic assistants/food workers should be made aware, by the supervising dietitian for
that block, that this activity is scheduled in order that they may be available. They should be
briefed to co-operate with the students but not to do the tasks for them. If appropriate and
time allows, a shadowing session could be arranged but this is up to the student to do.

The students should be prepared to go to visit the assistants/food workers.


Activity

All students will be briefed on this activity together and left to decide who does what. The
brief could be given by an assistant /food worker or a dietitian and the feedback session
likewise.
No written work is required as the feedback should be discussion only at the end of the
session.




                              The above activity links to Learning Outcomes:
                              B: K1, C2, C3, P5, P6, P7, P8, P9, P10, P11
                              C: K1, C2, C3, P5, P6, P7, P8, P9, P10, P12



PAL resource pack                                                                                                  Page 42 of 69
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                                               PAL
                                        CLINICAL - PAL
                                ENTERAL FEEDING – PAL

Purpose

The purpose of this activity is for you to research and investigate 3 key elements of enteral
feeding – feeds, tubes and administration systems. This information should provide a
baseline from which you can develop your practical knowledge of enteral feeding during your
placement.

TIME ALLOCATED: 1 hour & 2 hours & 2 hours

Key Activities:

For this activity you will be working in pairs and reporting back your findings to your student
peers and supervising dietitian.

You will look at the range of enteral feeds and equipment used and identify the differences
and specific qualities they offer. This should enable you to understand the rational behind
feed/tube and administration choice and help you make suitable choices for yourself.

Task 1: Enteral feeds

Look at the range of feeds available in the local area and create a reference table including:


    Kcal.

    Protein

    Fat

    Type and percentage of Fibre content

    Osmolaity (mOsm/Kg H2O)

    Clinical properties and usage.

    Target group for feed.

Task 2: Enteral Feeding Tubes.

The purpose of this task is to familiarize yourself with some of the enteral feeding tubes used
in your area and develop a fuller understanding of their usage.
Collect a selection of tubes including:

 Naso-gastric & Naso-jejunal

 PEGs

 Balloon Gastrostomies


Look at the variety of tubes and comment on:
 Design of the tube e.g. the material used and it‟s flexibility, length, positive and

   negative aspects of the tube features e.g. blind pockets where feed can sit and fester,
   aspect that ease placement etc.
 When they may be used.

 How and where they are placed.

 How long they can remain in situ.


Watch a PEG insertion DVD



PAL resource pack                                                                                             Page 43 of 69
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                                                   PAL
Task 3: Feed Methods

For this activity you will work as a pair. You will independently looking at 2 methods of
feeding and report back/demonstrate your findings to your peer and supervising dietitian.

The purpose of this task is to familiarize you with the various methods of feed delivery to
help put the theory into practice and to facilitate fuller care planning.

Student 1: e.g. Patrol Pump and Abbot Gravity sets.
Student 2: e.g. Kangaroo Pump and bolus feeding with catheter tip syringe.


    Collect:

    A drip stand.

    An unopened bottle of feed.

    The relevant giving sets for pump and non pump methods.

    Your allocated pump (e.g. kangaroo 224 or Patrol)

    Pump instruction manual and relevant discharge literature.

Using the above literature familiarize yourself with the techniques of setting up of a tube
feeding using your allocated methods.
Practice setting up the tube feed as if you were going to give it to a patient.

When you feel competent, present this to your peer and supervising dietitian as if you were
instructing a patient taking into consideration:

 Possible sources of contamination.

 Any alarm functions of the pump.

 Compatibility of the feeding method with different feeding tubes.


Comment on the design of all the pumps and gravity sets considering any advantage and
disadvantages the system may have e.g. noise, size, ease to set up etc.
Reflect on your experience for your portfolio.




                              The above activity links to Learning Outcomes:
                              C: K1, C2, C3, P1, P2, P3, P5, P6, P9, P10, P12
PAL resource pack                                                                                                 Page 44 of 69
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                                               PAL
                                      CLINICAL - PAL

            ENTERAL FEEDING - OVERVIEW OF ACTIVITY FOR DIETITIANS

Purpose

The purpose of this activity is for the students to research and investigate the 3 key elements
of enteral feeding – feeds, tubes and administration of feeds.

The students should work in their PAL pairs and should investigate thoroughly all the
feeds/tubes and pumps used in the local area and rationale for use of each of these. They
should be expected to use product information in the department, internet searches and
physically look at/handle the products. This activity should allow them to create a ready
reckoner for use in the rest of their placement.

