Implementing a CompetencyBased Dietetics Education Model: Exploring Fiscal Components

Unparalleled changes in dietetics education are underway with a new competency-based model and graduate degree requirements. This two-phase mixed methods study explored dietetics directors’ perceptions of costs and benefits to implement the new model. First, e-Delphi participants identified 34 cost and 22 benefit items, which were then used to develop a questionnaire for Phase Two. In Phase Two, dietetics directors agreed that the benefits were numerous (e.g., opportunities to collaborate, curriculum review) and they expected additional costs (e.g., educating directors, student services). Those responsible for dietetics education may utilize the findings when making financial decisions regarding implementation.

Janet S. Millikan, PhD Graduate Apparel, Events, and Hospitality Management

Iowa State University Ames, IA janetm@iastate.edu

Susan W. Arendt, PhD Professor Apparel, Events, and Hospitality Management

Iowa State University Ames, IA

Changes are planned for dietetics education in the United States, including a shift to a competency-based curriculum and an advanced degree requirement. These changes are outlined in the Future Education Model (FEM) and described elsewhere (Accreditation Council for Education in Nutrition and Dietetics [ACEND®], 2015). Recognizing that changes in curriculum could add expenses to existing budgets, dietetics stakeholders initially voiced concerns about the cost of implementing the FEM (ACEND®, 2015). Currently, there is no known reported research regarding cost implications of the FEM. Given that dietetics students are educated in family and consumer sciences (FCS) departments or courses, these research findings are relevant to faculty, administrators, and institutions actively recruiting and educating dietetics students.

A new curriculum mandate, tight budgets, and limited funding sources in healthcare environments and institutions where dietetic professionals are educated have led to an interest in financial research in health professions (National Academies of Science, Engineering, & Medicine, 2017). Competency-based curriculum, patient-centered care, and inter-professional collaboration are emerging foci in the education of health professionals (Frenk et al., 2019). These changes in foci present challenges for institutional leaders. Cost accountability lacks appeal in higher education due to hurdles that exist in separating individual costs, reliance on other departments’ information, lack of interest in transparency, and fear that information obtained will threaten the status quo (Cheslock et al., 2016). Determining costs and categorizing spending appropriately are complicated due to shared costs across departments as well as spending inequities across disciplines and degree levels (Breneman, 2001).

Finances are indubitably a concern during times of curriculum change; thus, these changes require a knowledgeable planning approach. Difficulties exist when studying aspects of new programs such as the FEM; variables such as institutional size, type, and budget models make comparisons challenging (Academy Administration Practice, 2014; Desrochers & Staisloff, 2016). For example, given that the FEM change involves moving to a graduate-level professional program, rather than research-based, funding models may be different.

Many institutions educating dietetics students may shift from the traditional knowledgebased content to the new model irrespective of their differences; however, understanding the financial implications of such a change can be useful in the decision-making process.

When transitioning to the FEM, dietetics programs will have similarities allowing for assessment of cost and benefit categories related to curriculum change. Many institutions educating dietetics students may shift from the traditional knowledge-based content to the new model irrespective of their differences; however, understanding the financial implications of such a change can be useful in the decision-making process. Also, most dietetics directors implementing the FEM likely will be doing so within institutions not following a competency-based learning model institution-wide (Kelchen, 2015). Therefore, investigations regarding costs or savings provide insights into programs undergoing curriculum change and provide guidance on informed spending. Other health professionals (e.g., occupational therapy, physical therapy) have added increased degree requirements and competency-based coursework (American Physical Therapy Association, n.d.; Coppard & Dickerson, 2007) but comparisons to new dietetics programming are difficult due to lack of information about the financial impact of these other medical programs. Dietetics programs may maintain alignment with departments such as FCS and medical units as they transition to the FEM.

Various frameworks have been used to assess financial components of current or new academic programs in higher education. These frameworks have been used to identify cost categories in different institutional settings (e.g., community colleges) and in different health science disciplines (e.g., nursing) while striving for accountability and efficiencies (Franzini & Berry, 1999; Manning & Crosta, 2014; Valberg et al., 1994). Similarly, the current study uses the framework of instructional cost categories including both direct and indirect costs.

Thus, the research objectives were to: (a) identify perceived costs and (b) identify perceived benefits of implementing the FEM. This research provides valuable insights about perceived financial implications of the FEM to those who will implement dietetics curriculum reform in the future, including dietetics programs housed in FCS departments with FCS courses as part of the curriculum. Research supports implementing educational tools for financial awareness and management so that students can enhance future career roles (Hurst, 2013); FCS leaders highlight the need for development of financially knowledgeable educators and students (Georgiou, 2015; Jackson, 2013). Dietetics students may be educated in FCS departments or take FCS courses; therefore, this research is relevant to faculty, administrators, and institutions actively recruiting and educating dietetics students.

