Development of affective learning in dietetics graduates: A qualitative longitudinal study

Abstract Background The development of affective learning during healthcare student education is essential for professional practice. Current studies are limited to short‐term studies with medicine and nursing students. Longitudinal studies are emerging; however, the research within allied health students remains scant. The present study investigates the value of simulation‐based learning activities in relation to affective learning among dietetic students. Methods A double hermeneutic, interpretative phenomenological approach (IPA) approach was employed, followed by an analysis of the trajectory of participants' affective learning across three‐interview time points via the application of Krathwohl's affective learning levels. Results The simulation developed affective learning in four of the six participants, specifically in relation to their view of themselves as practitioners and their understanding of their future responsibilities to patient care. Three key themes were identified in the participants: (1) feeling of workforce readiness, (2) valuing lifelong learning and (3) attitudes towards interprofessional teamwork. Conclusions This IPA methodology described dietetic students' affective learning development as they transitioned to practice as graduate health professionals. Simulation‐based learning is one activity that enhances students' learning in the affective domain and educators should consider its value within their programs


INTRODUCTION
Affective learning, which focuses on values and attitudes, has long been a key component of health professional education, given the need to work with diverse patient groups in complex situations. [1][2][3] As one of the three domains of learning, affective learning sits alongside the psychomotor and cognitive domains. 4 Following the initial description of learning levels in the cognitive domain by Benjamin Bloom in 1956, a model for the affective domain was developed by Krathwohl et al. 5 in 1964. Affective learning has been categorised in a hierarchy of five levels: receiving, responding, valuing, organization and characterization. 5 Affective learning processes, related to emotions, attitudes and motivation, also contribute to the development of cognitive and psychomotor domains. 6 The governing bodies of all health disciplines provide frameworks of competency or entry-level graduate standards. When reviewing these standards, a varying terminology is used to describe affective learning or related attributes in each profession, with no uniformity evident 2,3,6-8 despite the three domains being 'extricably intertwined'. 9,10 In medical education, communication and teamwork have been identified as affective domain skills 3 ; however, these cannot be isolated, and other affective aspects of respect, responsibility, duty 7 and professionalism 11 are also at play. Among the few studies in this area with dietetic students to date, affective learning has always been paired with cognitive learning and the studies have not focused on defining each domain separately. [12][13][14] Aspects of professionalism in dietetics students have been considered difficult to describe 15 and assess with current knowledge tests in relation to competency-based education. 16,17 Despite the widely-recognised importance of the affective learning domain, measuring or assessing its development in health students has received far less study. 6,11,18 In dietetics education, the literature investigating affective learning is scant. Of the evidence that exists, work integrated learning experiences with associated blog entries support transformative learning through critical reflection where students create new meaning from their experiences. 13 There remains a need for evidence of the affective behaviour changes that occur as students develop into practitioners. Although the literature in student healthcare research has recognised the need to measure 8,19 and assess affective learning 2,3,18 the range of approaches remains varied and mainly focused on the short term, such as during or immediately after the learning. 11,20 Longitudinal studies of affective development over time are beginning to emerge but remain rare.
Teaching and learning approaches to develop affective learning skills Various teaching techniques are known to enhance affective learning in health professional students. Studies supporting journaling and reflective practice have been documented 1,2,6,19,21 with various assessment criteria having been established to measure the level of affective development. 11,18,22 The development of motivational interviewing skills has been shown to increase health student self-efficacy 23 and communication skills and have been linked to increased professionalism. 18 The immersive nature of simulation-based learning (SBL) offers a safe space for student learning and has been utilised in nursing education to incorporate more depth into affective domain development activities. 2,24 When combined with interprofessional learning (IPL), simulation can be a 'powerful affective teaching' method, combining communication and collaboration amongst health professional students. 18 We would contend that the development of the affective domain is essential to the demonstration of competence in graduate dietitians internationally.
The question remains, how can affective learning be engendered in dietetic students? At one Australian university, SBL activities are embedded throughout the 4-year undergraduate program, with the majority of SBL completed during the third year of study. These SBL include both uni-and IPL activities and include human simulated patients. (Supplementary Table A2). The present study was conducted to investigate the value of SBL in relation to professionally-focused affective learning among dietetic students. More specifically, the study addressed the research questions: (1) What changes in affective learning are observed in dietetics students as they move from student to graduate practitioner? (2) Can dietetics graduates demonstrate acquisition of affective domain capabilities?

