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Direct economic benefits associated withdietetic internshipsMARTHA T CONKLIN, PhD, RD; MARGARET D. SIMKO, PhD, RD

ABSTRACT

Objective We explored the direct economic benefits ofhospital dietetics departments sponsoring an internship fordietetics students.Design Forty-five dietetics departments in US hospitalsparticipated in a mail survey that involved comprehensive datacollection procedures using three instruments, includingactivity logs recorded by 298 dietitians and interns.Main outcome measures Direct benefits were defined as thenet student labor provided to the department during routineand staff relief experiences that released professional labor forother work. Net student productivity during routine assign-ments was calculated by subtracting the time dietitians spentteaching during a typical work week from the amount of timedietetic interns spent performing professional services withoutdirect supervision. Student productivity during staff reliefrotations was calculated by multiplying the number of studentsassigned to this type of experience by the length of therotation.Results While involved in routine learning experiences,dietetic interns provided a direct benefit. The differencebetween the time interns spent in independent, professionalservice in the departments and the time dietitians spent inactivities designed specifically for teaching was a mean of 29hours in favor of the students. All departments received adirect benefit from assigning dietetic interns to a staff reliefrotation. The median number of weeks of student labor gainedby the departments per year was 24.Statistical analyses A paired t test was used to analyze thedifference between the time dietitians devoted to teachinginterns and the time students spent in independent, profes-sional service in the departments. The difference was veryhighly significant (P<.001)Applications This study is a beginning step in objectivelydocumenting positive outcomes associated with sponsoring adietetic internship. It also represents a model that could beused by program directors to study the economic impact oftheir supervised practice program on the sponsoring organiza-tion. JAm DietAssoc. 1994; 94:174-178.

ietetic internships have been shown to prepare entry-leveldietitians effectively (1). The advantages for the profes-sion are obvious, but what effects do these programs haveon the dietetics departments that sponsor them? What, if

anything, do the departments gain from the presence of dieteticinterns? The latter question is particularly vital for hospitaldietetics departments, which have been under siege in recentyears to pare down expenses. If dietetic internships exist withoutbenefit to hospital dietetics departments, how can the expendi-ture of resources for their continuation be justified? This is a hardquestion posed in hard economic times. In an effort to learn moreabout this issue, we investigated the direct economic benefitsaccruing to hospital dietetics departments that sponsor an intern-ship for student dietitians (2).

Economic benefits are the desired outcomes derived from theexpenditure of resources. All positive changes in resources result-ing from these expenditures, including cost savings generated byprogram-related activities, are benefits (3). Direct benefits in thiscase are those that are clearly identified as resulting from theeducation of students and can be measured in real dollars (4). Thedetermination of benefits is always conducted from a specificpoint of view (3). In this instance, the perspective was that of thehospital dietetics departments that provided the resources usedby the internships.

Research on the outcome of supervised practice programs fromthe economic viewpoint of the sponsoring organization has beenconducted for programs in several medical and allied health fields(4-10). Although the economic impact of supervised practiceprograms has been an area of interest in dietetics (11-13), to ourknowledge no research has been published that establishes arelationship between the presence of dietetic interns and depart-mental benefits.

The primary economic resource provided to internships byhospital dietetics departments is professional labor. When aninternship is sponsored by a department, most of the instructionis performed by staff dietitians who assume teaching duties inaddition to their routine assignments. Dietetics students also

M. T Conklin (corresponding author) is a researchscientist in the Division of Applied Research, NationalFood Service Management Institute, The University ofSouthern Mississippi, Hattiesburg, MS 39406-0077.M. D. Simko is clinical professor, Department of FamilyMedicine, University of Medicine and Dentistry of NewJersey, Robert Wood Johnson Medical School,New Brunswick, NJ 08903-0019.

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contribute to the production of food and nutrition services in theprocess of their training, and as their education progresses,dietitian preceptors assign them to professional activities per-formed independently, without direct supervision. The differencebetween these two levels of productivity represents net studentproductivity, which constitutes either a direct benefit, a neutraleffect, or a direct cost to the department by affecting the potentialproductivity or output of that organizational unit through theavailability of professional labor (14).

METHODS

InstrumentsWe developed three questionnaires to gather data on the directeconomic benefits associated with dietetic internships: an admin-istrative questionnaire, a teaching activity recording form, and alearning activity recording form. Each instrument was testedbefore use in the study. Several questions were adapted fromprevious research (7,15). A panel of dietetics educators evaluatedthe content of the instruments. The administrative questionnairewas pilot-tested by a random sample of dietitians who wereinvolved in supervising dietetics students throughout the UnitedStates. A group of dietitians and students from an internship in theMidwest used and evaluated the teaching and learning activityforms. Suggested improvements were incorporated into the finalinstruments (2).