TIME ALLOCATED: 1 hour & 2hours & 2hours (timetabled over 1 week)

Preparation required

The supervising dietitian ensure the students have access to product information, feeds,
tube samples and feeding pumps and associated giving sets and instruction materials e.g.
manufacturers‟ instructions, educational DVD‟s.

The activity should include a debrief session for all students at the end of the activity to
discuss their findings and demonstrate task 3. The supervisor should ensure that all
students should participate in the group session and the student has obtained the correct
information. The feedback session will begin to develop their skills in presentation and
feedback. The supervising dietitian should ensure that this has been timetabled and a room
has been booked for this purpose.

Key prompt questions:


Task 1


    What are the options for a fibre/peptide/low volume feed?

    What differenced in feed presentation did you observe?

    Are there any areas you feel have been omitted in this range of feeds

    Why do you think this range has been selected?

    Did you see more than one manufacturers‟ feed?


Task 2
 What types of feeding tubes are used and when do you think each of them might be

  selected
 What are the pro‟s & con‟s of the tubes e.g. needs endoscopic removal/life span of only

  6 weeks
 What tubes have you observed being used in practice and why?





PAL resource pack                                                                                             Page 45 of 69
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                                                    PAL
Task 3

 How easy was it to operate the feeding pump you were given?

 Would your preference be for pump or bolus feeding? Why?

 How easy was it to use the instructions you had and did you find any other

  information which helped?
 What other services do the companies provide e.g. home delivery





                              The above activity links to Learning Outcomes:
                              C: K1, C2, C3, P1, P2, P3, P5, P6, P9, P10, P12




PAL resource pack                                                                                                  Page 46 of 69
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                                                    PAL
                                                CLINICAL - PAL

                                 HEALTH PROMOTION PROJECT

Key Activity

You will work in pairs for this activity and will be expected to submit a written report. You will
also be expected to present your findings to a wider group. This task will allow you to
appreciate the complete cycle of planning, delivering and evaluating i.e. health improvement
event/activity.

TASK 1

You will be given an activity to research and complete. You should consider the following
points and these should be included in your written submission.


    Aim of project (1-2 sentences) clearly defined.

    Objectives (3 if possible)

    Pre-planning required e.g. venues, target audience and number, timings of any sessions.

    Resources – Do some exist or do they need to be developed.

    Rationale behind choice of activity or presentation.

    Any pending implications.

    Evaluation – tools or methods to be used.

You may want to also consider:-
 What went well?

 What could have gone better?

 What would I do differently next time?


You may also wish to include the rationale behind.
 The model of health promotion that underpins your activity.

 The external factors that influence the nutrition and health agenda.

 The presentation methods chosen.


TASK 2

In pairs you will present your project to other students and a wider dietetic audience.




                              The above activity links to Learning Outcomes:
                              B:C2, P5, P6, P11, P12
                              C: C2, P5, P6, P11, P12


PAL resource pack                                                                                                  Page 47 of 69
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                                                  PAL
                                           CLINICAL - PAL
                                                HOME VISITS

Purpose
This task is designed to encourage you to think about the role of lone working and the
considerations that need to be made for safety or themselves and the patient. Also to
highlight the advantages and disadvantages this environment can have in assessment.

TIME ALLOCATED: 2 hours + Home Visit

Key Activity:

For this activity you will work as a pair.

During your placement you may be required to visit a patient in their own home with your
supervising dietitian. It is important that you are aware of the impact of working in this
environment for both the patient and dietitian.

Use any experience gained on previous clinical placements.

Task 1

In your pairs discuss the safety issues to consider when undertaking home visits:

 What are the risks and barriers of lone working?

 How can these be reduced/avoided?

 What measures are in place within the dietetic department to deal with this?


Task 2

In you pairs discuss the practicalities of home visits.

 Think about what type of patients require dietetic home visits and why?


 What are the advantages/disadvantages of seeing someone in their own

  home practically, socially and dietetically?

Task 3
 What factors need to be considered for these patients when planning a dietetic treatment

   plans?
Discuss your findings with your supervising dietitian.

Students should then be allocated patients that can be seen in conjunction with their
supervising dietitian. They would then have an opportunity to reflect on this experience and
compare their initial findings with what hey have encountered.


                              The above activity links to Learning Outcomes:
                              C: K1, C1, C2, C3, P1, P2, P3, P5, P7, P10, P12



PAL resource pack                                                                                                Page 48 of 69
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                                                PAL
                                         CLINICAL - PAL
                                              HOME VISITS

As part of student training it is important that students see the different environments which
Dietitians work in including the home environment. It is equally important that the student
has an appreciation for the issues around working in this area prior to being exposed to
them.