METHODS
The researchers employed a double hermeneutic, interpretative phenomenological approach (IPA) approach, followed by an analysis of the trajectory of participants' affective learning across time via the application of Krathwohl's affective learning levels 5 as previously described by Rogers et al. 22 Ethical clearance for this study was obtained (GU2019/009) prior to study commencement.

Participant recruitment
All students (n = 56) enrolled in a communication and counselling course of a dietetics program at an Australian university were provided with an overview of the study and invited to participate. Interested participants expressed their willingness to participate via email and were then provided with the study information sheet and interview times were arranged.
Each participant was interviewed on three separate occasions: the first prior to clinical placement, the second immediately after clinical placement, with the final interview taking place 6 months after graduation. A semistructured interview schedule, adapted from the work of Smith and Osborn, 25 was pilot tested with PhD students and adjusted following feedback, prior to implementation with participants. All interviews were led by one researcher (MCO), a female dietitian involved in the program. Half of the initial interviews were jointly conducted by one other researcher in the team (GDR or CP). All interviews were recorded and transcribed verbatim. Consent to participate in the study and record each interview was obtained in both written and verbal format at the commencement of the first interview (Supplementary Mat_1).

Statistical analysis
Prior to undertaking any analysis, the relevant researchers met online to reflect and discuss their positioning in regard to the study. 26 The transcripts were then analysed by two investigators (MCO and CP) and a research assistant independent of this study, applying a method adapted from Rogers et al., 22 using NVIVO, version 12 (QSR International). A step-by-step approach to analysis of the transcripts was undertaken based on the work of Smith et al., 27 van Manen et al. 28 and Saldaña. 29 We utilised a highlighting method, where transcripts were viewed as section or phrases, rather than line by line. This 'double hermeneutic process' is explained simply as 'the researcher making sense of the participant, who is making sense of x'. 22,27 In this method, the analyst first looks for how the participant has made sense of their learning experience. Then, as a second phase, the analyst seeks to make sense of the participant's sense-making in psychological terms, looking for evidence of affective domain learning that may not have been fully evident to the participant at the time. Rather than frequency analysis, which is the number of times a theme could be counted in the analysis, the resulting emergent themes were identified as phenomenon avoiding hierarchical thinking. 30 In doing so, the analyst aimed to interpret the meaning of the identified phenomenon, or the participants' lived experience. 31 Interpretations were discussed by the researchers until agreement was achieved. To align more closely with true IPA methodology, the findings were reported with interpretations of meaning rather large sections of direct quotes. 32,33 To answer the first research question and identify evidence of affective learning and changes across time, the researchers reviewed each participant's transcript series against Krathwohl's five levels of affective learning: receiving, responding, valuing, organization and characterization. 5 To answer the second research question, the emergent themes were reviewed and linked to the affective domain where possible. The method previously described by Rogers et al. 22 was employed: (i) identification of examples of affective learning in transcripts, (ii) comparison with the Krathwohl's level of learning 5 and (iii) identifying the highest Krathwohl level of affective learning for which there was evidence in the transcript. To maintain research rigor, the identified themes and associated student quotes were compared and discussed to identify and acknowledge the lens through which each researcher viewed the transcripts. Minor discrepancies in interpretation were resolved by discussion.

RESULTS
Seven female third-year dietetics students initially consented to participate in the sequence of in-depth interviews for the study. Six students completed all three interviews. One did not and was removed from the study. One participated in interview #2 twice as a result of an extension of clinical placement for remedial purposes.

IPA and Krathwohl's levels analysis
The results are presented in two sections. First, evidence of affective learning across the three time-points is reported and tabulated using Krathwohl's five levels of affective learning 5 (Table 1). Second, a summary is provided of the development of the attributes of affective learning across the course of the study evident in the participants and categorised into key themes. Quotes and examples have been linked to participant and interview number using 'P' to indicate the participant ID (01-06) ( Table 1), followed by a hyphen (-) and then the interview number (1,2 or 3) ( Figure 1).

