Dietetic departments are challenged to assure and maintain staff competency in skills not learnt during university qualification. Subjective Global Assessment (SGA) is traditionally learnt on-the-job in most hospitals in Australia. This paper describes our experience in developing and evaluating an SGA training programme for dietitians.
Literature review(Reference Detsky, Smalley and Chang1–4) and consultation with those experienced in SGA, local and international, was conducted by two department experts. These experts underwent further training through a combination of methods and then performed tests of clinical reproducibility on six patients. Modules one and two were developed for department staff training. Module one included an in-depth instructional component, an interactive workshop and bed-side demonstration of the technique by the department experts. Trainees received a training package including written guidelines, relevant resources and a ‘learner's version’ of the SGA form.
In module two, staff performed hands-on patient assessments (3–4 patients) in small groups, followed by review with the department expert to reach a consensus about each patient's nutritional status. After a minimum period of two weeks, department experts and staff performed bedside SGA in pairs independently on assigned unknown patients (1–2 patients). Competency standards were met if ≥80% agreement was achieved between trainees and department experts in the overall ranking and when trainees had completed all listed tasks.
Eleven dietitians completed module one of the above programme. Nine dietitians, half of them with more than 5 years clinical experience, completed the second module. There was 74.8% agreement between department experts and trainees in assessing the medical history features and 63.8% agreement in assessing the physical status of patients. Dietitians tended to over classify the physical examination rating more severely than did department experts. However, dietitians were in agreement with the department experts for the overall SGA ranking 100% of the time. Analysis of evaluation by participants indicated that the programme objectives were met; knowledge and understanding had increased and the experience of the bed-side physical assessment and group discussions were particularly valuable.
SGA can be taught with a high degree of agreement in overall rating in a group of experienced dietitians using a structured training programme. Strategies recommended to improve precision and validity of assessing the individual features of the SGA include performing the tests of agreement on more patients regularly, routinely using SGA as part of day to day clinical practice and regular patient-case reviews during professional development activity times.
To ensure that competency standards are maintained it is proposed to review staff performance in a format similar to Module two on an annual basis. A programme such as this will assist dietitians in their professional development to gain skills, knowledge and confidence in diagnosing malnutrition in appropriate hospital patients.