PAL Worksheet

Aim: This task is designed to encourage the students to think about lone working and the
considerations that need to be made for safety of themselves and the patient. They should
also highlight the advantages and disadvantages this environment can have in assessment
and treatment planning.

When: The students should be given this task prior to doing their first home visit, they should
work on this together and have a facilitated session with the supervising dietitian to ensure
they have developed and understanding of what may be expected of them. After the home
visits have been completed you may wish to compare their initial thoughts with what they
experienced.

Time Allocation: This is unlikely to take more than 2 hours. It may be beneficial to discuss a
couple of the patients they may be visiting at this stage

The Home Visit

Example of areas for discussion: -


    Health Board have working policy.

    Dietetic Department lone working guidelines

    Buddy systems

    Dietetic procedures (on contacting and visiting patient i.e. telephone calls,

    arrangement of appointments, ID badges).

    Health and Safety considerations including Violence and aggression training and
     breakaway techniques.

    Procedures for alerting staff of difficult patients.

    Guidelines for client groups/medical conditions/services that will be provided with a
     domiciliary service.

    Time issues for domiciliary service.

    Practical and social considerations that can be determined when consultation is done
     in patient‟s home i.e. cooking facilities/ability to cook/shop/foods in home.

    Care that an individual may receive at home i.e. carers, meal services.

    Ability and facilities available to carry out dietary goals and targets.


It is advisable to phone the patient prior to visiting in their home.




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                                                    PAL
If you have two students there are different approaches that can be taken:

Option 1:
 Both students enter the house with the supervising dietitian.

 One student takes the lead with the assessment/treatment planning (whilst the other

   student observes) then hand over to the supervising dietitian to complete the
   consultations (whilst both the students observe).
 After leaving the patient homes then the supervising dietitian can give the participating

   student feedback.
 This would then be reversed on the next home visit.


Option 2:
 Only one student enters the house with the supervising dietitian, the other student would

   wait in the car or at an appropriate place where they could read up or prepare for their
   home visit.
 The consultation would then be as it would for one student and feedback given.

 The students would then swap for the next home visit.

 The students would then participate in case reviews on the patients seen to share their

   experiences.

Option 3:
 Traditional one to one student dietitian supervision and the students do case reviews

   after the home visits.

Option 4:
 Two students visit an existing patient who has been seen by the dietetic service. The

   patient will have been contacted by the dietitian to request consent to being seen by the
   students. They will be asked to complete a thorough assessment and after the visit
   decide on a treatment plan. This can then be compared with the dietitian
   recommendations at a facilitated session with the supervisor.




                              The above activity links to Learning Outcomes:
                              C: K1, C1, C2, C3, P1, P2, P3, P5, P7, P10, P12




PAL resource pack                                                                                                  Page 50 of 69
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                                                    PAL
                                                CLINICAL - PAL

                                    NUTRITIONAL SCREENING
Purpose
This activity aims to familiarise you with nutritional risk screening using MUST. You will be
expected to access and use MUST paperwork in ward settings and identify potential barriers
to screening in a practice setting.
TIME ALLOCATED: 4 hours
Key Activities
For this activity you will be working in pairs. Be prepared to report back your findings at a
student led discussion.

Task 1
Familiarise yourself with the MUST screening tool and care plans.

Task 2
You will be allocated a ward in which to undertake nutritional risk screening.
Working in pairs, choose a total of 6 patients in the ward who may or may not require
nutritional intervention.
Working individually and without looking in the patients‟ notes (use clinical judgement based
on speaking with the patient (if possible) and visual clues only). Determine whether each of
the 6 patients would appear to be at low, medium or high risk of malnutrition.
Share your decision and reasons with your student peer and discuss whether they would
agree or disagree with your “assessment”.

Task 3
Working collaboratively, complete nutritional risk scores (MUST) on 2 of the previous 6
patients. Working individually each student should then complete nutritional risk scores
(MUST) on 2 of the remaining patients. (In this way, MUST scores will be obtained on all 6
patients)
Compare the MUST score results with results obtained by clinical judgement alone (in Task
2).

Task 4
For all 6 patients, had MUST screening (and re-screening) been undertaken by nurses prior
to your visit to the ward?
If so, did the scores the nurses calculated, correspond to the scores you calculated? If not,
why not?
What might be the consequences of not undertaking nutritional risk screening on admission
and throughout the patient‟s hospital stay?