Affective learning: Evidence of change over time
Four of the six participants demonstrated evidence of characterization, the highest level of Krathwohl's affective learning taxonomy. 5 One of these students, demonstrated this during interview #2, whereas the others did so during interview #3. The two who did not reach characterization level showed evidence of the organization level of affective learning during interview #2 but did not demonstrate further affective development during interview #3.
Attainment and demonstration of the highest level of Krathwohl's affective learning levels was clearly identified for participant 1. During interview #1, participant 1 displayed evidence of receiving and responding as they transitioned from a simple description and observation of their role within an IPL team to recognising an emotional reaction to them; frequent use of the word 'I' along with a description of their feelings was evident. During interview #2, the participant appeared to demonstrate Receiving: is being aware of or sensitive to the existence of certain ideas, material, or phenomena and being willing to tolerate them Evidence -the student has at least noticed some aspects of the experience that might ultimately lead to affective learning. For example, a report of something the student found novel or interesting but no discussion of the emotions that the experience has engendered in them progression through the next three levels of valuing, organization and characterization as she described the personal impact of the IPL experience and 'rapport building' and reflected on why it was valuable to her. In demonstrating organization, the participant shifted from a focus on self to a broader worldview where she values 'empathy' rather than her intellectual ability, as in receiving. A key characteristic of characterization is a sense of consolidation of affective learning, where planned behaviour is evident. This participant spoke of 'transferrable skills', which represents a profound shift from interview #1 where the observation of skills required and the need to possess a specific skill set was of high importance to her. Conversely, participant 4 did not demonstrate the same progression of affective learning as participant 1. She moved from lower levels of receiving and responding in interview #2, where she described experiences that might lead to affective learning but stopped short linking these to personal and impactful examples. Following her practical placement experience, this participant provided evidence that the IPL experiences had a significant impact on her value system when she described her expectation of nurses' and doctors' approach to dietitians in the workplace. However, this participant stopped short of characterization, with no foreshadowing of a change to her practice or a planned changed to professional behaviour.
There did not appear to be a link between having worked as a dietitian since graduation and the achievement of characterization level. For example, P01 at interview #3 was still looking for work as a dietitian yet demonstrated a value system that was congruent with that of the profession. She had moved beyond a focus on the need for skill development and repetition toward recognising the role of feedback in learning, rather than feedback as criticism; 'feedback … as if it is a reflection on them personally instead of their practice …' (P01-3). On the other hand, P04 who was working as a dietitian at the time of interview #3 did not yet show a change in her principles or ideals regarding professional behaviour. This is not to say that the participant was unprofessional, but rather that there was no evidence of a change of her self-perceived roles and responsibilities as a practitioner. There was evidence of organization level affective learning in P04 where patient care was acknowledged as the most important aspect of practice, but the participant was yet to link this to an over-arching sense of her responsibility as a clinician in a healthcare system. P04 reflected on her patient-centred care focus during university SBL conducted prior to clinical practice, compared to the sense of responsibility to the patient she felt after graduation: 'I just know when I saw the patient … and I had to give the … I didn't do it very well because I didn't really know what I was talking about so I was just saying words without actually portraying what I wanted to say, with care' (P04-3) The shift from concentration on themselves towards a patient-centered focus demonstrated the development of affective learning over time. Prior to practical placement, participants spoke of lectures, theory and their own feelings of their skill level, 'it really allowed you to see how much of yourself you could bring to the table' (P01-1). Six months later, after 20 weeks of practical placement, a metaphor of a 'bridge' was used to describe feelings linking university learning with practical experiences: F I G U R E 1 Visual representation of interview timeline in relation to simulation activity within program of study, placement, graduation and employment 'you think about the expectations of the supervisors … and then you think about what university has taught you and then you've got to make a bridge' (P01-2). Finally, a genuine shift from a focus on self to their impact on the patient, away from individual and personal learning experiences, was evident: 'Someone's condition in front of you. Someone's emotions in front of you. It's all just very different. It's not just textbook stuff' (P01-3) ( Table 2).

Affective learning: Key themes identified in dietetics students and graduates
Three key themes were identified within the affective learning in the participants: (1) feeling of workforce readiness, (2) valuing lifelong learning and (3) attitudes towards IPL teamwork.

Theme 1: Feeling of workforce readiness
The participants appeared to be shaping and developing their own views of themselves as practitioners during the final interview especially. All described a sense of confidence enabling them to feel ready to practice. No longer needing to 'seek approval' to complete tasks was described by P02 following practical placement, the participants developed a sense of their own resilience, evident in the final interview where they were 'accepting that things aren't always going to go amazing' (P02-3).
All participants described strong feelings of being 'practice ready' during their third and final interview. 'This is my practice. This is what I'm bringing' (P05-3). They no longer viewed themselves as a novice student, but rather as an independent practitioner. This was evident with one student feeling like they were 'the blind leading the blind' prior to practical placement, then feeling that their opinion was valued in the clinical setting, to a lifting of the 'student mentality' (P02-3).

Theme 2: Valuing lifelong learning
Prior to practical placements, participants reported feeling 'ready' and 'confident' to embark on the 20-week learning journey, despite some misgivings; 'I just hope that I have got that knowledge stored and that I can apply it' (P05-1). In the final interviews, participants reflected on their placement journey, recalling positive and negative experiences. Over time, students changed from the view that placement was discrete (beginning and end) to the realisation that a formal learning endpoint was never going to emerge. Participants then appeared to acknowledge and value lifelong long learning; 'if you're perfect from day one, then you would not need to be learning' (P03-3).