Methods

An exploratory sequential mixed methods research design was used to develop a questionnaire for identifying perceived costs and benefits of implementing the FEM. In Phase One, qualitative data were collected via an eDelphi process that informed the development of a Phase Two questionnaire. The Phase Two questionnaire was used to collect more quantitative data (Creswell & Guetterman, 2018) about the financial components of implementing the FEM.

Phase One: eDelphi

The Phase One eDelphi process involved two rounds of inquiry posed to dietetics directors from a variety of accredited dietetics program types (e.g., graduate coordinated, undergraduate coordinated, didactic, dietetic internship programs, FEM programs) and geographic locations to build consensus on costs and benefits categories for implementing the FEM. During the Delphi process, participants are blinded from one another because anonymity among experts is a way to equalize the weight of experts’ perspectives (Delbecq et al., 1975). Researchers have used the Delphi method in different research settings as an efficient way of obtaining consensus (Allen et al., 2019; Barrett et al., 2020; Boulkedid et al., 2011).

Questions were developed after a review of the literature. During question development, feedback from five university faculty member experts in dietetics, finance, and education was incorporated. A pilot test was conducted with three dietetics directors, who were not participants in the eDelphi process, to confirm clarity and scope of questions (Dillman et al., 2014). Resultant minor grammatical adjustments were made. After analysis by two independent researchers, categorical statements were developed from this inquiry and incorporated into the Phase Two Questionnaire.

Phase Two: Questionnaire

A pilot test was conducted with four dietetics directors; they were asked to complete the questionnaire and respond to questions about understandability, appearance, content, and ease of use. Minor grammatical changes were made based on recommendations. Five university faculty researchers with expertise in finance, dietetics, and education also reviewed the items. Minor changes were made, and questionnaire content was finalized.

All dietetics directors in the U.S. identified as working in ACEND-®accredited dietetics education programs in 2019 (N = 520) were emailed a Qualtrics® questionnaire link. The questionnaire included demographic questions, 34 items about dietetics directors’ perceptions of costs when implementing the FEM, and 22 items about perceived savings and other benefits. Table 2 and Table 3 contain the items derived from the Phase One inquiry and are listed as Categories and Items. Directors rated their agreement using a 5-point Likert-type scale (1 = strongly disagree, 2 = disagree, 3 = neutral, 4 = agree, and 5 = strongly agree). DeVellis (2017) noted that participants may look for a midpoint regardless of the semantics used to describe the scale item; therefore, we chose the term neutral for midpoint response.

Data Analysis

For Phase One (qualitative), 13 participants’ responses were collected and analyzed systematically by two researchers who independently reviewed them by looking for similarities in identifying relationships and then manually coded data into meaningful categories and sub-categories after Round 1 (Saldaña, 2021). This type of data organization (i.e., coding) and verification (i.e., level of interpretation agreement among researchers) creates a solid framework for the qualitative information through the open coding process (Tashakkori & Teddlie, 2010). This information was used for a second round of statements (Round 2); 11 panelists completed Round 2. Using cost and benefits categorical statements developed from the eDelphi data, a consensus level of 51% or greater for a statement in Round 2 determined inclusion in the Phase Two Questionnaire (Hasson et al., 2000).

For Phase Two, questionnaire data analyses were performed using IBM SPSS Version 26.0 (SPSS, Chicago, IL, USA). Descriptive statistics (frequencies, percentages, means, and standard deviations) were compiled.

Findings and Discussion

In Phase One, e-Delphi participants identified 34 cost items and 22 benefit items. These items were then used on the questionnaire for Phase Two.

A total of 172 (33% response rate) dietetics directors responded to the Phase Two questionnaire. All directors were 31 years old or older with the largest percentage (48.5%) working as internship directors. This is not surprising because there are more dietetics internships (249 at the time) than other programs. The majority reported working in their current role for 3 years or more (see Table 1).

The first research objective was to examine dietetics directors’ perceptions of additional costs related to implementing the FEM; results are presented in Table 2. Reliability coefficient Cronbach’s alpha was 0.861, confirming good internal consistency of this scale (George & Mallery, 2019). Cost categories were grouped as follows: (a) educator and support staff, (b) executive administration, (c) equipment and supplies, (d) food and travel, (e) accreditation, (f) students, (g) external vendor services, (h) dietetics directors, (i) salaries, and (j) additional costs. Of these 10 categories, the items with the highest agreement were: educator and support staff costs for compilation of the FEM application (86.5% agreed/strongly agreed) and additional costs for educating dietetics directors (86.5% agreed/ strongly agreed). Dietetics directors agreed that all cost items, except food and events, would be included in planning and implementing the FEM.

Eighteen of the cost categories seem to be short-term or one-time costs (e.g., compiling FEM application). Six categories represent long-term costs that could be incorporated into budgets over time with adequate preparation. For example, educating instructors about the FEM could be incorporated into department meetings or provided virtually during non-instructional or planning time. Most cost categories identified are not unusual in higher education institutions but may be novel for dietetics programs. For example, integrating experiential activities may require new physical space or developing affiliated partnerships; these may be new cost categories at the program level, but institution-wide, these two costs would not be considered novel.