Data CollectionOf the 96 internship directors from hospital-based dietetic intern-ships who received a letter of inquiry, 55 (57.3%) expressedinterest in participating in the study. The instruments weremailed to the internship directors to administer at their primaryhospital facility or to assign to an administrative person in thedietetics department identified by the director as the hospitalfacility where the most students were supervised for the longestperiod. These individuals took the responsibility of distributingquestionnaires according to the procedures outlined in an accom-panying cover letter.

The packet of instruments included one copy of the administra-tive questionnaire, which was completed by an individual withmanagement responsibility in the departments, and several cop-ies of the teaching and learning activity recording forms. Internsinvolved in routine assignments and their supervising dietitiansrecorded educational activities on these forms. Three follow-upprocedures to encourage return of the instruments were insti-tuted (16).

Calculation of Net Student ProductivityDirect economic benefits were measured by two types of studentproductivity. One form of productivity, which is explained in thissection, was the amount of time dietetic interns spent performingindependent, professional activities compared with the amount oftime required from dietitians for educating the same group ofstudents. The difference was net student productivity.

The total number of teaching hours was obtained from theteaching activity recording forms. Directions for the form re-quested that each dietitian record the time, to the nearest 5minutes, spent each day in educational activities specificallyrelated to the internship program. Teaching activity codes iden-tified time spent in the following areas: administrative activities,including student evaluation, counseling, and monitoring of writ-ten work; lectures or demonstrations; professional activities per-formed jointly with a student; and the direct supervision ofstudents performing professional procedures. These activitieswould not be conducted if students were absent from the depart-ments. Total teaching time for each dietitian was calculated by

Table 1Comparison of mean total departmental teaching time to student timespent in independent, professional activities (No. of departments = 43)

Total time Mean + standard deviation Median

- hours per week -Teaching time 37.3 18.8 31.4

Student time 66.5± 42.6 68.0

Net productivitya 29.2+35.7*" 21.7

aFormula for net productivity: ST(5) - TT(5) = NSP ST(5) = time students spentin independent, professional activities over a 5-day period, summed for thedepartment; TT(5) =time dietitians spent teaching this group of students overthe same 5-day period, summed for the department; NSP=net studentproductivity per department over the work week.***Highly significant at P<.001.

summing the minutes spent in teaching activities over 5 consecu-tive days, or a standard work week (6,7).

The total number of student hours spent performing indepen-dent, professional procedures was obtained from the learningactivity recording forms. The interns followed recording proce-dures similar to those of the dietitians. Only one category oflearning activities, however, was used to calculate total studenttime: performing a professional procedure independently, with-out direct supervision (6,7,17).

The recording of time occurred during typical work weeks inthe hospitals. Staff relief records reported on this form weredisqualified for both dietitians and students. The amount ofstudent time spent in this type of experience was measuredelsewhere. Dietitian time, by definition, would be negligible forthis type of experience, because relief is a summative experiencein which the student assumes the total responsibilities of adietitian. We took care to match student records for a departmentwith the appropriate number of dietitian records according to thetype of learning experience and the number of students thedietitians supervised during the recording period. In all, 37 re-cording forms were discarded and were not counted as part of the298 records analyzed.

Net student productivity for a department was calculated bysubtracting the total teaching time provided by dietitians from thetotal time in independent, professional services supplied bystudents. The formula for calculating net student productivitywas as follows:

ST(5) - TT(5)=NSPwhere ST(5)=the time students spent in independent, profes-sional activities over a 5-day period, summed for the department;TT(5))=the time dietitians spent teaching this group of studentsover the same 5-day period, summed for the department; andNSP=the net student productivity for the department over thework week. A paired t test was used to determine whether thedifference between total teaching time and student time observedin each department was statistically significant at P<.05.

Total Time in Staff ReliefA second form of student productivity for indicating a directprogram benefit was the use of dietetic interns in a staff reliefrotation. This information was collected by the administrativequestionnaire. The staff relief variable was calculated by multiply-ing the number of weeks each student participated in staff reliefby the number of students performing staff relief rotations peryear. This new variable represented the total number of studentlabor hours per year donated to the department through staffrelief. Additional questions on staff relief were summarized tocharacterize how departments used the dietitians' time whilestudents relieved them of their routine duties.