                              The above activity links to Learning Outcomes:
                              B: C3, P1, P2, P5, P6, P9, P10, P11
                              C: C3, P1, P2, P5, P6, P9, P10, P11




PAL resource pack                                                                                                  Page 51 of 69
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                                                    PAL
                                              CLINICAL- PAL
       NUTRITIONAL SCREENING - OVERVIEW OF ACTIVITY FOR DIETITIANS

Purpose
This activity aims to familiarise students with nutritional risk screening using MUST. By
allowing the student to investigate how to access MUST paperwork in ward settings and how
wards re-order supplies you are helping them to identify potential barriers to screening in a
practice setting and „find out what they need to know‟. Students will be working
collaboratively to build confidence but also individually given an opportunity to practice
MUST screening. This activity also builds confidence working in ward settings.

The student led discussion session after the activity (attended by all students) will allow all
students to discuss how they use clinical judgement and how reliable this may be. The
students will each report back on their individual findings in the group session, which will
further develop their skills in reporting back.

TIME ALLOCATED: 4 hours

Preparation

Provide the students with a copy of MUST paperwork including Care Plans (these can be
obtained from any ward area or from the dietetic department)
Identify a suitable ward where MUST screening can be undertaken. This can be in either an
Acute or Community ward setting.
Timetable direct feedback from students on the MUST screening activity with all students
present.
You may wish to introduce the students to ward staff & explain to the purpose of the student
activity.

Activity

Students will be using clinical judgement to determine whether 6 patients in the ward are at
risk of malnutrition.

Working together MUST scores the students will calculate MUST scores for 2 of the 6
patients then working individually for a further 2 patients each. In total, all 6 patients will have
MUST scores calculated. All 6 patients will have their notes scrutinised for evidence of
MUST screening by nurses and whether this has been undertaken correctly/all steps
completed.

Comparisons can therefore be made between risk scoring based on clinical judgement and
MUST scoring undertaken by students and ward staff.




                              The above activity links to Learning Outcomes:
                              B: C3, P1, P2, P5, P6, P9, P10, P11
                              C: C3, P1, P2, P5, P6, P9, P10, P11



PAL resource pack                                                                                                  Page 52 of 69
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                                                      PAL
                                              CLINICAL - PAL
                              ORAL NUTRITIONAL SUPPORT (ONS) - PAL
Purpose

To investigate the role of food fortification and ONS products in nutritional support, and their
practical application.

TIME ALLOCATED: 4 hours

Key activities:

For this activity you will be working together and individually. Make notes on each of the
following tasks for the student led discussion later in week, which will be attended by all
students.


Task 1 - generic

Working together, familiarise yourself with the range of ONS products available in the
department. Consider the nutritional content, volume, flavour, appearance and how it is
presented.

Taste any products that you have not tried before.

Select one product each from the range and taste (if possible try to consume the full dose)
and be prepared to describe this product, how you might use it and when you might use it.
Consider how you would describe this to a patient.

Be prepared to share this information at the student led discussion.

Task 2 – (B)

Select one of the following items on the hospital menu and consider how you might advise
your patient to increase the nutritional value of it if they were at home.

     Soup                         Main course                       Hot pudding                        Cold pudding

Consider the use of food fortification, ONS products, ease of preparation and cost and what
nutritional value it can add.

If possible, make your adapted dish and comment on the taste and appearance of the end
product.

Task 3 (C)

Thickening supplements:
 Pick a protein/energy dense supplement and thicken it to a double cream consistency

   following the manufacturers/local instructions.
 What thickener did you use, how much did you use and what method did you use?

 Any problems?





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                                                    PAL
Freezing supplements:
 Pick a protein/energy dense supplement and make it into „ice lollies‟ and cubes, checking

   manufacturer‟s guidance first.
 In your opinion is freezing successful?

 Does freezing alter the flavour?


Heating supplements:
 Pick a couple of protein/energy dense supplements; one flavour which is traditionally

   taken warm and another that perhaps is not commonly served heated. Check
   manufacturer‟s guidance first.
 In your opinion is heating successful?

 Has the flavour altered?

 Can you add any other ingredient[s] to improve the flavour or add to its nutritional value?


Adding things:
 Many patients find the supplements too sweet, too thick, metallic tasting …… remember

   we often advise patients to drink up to 400ml of supplement/day.
 Can you think of simple ways of „diluting or modifying' supplements to improve their

   palatability?
 Try them. Did it work?

 What are the advantages/disadvantages of diluting or modifying supplements?



Task 4- C

You will each be allocated a patient who is receiving nutritional support in the ward/clinic.
Speak to this patient to find out their perspective on this. Consider if they are receiving food
fortification/snacks/ONS products or a mixture of these.
Be prepared to share this information at the student led discussion.

NB: you are not expected to make any changes to this person‟s diet prescription.