The second research objective was to examine dietetics directors’ perception of benefits when implementing the FEM; results are presented in Table 3. Reliability coefficient Cronbach’s alpha was 0.961, confirming excellent internal consistency of this scale (George & Mallery, 2019).

Cost savings were perceived due to consolidation of positions (29.4% agreed/strongly agreed), expected future savings (29.4% agreed/strongly agreed), and consolidation of programs (31% agreed/strongly agreed) by some and others disagreed (44.3%, 40%, and 47%, respectively). The overall divergent views may reflect the diversity of realities for different dietetics programs across the U.S. and/or lack of knowledge by dietetics directors given the newness of the FEM.

Regarding other benefits, participants’ agreement was highest for the following: opportunity for curriculum review and analysis (65.7% agreed/ strongly agreed), opportunity for later in life entry into the profession (52.9% agreed/strongly agreed), and opportunity to collaborate (50.6% agreed/strongly agreed). Disagreement was highest for the two items: the FEM would generate enthusiasm (47.6% disagreed/strongly disagreed) and increase student enrollment (52.3% disagreed/ strongly disagreed). The need for global healthcare workers, including dietitians, is expected to exceed supply by 2030 (Cuff, 2014). The future scan of the dietetics workforce (ACEND®, 2015) and workforce demand research (Rhea & Bettles, 2012) also demonstrated an increased need for dietitians; this perceived disagreement may warrant further investigation.

Limitations

This study is not without limitations. Budgeting and program financing at universities are unique from one institution to another, and the approach each institution takes related to the FEM may be different. For example, some programs may decide to add the FEM as a new program while others may replace an existing program; these decisions have implications for costs. In terms of response rate (33%) and sample representation, the overall smaller sample size may be reflective of timing because programs may not have decided if implementing the FEM would occur; therefore, dietetics directors may have been hesitant to participate. Additional efforts were made to

Note. FEM = Future Education Model. Percentages may not total exactly 100% due to rounding. a = multiple-answer responses.

Table

Note. FEM = Future Education Model. Rating scale: Strongly disagree = 1, Disagree = 2, Neutral = 3, Agree = 4, Strongly agree = 5. Percentages may not total 100% due to rounding. Item descriptions were truncated.

Note. FEM = Future Education Model. Strongly disagree = 1, Disagree = 2, Neutral = 3, Agree = 4, Strongly agree = 5. Percentages may not total 100% due to rounding. Item descriptions were truncated.

improve the response rate including resending the questionnaire and email reminders multiple times. Geographic location and other program information was not collected, thereby limiting generalizability of findings. Another possible limitation is the potential for bias because other healthcare educators’ insights about costs and benefits were not investigated. Incorporating perspectives from healthcare educators in other professions and educators in other programs with competency-based education are opportunities for future research.

Applications and Conclusions

To identify areas of the financial impact of curriculum change in dietetics education, leaders will need to understand current cost structures and identify potential hidden or new costs for implementation of the FEM. Because determining actual costs of programming change can be difficult, initially establishing these cost categories, as was done in this study, serves as a catalyst for future cost-related research. These study results provide foundational research about the components of implementing the FEM. service, FCS, and other sciences (e.g., chemistry and biology), the financial impact of FEM implementation may need to be discussed with leaders of these departments, making the cost categories outlined here useful. Like other programs (e.g., teacher education), the addition of these experiential learning components has evolved and expanded. Furthermore, leaders in programs such as hospitality management and FCS may be able to utilize the cost and benefits categories as a starting point for research in their own programs.

Higher education researchers recognize the importance of determining cost categories as a first step in identifying expenditures in education, but financial research or exploration of cost categories in dietetics education is lacking (Nousiainen et al., 2016; Zandejas et al., 2013). From a practical perspective, findings may be useful for dietetics directors on several fronts. Identified cost and benefit information can be used when developing budgets for funding proposals and stakeholder presentations, and they can serve as a foundation for future costing studies. In addition, this research provides transparency about financial aspects of the FEM to allow for positive collaboration and shared strategies among stakeholders of the education organization responsible for dietetics education.

Because dietetics education includes coursework in nutrition-related departments including food service, FCS, and other sciences, the financial impact of FEM implementation may need to be discussed with leaders of these departments, making the cost categories outlined here useful.

Identifying costs and benefits to students (i.e., tuition changes and graduation rates) has been a priority in higher education research, while research and reporting of education costs in specific terms has been less of a focus (Cheslock et al., 2016). This void in research and cost information can make budgeting for new projects or programs difficult, unrealistic, or vague. Educating dietitians and other healthcare professionals includes an added layer of extensive clinical requirements in today’s rapidly evolving healthcare environments, which complicates obtaining accurate education cost information (Rogus et al., 2021). The results from this research will help dietetics directors with financial planning for implementing a new curriculum.

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