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RESEARCH

Table 2Types of activities performed by students (N = 145) while engaged inindependent, professional service in the departmentsa

Activity Frequency %b

Giving nutrition education or dietary counselinginstructions to individual patients 70 48.2

Charting medical records 47 32.4

Conducting nutrition assessments and writing careplans 35 24.1

Obtaining initial or follow-up information from patients 26 17.9

Supervising foodservice employees 26 17.9Updating patient card files 24 16.6

Screening for nutritional acuity 23 15.9Conducting meal rounds 23 15.9

Conducting group nutrition education classes 19 13.1Conferring with physicians, nurses, and other medical

staff 17 11.7

Calculating or monitoring enteral or parenteral feedings 16 11.0Conducting in-service training sessions for foodservice

employees 16 11.0

Calculating patient food intake information 15 10.3Obtaining patient information from medical records 14 9.7

Calculating diets 12 8.3Conducting foodservice quality control audits (eg,

sanitation, temperatures) 12 8.3

Meeting with vendors or suppliers or ordering food 12 8.3Planning or coordinating snacks and supplements and

solving other problems with foodservice 11 7.6

Conducting a physical inventory of food and supplies 9 6.2Checking menus 8 5.5

Developing and analyzing foodservice jobdescriptions or work schedules 7 4.8

Conducting chart audits or reviews 7 4.8

Developing foodservice policies and procedures 6 4.1Conducting employee meetings 5 3.4

Planning or supervising catered functions 5 3.4Conducting and analyzing patient or cafeteria-patron

survey information 5 3.4

Attending or presenting at medical rounds 4 2.8Conducting in-service training session for hospital or

agency employees 4 2.8

Computer-generating patient or foodservice data 4 2.8Calculating food cost data and compiling financial

information 4 2.8

Developing standards or compiling data for employeeperformance appraisals 3 2.1

Calculating employee payroll data 3 2.1

Checking trays on the patient tray line 3 2.1Receiving food and supplies 3 2.1

Conducting food yield studies and standardizingrecipes 3 2.1

Miscellaneous 13 9.0

Total 514

altems were categorized and hand-tallied from an open-ended question. Eachstudent answered with one or more responses.bPercentages were calculated by dividing the number of students who listedthat response by the total number of students responding. Percentages do notsum to 100.

RESULTSForty-five dietetics departments completed the administrativequestionnaire, and 43 departments submitted teaching and learn-ing activity forms. The rate of return for departments completingall sections of the study was 78.2%. Each department had a meanof 3.3 dietitians and 3.6 dietetic interns who kept time records, fora total of 143 dietitian and 155 intern respondents. The activityanalysis records represented 1,456 days of educational activities.Recording occurred on all days of the week, but 63.3% of theactivity analysis forms were completed on Tuesdays throughThursdays.

Total teaching time per department ranged from 4.5 to 84.1hours/week. Table 1 summarizes information regarding totalteaching time. The departments donated a mean of 37.3 hoursduring a standard work week in professional labor to teachdietetic interns. This represented 0.93 of a full-time equivalent(FTE) dietitian (37.3+40).

The total hours per week spent by dietetic interns in indepen-dent, professional service per department ranged from 6.5 to156.5. The students in the departments spent a mean of 66.5hours in independent, professional work (Table 1). This was 1.66of an FTE professional employee in training.

Students were asked to list the types of activities they wereperforming when they used the code for independent, profes-sional activities. The types of activities to which students wereassigned were appropriate for the development of professionalcompetence. Approximately 20% of the students were assignedto a foodservice management rotation. The remainder of theinterns were involved with inpatient clinical nutrition (58%) oroutpatient clinical nutrition (10%), or they did not supply thatinformation (12%). Of the 145 students responding to this ques-tion, each listed one or more activities. We collected 514 com-ments, which were then grouped into the 36 categories shown inTable 2.

Total teaching time was subtracted from total student time foreach of the departments in the survey. Each department had aunique amount of hours resulting from this calculation. Eightdepartments (18.6%) had negative values, ranging from -31.3 to-3.6 hours/week. This finding indicated that for the study period,8 of the 43 departments had programs in which the presence ofdietetic interns constituted a cost to the department. For theremaining 35 departments (81.4%), the programs were a benefit:net student productivity values ranged from 0.9 to 133.4 hours forthe 5-day recording period.

The mean net student productivity value for all departmentswas 29.2 hours (Table 1). When analyzed by a paired t test, the netproductivity value was found to be highly significant (P<.001).This figure represented a mean of 0.73 FTE of labor accruing tothe departments after they had been reimbursed for the dietitianlabor used in teaching.