                              The above activity links to Learning Outcomes:
                              B: K1, C3, P1, P2, P5, P9, P10, P11
                              C: K1, C1, C3, P1, P2, P5, P9, P10, P11


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                                                     PAL
                                                 CLINICAL - PAL

                              ORAL NUTRITIONAL SUPPORT (ONS) – PAL
                                    OVERVIEW FOR DIETITIANS


The aim of this task is to make the students aware of the many ways in which nutritional
support can be provided. Although they will be asked to look at ONS products and their role,
it is hoped and expected that they will adopt a „food first‟ approach to nutritional support.

Task 1
This activity is suited to both B & C placement students.
If the student is to use ONS products it is vital that the have an appreciation of the taste,
texture, flavour and volume of the product they are expecting the patient to consume. It is
expected that products are tasted and that the students can accurately describe these in
order to select appropriate products and motivate patients to take them. Often students will
taste a mouthful of a supplement, but consideration must be given to the volume to be
consumed.

Key prompt questions
 How many products were there?

 Was there overlap in varieties e.g. Fortisip/Ensure Plus?

 How much did you manage to take?

 What is your experience of using these so far?



Task 2
This activity is designed with B students in mind but could be applied in C
depending on experience.
In hospital there are often pre-set systems for fortification of hospital meals. The students
should already have knowledge of this for their diet bay experience. What they are now
being asked to do is consider the practical application of this and how a patient might do this
at home.

The dietitian should ensure that there are 4 suitable options on the hospital menu for
adaptation. The students should select one each and work out how they could increase the
nutritional value of this dish. If possible they should make this product up e.g. in the diet
bay/at home and see how well it works and what it tastes like.

Although they may veer towards using ONS products, it is expected that they consider the
nutritional value of everyday foods such as cream, cheese, sugar, milk etc. They should also
consider the cost associated with this – to the patient and also to the GP.

Task 3
This activity is suited to C students.
The dietitian should ensure that the students have access to ONS products, manufacturer‟s
guidance and be able to utilise freezing and heating methods.




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                                                    PAL
Task 4
This activity is suited to C students
Although the previous tasks have been practical, they have not included the end user i.e. the
patient.

The dietitian should select 4 patients on the department‟s caseload, who are on
supplemented diets, and allocate one to each student.

The student should be briefed to go and speak informally to the patient and find out what it is
like to be at the receiving end of nutritional support. How do they find the supplements?
The student should be aware that this is a fact finding exercise and they are not expected to
provide any dietetic intervention. If any issues are raised the student should feed this back
to the dietitian.




                              The above activity links to Learning Outcomes:
                              B: K1, C3, P1, P2, P5, P9, P10, P11
                              C: K1, C1, C3, P1, P2, P5, P9, P10, P11

PAL resource pack                                                                                                  Page 56 of 69
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                                                    PAL
                                             CLINICAL - PAL
                                   PATIENT INTERVIEWS - PAL

                                                 ASSESSMENT

Purpose

The purpose of this activity is to allow you to practice your interviewing skills on patients
without direct supervision by the dietitian. Your student peer will observe your interview and
will be expected to give you feedback on your performance. You will then swap roles,

Time allocated: 4 hours

Key activities

Familiarise yourself with the dietetic notes for this patient.

Review the patient‟s case notes and update the dietetic records with any information you
consider to be relevant. Consult your peer if you are uncertain.

Working together, review each patient‟s current dietary intake and compliance with the
existing dietary plan by interviewing each patient. One student should lead the interview,
while the other observes, then swap over for the next patient. The observing student should
complete the student observer form.
 Document your findings clearly on the dietetic record card.


Once all 4 patients have been reviewed, discuss your findings with your peer. Give
feedback to your peer about how they performed in the interview and any areas they
missed- aim to give 2 points they did well and 1 area for improvement.

Be prepared to share your findings with the supervising dietitian




                              The above activity links to Learning Outcomes:
                              C: K1, C1, C3, P1, P2, P3, P4, P5, P7, P8, P9, P10, P12

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                                                    PAL
                                             CLINICAL - PAL
                                   PATIENT INTERVIEWS - PAL

                                              CARE PLANNING

For this activity you will work individually and in pairs. The supervising dietitian will allocate
4 patients who are already under dietetic care.
You will each review 2 patients.

Individually

Familiarise yourself with the dietetic notes provided by the dietitian.

Review the patient‟s case notes and update the dietetic records with any information you
consider to be relevant. Consult your peer if you are uncertain.

Together

One student should review each patient‟s current dietary intake and compliance with the
existing dietary plan by interviewing each patient. One student should lead the interview
while the other observes, then swap over for the next patient. Document your findings
clearly on the dietetic record card.

 Using this information, what would be your recommended care plan for this patient? Be
prepared to justify your decisions.
After each patient, discuss your findings with your peer. Did your peer have any differing
opinions?