Theme 3: Attitudes towards interprofessional teamwork
Learning 'with, from and about' 34 colleagues in other professions commenced during the simulation experiences at university and continued throughout practical placement. The 'about' aspects were particularly evident in the participant stories as they became more aware of the role and contribution other disciplines made to patient care. Equally important was the learning that took place about their own role as a dietitian and a newfound insight 'of what it might be like so that I can interact with other disciplines' (P05-1).
Participants were seen to progress from learning with, to learning from other disciplines 34 in the clinical setting. 'I learned a lot from their approach to each patient' (P05-3). Participants moved from assessment of the patient through their own eyes, to an understanding of how others interact with the patient, communicate, and undertake tasks. In the characterization stage, there was evidence of the team approach developing where participants describe their ability to 'bounce ideas' when 'the multidisciplinary team works together' (P03-3). They reflected on the importance of a developed understanding of each other's role and 'knowing how you all interact together' (P05-3).
The participants also reflected on negative IPL encounters particularly relating to the perception of the doctor-dietitian hierarchy. The IPL simulations at university appeared to break some preconceived ideas some participants held about doctors: 'We just have this mentality that doctors run hospitals. But they know everything and that everyone else is just underneath them but no, it's nothing like that' (P03-1) These feelings were confirmed during practical placement as the doctors were considered 'just normal people' (P03-2). An interesting change occurred as the participants moved into the workforce. There was a newfound ability to distinguish between the profession and the person. The participants no longer spoke globally about a discipline or role, rather they looked beyond the title and saw the other practitioner as a person, acknowledging that the person may have their own beliefs that are not representative of a whole profession; 'some people think they're more important than others' (P03-3).

DISCUSSION
To our knowledge, this is the first longitudinal study of affective learning in dietetic students and graduates. affective learning identified with Krathwohl's hierarchical levels 5 enabled participants' affective learning trajectories to be seen over time. The IPA approach also identified key themes within the development of affective learning that are consistent with the capabilities required of graduate dietitians. These findings can inform the development and refinement of innovative teaching methodologies such as SBL to enhance the affective development of dietetic students. The inclusion of SBL within health professional education programs has been shown to have positive impacts on affective development in medicine 22 and nursing, 23,35 as well as more broadly. 18 The present study has demonstrated the link between human-patient SBL in dietetic undergraduate education and affective learning, specifically in relation to their view of themselves as practitioners and their understanding of their future responsibilities to patient care. The theme surrounding workforce readiness was directly attributed to the IPL simulations undertaken in year 3 of the program during both the second and third interviews in the present study. The participants described 'light bulb' moments where they were able to recall the specific experiences during practical placement that resembled the IPL simulation the year prior, and the profound impact that the activity had had on their practice. After graduation, similar stories were recalled by participants, suggesting a lasting impact of these activities on their learning and practice. There was evidence of a shift in their value systems towards 'professional responsibility, interprofessionalism and the primacy of patient or client welfare', which mirrors the findings in the work of Rogers et al. 22 among medical students. Similarly, the dietetic literature provides evidence of the impact of SBL on placement and workforce readiness. SBL in coursework that mimics the work of a dietitian supports preparation for placement 36 and enhances their preparedness for placement. 37 Affective learning should be fundamental to all learning objectives in curriculum and SBL included because it can shape affective development. 18 The present study poses further questions about the assessment of the affective domain in health professional students. The literature indicates common methods of evaluating affective attributes, including self-reporting questionnaires and Likert scales, 20 to the formative assessment of professional role development, 2 to summative assessments required to determine competence in this domain. 3 These summative assessments, usually undertaken by a preceptor or supervisor to assess professionalism, are reported as uncomfortable because of their subjectivity. 17 The challenge is therefore to develop a robust tool for assessing affective development that has been trialled and validated and for which assessors have been trained. The present study has identified one possible method for assessing affective learning development using a hierarchical system, althoughg further testing is still required.
This small-but-deep longitudinal study has successfully applied an IPA methodology to describe dietetic students' affective learning development as they transition to practice as graduate health professionals. Larger scale studies will be needed to test this proposed methodology further and advance our understanding of the development of affective learning in health professional education over the course of students' study programs and into the workforce. Educators should consider embedding activities that enhance students' learning in the affective domain at the same time as planning to assess their capability in this complex area, which is vital to patient-centred care.