Total Time in Staff ReliefEach department received a direct economic benefit by assigninginternship students to a staff relief rotation. The length of therotation varied from 2 to 12 weeks; most departments (37.8%)reported a 4-week experience. The mean number of weeks in staffrelief was 4.3+2.0. Data on the length of the staff relief rotationwere similar to those reported previously (18).

The number of interns assigned during the year to a staff reliefexperience varied from 1 to 18. Twenty-four percent of thedepartments assigned 6 students to this type of experience duringthe year, which was the median. The mean was 7.7+4.9 interns.The total number of weeks of student labor contributed to thedepartments each year by the interns in a staff relief rotationvaried from 2 to 216 weeks (number of students x number ofweeks in rotation). The mean was 36.9+40.4 weeks, and the

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median number of weeks contributed by this type of rotation was24.0.

Each department was asked to characterize the use of dietitiantime made available to the department by the fact that routineduties were assumed by students during the staff relief rotation.These findings are summarized in Table 3. When asked which ofthese uses occurred most frequently during the year, most de-partments (42.2%) responded that students were used to replacedietitians on vacation.

DISCUSSIONThe dietetic internships examined in this study began at differenttimes of the year, and interns had differing backgrounds at thetime of the study, as noted in Table 4. The results represented adiscrete time in each program's history, but the composite of allthe data represented the equivalent of collecting information overa much broader spectrum of time. Instead of analyzing oneinternship program for several months, as is done by someresearchers (5,17), we investigated data from many supervisingdietitians and students in severalinternships for a relatively short,but meaningful, period.

Our findings indicated that direct economic benefits wereassociated with the presence of dietetic interns in the participat-ing departments. An argument could be made, however, that the1.66 FTE of average student time donated to the departments washardly equivalent to the quality of the 0.93 FTE of professionallabor used for teaching, and that the interns undoubtedly tooklonger than professionals to perform these same activities, whichwould have inflated the time recorded.

We assumed that these accredited programs were capable ofevaluating the professional skills of interns and that the precep-tors would not have assigned students to work alone if they werenot capable of performing at an adequate level. The oversightsupervision required to check the independent work of internswas accounted for in the administrative code used by the dieti-tians who recorded teaching activities. The length of time stu-dents took to perform these tasks may have been problematic, butvariation occurs in time required to complete tasks among profes-sionals, too.

Despite these issues, remember that if students had not beenperforming these activities, professionals in the departmentswould have, or the tasks would not have been accomplished at all.As shown in Table 2, the types of activities students performedindependently were professional in nature. The presence ofstudents could be interpreted as relieving a mean of 1.66 FTE ofprofessional time for alternative use by the department. Part ofthis release time would reimburse the department for dietitiantime used in the education of students. The remainder, 0.73 FTE,would be a bonus or direct benefit associated with the presenceof dietetic interns in the department.

A caveat should be mentioned about the pitfalls of surveymethodology. Although detailed instructions were supplied withthe questionnaires, we were not available to ensure that the formswere being filled out correctly. All spurious time records werediscarded, but there is an increased opportunity for error withlong-distance data collection. Given these facts, a conservativestatement concerning our results is that for the 35 departments inour study (81.4%), the balance seemed to be in favor of the internscontributing as much, if not more, to the departments than theyused in professional labor.

The second measure of student productivity added additionaldietitian release time to the time contributed from routine activi-ties. The staff relief experience contributed a median of 24 weeks/year of release time. The departments used this time to engagedietitians in a variety of activities, all of which were beneficial tothe departments.

Table 3How dietetics departments (N = 45) used dietitian time during staffrelief rotations

Use of dietitian time Departments %/o % Citingwith as mostpositive response frequentb

Vacation time 42 93.3 42.2

Maternity or sick leave 14 31 1 0.0

Personal continuing education 15 33.3 2.2

Special projects for department 34 75.6 13.3

Delivery of more complicatedpatient care 14 31 1 13.3

Development of protocols,procedures, or programsdirectly related to job 38 84.4 17.8

Catch up on backlog ofpaperwork 27 60.0 11.1

Participation on hospitalcommittees 4 8.9 0.0

Outreach to new clients and/ormarkets 4 8.9 0.0

aRespondents chose any or all of nine alternatives listed. Percentages do notsum to 100.bPercentage of respondents who listed that alternative as the most frequent useof dietitian time while students were assigned to staff relief.