Finally, document the recommended care plan on the dietetic record card.

Once all 4 patients have been reviewed, discuss your findings and plans with your peer.
Give feedback to your peer about how they performed in the interview and any areas they
missed- aim to give 2 points they did well and 1 area for improvement.

Be prepared to share your findings with the supervising dietitian




                              The above activity links to Learning Outcomes:
                              C: K1, C1, C3, P1, P2, P3, P4, P5, P7, P8, P9, P10, P12

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                                                    PAL
                                             CLINICAL - PAL
                                   PATIENT INTERVIEWS – PAL

                                               CARE DELIVERY

For this activity you will work individually and in pairs. The supervising dietitian will allocate
4 patients who are already under dietetic care.
You will each review 2 patients.

Individually

Familiarise yourself with the dietetic notes provided by the dietitian.

Review the patient‟s case notes and update the dietetic records with any information you
consider to be relevant. Consult your peer if you are uncertain.

Together

Working together, review each patient‟s current dietary intake and compliance with the
existing dietary plan by interviewing each patient. Discuss and agree a care plan with the
patient.

One student should lead the interview, while the other observes, then swap over for the next
patient. Document your findings and recommended care plan clearly on the dietetic record
card.

After each patient, discuss your interview with your peer.
What skills did you use in delivering this?
What was the patient‟s response to your suggestions?
What action will you have to take to ensure this care plan is carried out?


Once all 4 patients have been reviewed, discuss your findings and plans with your peer.
Give feedback to your peer about how they performed in the interview and any areas they
missed- aim to give 2 points they did well and 1 area for improvement.

Be prepared to share your findings with the supervising dietitian




                              The above activity links to Learning Outcomes:
                              C: K1, C1, C3, P1, P2, P3, P4, P5, P7, P8, P9, P10, P12

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                                               PAL
                                        CLINICAL - PAL
           PATIENT INTERVIEWS – OVERVIEW OF ACTIVITY FOR DIETITIANS


This activity aims to allow the students to build confidence in interviewing patients. Building
on their experience in their B programme, they can now use this format in patients who are
more complex in nature or require different methods of communication e.g. visual/hearing
impairment. This is a true PAL activity and gives the students the opportunity to speak to
patients without the presence of a supervising dietitian. Students may be more relaxed with
their student peer as an observer and they have the opportunity to learn from someone
else‟s style of interviewing and how they cope with situations.

This activity is in 3 stages; the stage you choose to issue will depend on the competency of
the students/stage in their C placement.

Preparation

Identify appropriate patients‟ for students to review on the ward, or Care Home. Ideally the
students will have seen these patients previously but this is not mandatory. Appropriate
patients should be currently under dietetic care. Specialist areas e.g. paediatrics, renal may
be used during the Assessment block as the student is only required to gather information,
not give advice. Patients on long stay wards or well-known patients on acute wards are
ideal for this activity.

Ensure that the nurse in charge of the area is aware of the student‟s activity and is happy for
them to proceed. Ensure the students know what to do in the event of an emergency e.g.
fire or if they are experiencing difficulties with their task and that they have a contact name
and number for the supervising dietitian.

The activity should be scheduled for a time when the patient and their medical records are
available (e.g. not at a time when ward rounds are scheduled). Students can undertake this
activity on a ward or in a Care Home environment.

Provide the students with the dietetic record cards for these patients.
Set aside time for a student led discussion, lasting approximately 1 hour, to review this
activity on the same day. Both students should attend this together,

The supervising dietitian should be available to contact throughout this activity but need not
necessarily be in the same ward/clinic area

Activity

Students will work in pairs. Each student will review the dietetic records and case notes for a
patient and update the dietetic record card for that patient. The same student will then take
a diet history from this patient and assess compliance with the existing care plan, whilst
been observed by the other student. The observing student will complete the student
observer form. They will then swap roles and repeat the process.




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                                                    PAL
The observing student must give feedback about their student peer‟s interview and
assessment performance at the review session, to both the student and the supervising
dietitian. It is suggested that the observing student completes the local student interview
assessment tool on their peer to assist them in giving feedback.

The dietitian will facilitate the review session.
Obtain feedback from the students on the information they have collected, the record cards
they have completed and their interview performance. Ask the students to feedback from
the student observer forms.

Prompts for supervising dietitian

What difficulties did they experience and how did they manage their time?
Did the student base their care plans on appropriate information?
Could they justify their decisions?
How did the students differ in opinion (if at all?)?
How did the patient respond to advice and suggestions and what (if any) negotiation was
required.
What did they have to do to implement the care plan – e.g. FRC, discussion with health care
staff, charting patient for diet, contacting menu clerk/diet bay.
How well was the information documented on the dietetic record card?




                              The above activity links to Learning Outcomes:
                              C: K1, C1, C3, P1, P2, P3, P4, P5, P7, P8, P9, P10, P12




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                                                    PAL
                                              CLINICAL- PAL
                                  TEXTURE MODIFICATION- PAL
Purpose
The purpose of this activity is to give you the opportunity to shadow the Speech and
Language Therapist and relate their work and influence to dietetic practice. You will
investigate the provision of all the texture modified diets and fluids available and their
potential impact on patients nutrition.
TIME ALLOCATED: 1 day
Key Activities:
For this activity you will be working singly then in pairs and reporting back your findings to
your student peers at a student led discussion later this week.
You will be shadowing a speech & language therapist (SLT) on the ward/ clinic/ home visit,
whilst they carry out a swallowing assessment.

Task 1
Observe the SLT‟s practice and make notes to inform the student led discussion later this
week.
For each consultation or episode you observe, consider the following questions:
What were the SLT‟s main aims for this consultation?

    Did the SLT liaise with anyone before the consultation? What this helpful? Why/why not?

    What information did the SLT collect?

    What strategies did they use to collect information?

    What was the SLT recommendations from this assessment and the potential nutritional
     implications?

    How did the SLT communicate their recommendations this to all the relevant people?

    How did the patient respond to the SLT‟s intervention?

    How did the SLT consultation differ from any dietetic consultations you have observed?

Task 2
Working in pairs, review the consistency alteration food and fluid options available
in your hospital.
How many different textured modified options are available for foods and
fluids and how are these provided?
Consider what are the nutritional issues associated with each of these stages, what are the
catering challenges and what (if any) special products are used?
Discuss this with your student peer and be prepared to feedback your findings at the student
led discussion.



                              The above activity links to Learning Outcomes:
                              B: K1, C2, C3, P1, P2, P3, P5, P6, P9, P10, P12
                              C: K1, C2, C3, P1, P2, P3, P5, P6, P9, P10, P12


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                                                    PAL
                                             CLINICAL - PAL
        TEXTURE MODIFICATION - OVERVIEW OF ACTIVITY FOR DIETITIANS

Purpose

The purpose of this activity is to give the students the opportunity to shadow the SLT another
relevant healthcare professional and relate their work and influence to dietetic practice.
They should consider how the SLT advice has been given and translated and what impact
this has on food choices, catering provision, nutritional intake and the psychological impact it
may have on the patient.

The students should work in their PAL pairs for the second part of the activity and should
investigate thoroughly all the textured modified diets and fluids available locally. The
students should be aware of the national descriptors for textured modified diets. It should be
expected that students will look at menu cycles, diet sheets, ward information and also
observe/taste the actual food being prepared/delivered to wards. They should speak to diet
cooks, ward staff to discover any practical problems with meal provision. They should also
identify how fluids can be thickened and which are routinely used on the ward. Some
knowledge of thickeners, pre thickened drinks and supplements should be demonstrated in
the feedback.

TIME ALLOCATED: 1 day

Preparation required

The supervising dietitian should arrange for the students to individually shadow a SLT – in
acute / community when they are carrying out swallow assessments/ reviews or video
fluoroscopes. For logistical reasons it may not be possible for all students to do this at the
same time.

As this part is completed individually, the student can use this element of the activity
as evidence by submitting a reflective piece or requesting a verified witness
statement be completed by the SLT.

The activity has a debrief session for all students to discuss their shadowing experience and
their findings on texture modified diets. The supervisor should ensure that all students
should participate in the group session and the student has obtained the correct information.
The feedback session will begin to develop their skills in presentation and feedback. The
supervising dietitian should ensure that this has been timetabled and a room has been
booked for this purpose.




                              The above activity links to Learning Outcomes:
                              B: K1, C2, C3, P1, P2, P3, P5, P6, P9, P10, P12
                              C: K1, C2, C3, P1, P2, P3, P5, P6, P9, P10, P12.