With both measures of direct benefits, the departments usedpreprofessional labor for professional activities and used the moreexpensive labor of experienced, registered dietitians for alterna-tive assignments to further the goals of the department. In thisstudy, the supervising dietitians had approximately 9 years ofprofessional experience and were undoubtedly paid a rate higherthan entry level (2).

Our findings are similar to those of other studies conducted inmedial and allied health education. Our research was based on amethodology that asked dietitians and students to record actualtime spent performing various educational activities. Other stud-ies that used log sheets documented greater or equal contribu-tions generated by students (5,6,8,17). Research using estimationtechniques rather than time data has had mixed findings. Twostudies (14,19) found greater or equal amounts of student laborcompared with professional labor. In another investigation usingestimation techniques (7), six allied health programs allocated agreater amount of professional time to the programs.

Residual student time expressed as FTE professionals was alsoreported in previous studies. Most found that the ratio of studenttime to professional preceptor time was greater than or equal to1.0 FTE professional, and the programs were judged to be abenefit to their sponsoring organizations (5,8,19). The results ofour study in dietetics concur with these earlier findings in occu-pational therapy, physician training, and pharmacy programs.

APPLICATIONSThis study was initiated because the current economic climatehas put hospital-based educational programs under scrutiny forcost-effectiveness. Dietetic internships are particularly vulner-able because they do not have benefits documented specificallyfrom the viewpoint of the dietetics departments that voluntarilysponsor them. Our study also served to test a model for determin-ing direct economic benefits associated with supervised dietetics

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RESEIIRCH

Table 4Selected characteristics of dietetic interns (N = 155) who completedthe learning activity recording forms

Characteristic Range Mean ± standard Mediandeviation

Age (y) 21-52 25.34 + 5.28 23.00Prior dietetics-related work experience

(mo) 0-84 13.18+ 14.79 8.00Length of time in internship before

study (mo) 0.8-11.0 8.02 +2.35 9.00Prior rotations (no.) 0-37 12.11 +8.46 10.00

practice programs (2). The dietetics profession has made consid-erable advancement in validating cost-benefit methodologies innutrition services (20,21), but emphasis on this type of researchin dietetics education has not received as much attention.

We found that direct economic benefits accrued to dieteticsdepartments participating in the study. Our study measured netstudent productivity during one standard work week in severalprograms to determine benefits that might exist in the population.Conclusions cannot be drawn concerning the relative amount ofstudent vs dietitian time used at other periods in the internships.In addition, this study does not make conclusions regarding thebenefits and costs associated with any one of these programs.

The direct benefits documented in this investigation wereassociated with student productivity. The benefits involved withroutine educational assignments were experienced by 81.4% ofthe departments, and 100% of the departments gained a benefitassociated with staff relief. Both measurements of student pro-ductivity illustrated that the internships provided student labor.This labor, in effect, released the more expensive time of theregistered dietitians for other productive work in the department.If the dietitians do not use release time to further objectives of thedepartment, it cannot be considered a direct benefit to thedepartment, but rather a direct benefit to the professional whocould spend this time in pursuit of personal interests. Whereasthis investigation determined the most frequent use of dietitiantime during the staff relief rotation, it did not track total produc-tivity of the teaching dietitians while interns were engaged inroutine learning assignments. These findings illustrate that re-lease time was available to some degree in the dietetic interns'tenure in the departments, and it would behoove departments insimilar circumstances to ensure that this time is spent judiciously.

The methodology of this study could be used by internshipdirectors to collect educational activity data at several points intheir internship to determine any positive benefits experiencedby individual departments. This information could be used todocument definite benefits to hospital administration by calculat-ing a ratio of benefits to cost. Results indicating that dieteticinternships provide net benefits to the hospital might be critical tothe continuance of the program. Similar results could also be usedto reassess the payment of a stipend or increase a stipend forinterns. If the data indicate that the program generates only costs,the information could be used to calculate a tuition for theinternship that will recover expenses while keeping the programin operation.

In a statement issued in support of dietetic education programs,The American Dietetic Association proclaimed that supervisedpractice experiences were mutually beneficial for faculty, practi-tioners, students, and the public (22). At the time, no researchhad been published to document the presence of these benefits.This study represents a first step in objectively establishing theeconomic framework associated with sponsoring supervised prac-tice programs for dietetic students. It indicates that internshipscan make contributions to most departments and that this fact

bears further investigation. It may also indicate that dieteticsdepartments that are considering discontinuation of such pro-grams should carefully evaluate whether these benefits can beestablished for their department. ·

This research wasfunded, in part, through the BeatriceDonaldson David Fellowship in Foodservice Administra-tion, ADA Foundation, 1987-88.

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