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                                                 PAL
     Acknowlledgementts off conttriibuttors tto pack and resources used::
     Acknow edgemen s o con r bu ors o pack and resources used

            Scottish PAL Implementation Group
           
            Subgroup members:
           
                 Fiona Struthers, NHS Forth Valley; Val Reid, NHS Grampian;
                 Moira Smith, NHS Lothian; Karen Lauder, NHS Ayrshire & Arran
            London Metropolitan University & Kings College London
           
            University of Plymouth
           
            NHS Forth Valley
           
            NHS Tayside
           
            NHS Ayrshire & Arran
           




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                                                      PAL
                                  Know Can Do Model – Block B
                                            B            B Block             B Block          B Block            B Block         B
                                          Block          Week 4               Week             Week                            Block
                                          Week                                 5/6              7/8                            Week
                                            1                                                                                    12
K1        Evaluating knowledge            know          know                know             know/can           can            can
          and applying it in a
          holistic way
C1        Information gathering           know          know/can            can              can                can            can
          and active listening,
          using available
          resources
C2        Communication                   know          know                know             know               can            can
          (presentations and
          facilitating groups)
C3        Accurate accounting,            know          know                can              can                can            can
          verbal feedback, written
          documentation
P1        Collecting information          know          can                 can              can                do             do
          and record keeping
P2        Evaluating information          know          know                know/can         know/can           can            can
          before deciding what to
          do
P3        Rationale care planning         know          know                know             know/can           know/can       can
P4        Follow up                       know          know                know             know/can           know/can       can
P5a       Dealing with clients            know          know                know             know/can           know/can       can
          barriers to change
P5b       Health promotion, how to        know          know                know             know               can            can
          help groups make
          changes
P6        Effective communication         know          know                know/can         know/can           can            can
          with health professionals
P7        Professional conduct            know          know/can            can              do                 do             do
          and confidentiality
P8        Anti-discriminatory             know          know/can            can              do                 do             do
          practice
P9        Time management                 know          know                know             know/can           can            can
P10       Reflective practice             know          know/can            know/can         can                can            can
P11       Hunger for knowledge            know          know                know             know/can           know/can       can
          and an enquiring mind
P12       Identifying ones own            know          know                know/can         can                can            can
          strengths and
          weaknesses
P13       Professional attitude           know          know                can              can                do             do

                                        Know                  Can                  Do
                       Know = knowledge and an understanding of the above
                       Can = demonstrate with supervision and support
                       Do   = student can independently demonstrate the skill




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                                                   PAL
                                   Know Can Do Model – Block C


                                                  C                  C              C              C                C           C
                                                  Block            Block          Block          Block            Block       Block

                                                   Week                            Week          Week                        Week
                                                    1                               5/6            7/8                         12
K1  Evaluating knowledge and                      can             can             can            do               do         do
    applying it in a holistic way
C1  Information gathering and                     can             do              do             do               do         do
    active listening, using
    available resources
C2  Communication                                 can             can             can            can              can        can
    (presentations and facilitating
    groups)
C3  Accurate accounting, verbal                   do              do              do             do               do         do
    feedback, written
    documentation
P1  Collecting information and                    do              do              do             do               do         do
    record keeping
P2  Evaluating information before                 can             can/do          do             do               do         do
    deciding what to do
P3  Rationale care planning                       can             can/do          do             do               do         do
P4  Follow up                                     can             can/do          can/do         do               do         do
P5a Dealing with clients barriers to              can             can/do          can/do         do               do         do
    change
P5b Health promotion, how to help                 can             can             can            can              can        can
    groups make changes
P6a Effective communication with                  can             can/do          can/do         do               do         do
    Dietitians
P6b Effective communication with                  can             can             can/do         do               do         do
    health professionals
P7  Professional conduct and                      do              do              do             do               do         do
    confidentiality
P8  Anti-discriminatory practice                  do              do              do             do               do         do
P9  Time management                               can             can/do          can/do         do               do         do
P10 Reflective practice                           can/do          can/do          do             do               do         do
P11 Evaluates practice                            know            know            know           can              can        can
P12 Hunger for knowledge and an                   can/do          can/do          do             do               do         do
    enquiring mind
P13 Identifying ones own                          can             can/do          do             do               do         do
    strengths and weaknesses
P14 Professional attitude                         do              do              do             do               do         do


                                     Know                  Can                  Do

                       Know = knowledge and an understanding of the above
                       Can = demonstrate with supervision and support
                       Do   = student can independently demonstrate the skill




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     Reference List
                                                PAL
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     Armson, H., Kinzie, S., Hawes, D., Roder, S., Wakefield, J. and Elmslie, T., 2007.
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     Blakeley, C., Rigg, J., Joynson, K. and Oldfield, S., 2009. Supervision models in a 2:1
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     Classen, J., 2004. A 2:1 clinical practicum, incorporating reciprocal peer coaching,
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     Currens B JA (2003.) The 2:1 Clinical Placement Model: Review. Physiotherapy,
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     Currens B JA and Bithell, CP. (2003.) The 2:1 Clinical Placement Model: Perceptions
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     Hudson, JN. Tonkin, AL. (2008). Clinical skills education: outcomes of relationships
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                                                PAL
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                                                PAL
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