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Comparison of student outcomes in distance learning internships versus traditional dietetic internships

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Comparison of student outcomes in distance learning internships versus traditional dietetic internships
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Wright, Lauri Y
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University of South Florida
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Education
Nutrition
Residency
Training
Professional development
Dissertations, Academic -- Higher Education -- Doctoral -- USF   ( lcsh )
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Abstract:
ABSTRACT: One way in which higher education is responding to technology advances, demographics changes, and economic pressures is through the development of distance learning. Distance learning represents one of the most prominent trends in higher education today. Understanding the impact of this technologically driven change on student outcomes is unmistakably important. One example of this trend in higher education is the distance learning internship in dietetic training programs. The purpose of this study was to compare student outcomes in distance learning dietetic internships to student outcomes in traditional dietetic internships. The pass rate of the registration exam for dietitians, levels of perceived preparation for practice, and evaluation of curricular experiences were compared. The study was divided into three phases. The first phase of the study was the recruitment of dietetic internship directors and program information, including registration exam pass rate. The second phase of the study consisted of surveys on preparedness for practice to the graduates and supervisors. The third phase of the study involved interviews of traditional and distance program graduates, their supervisors, and internship directors on curricular experience and preparation. No significant difference was found in pass rates for the registration exam. Significant differences were found in constructs of dietetic practice based on surveys with graduates and their supervisors. Common themes from interviews with graduates, their supervisors, and program directors confirmed survey results showing graduates of traditional dietetic internship were prepared at a higher level of practice, competence and clinical judgment. The results of this research do not support equivalency in preparation for practice between distance and traditional dietetic internships.
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Dissertation (Ph.D.)--University of South Florida, 2007.
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by Lauri Y. Wright.
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Comparison of Student Outcomes in Distance Learning Internships versus Traditi onal Dietetic Internships by Lauri Y. Wright A dissertation submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy Department of Adult, Career and Higher Education College of Education University of South Florida Co-Major Professor: Michael Mills, Ph.D. Co-Major Professor: Jan Ignash, Ph.D. Deidre Cobb-Roberts, Ph.D. Preston Mercer, Ph.D. Date of Approval: October 29, 2007 Keywords: education, nutrition, residency, training, professional developm ent Copyright 2007 Lauri Y. Wright

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Dedication I would first like to thank God for all his gifts a nd blessings. Thanks to my parents, Don and Ellie Ysseldyke, for their support during this process. From babysitting to moral support, my mom was always there. Dad ins tilled in me goal-setting and the drive to see each goal through to completion. Than ks to you both for all you have done to get me here. I would also like to express my gratitude to my hus band, Britton. You have supported my dream of a doctorate from the very beg inning. You never stopped encouraging or believing in me. Thank you. This dissertation is truly dedicated to my daughter s – Meghan, Molly, and Addie. My girls who had to endure night classes, lots of f rozen dinners, late pickups from dance, and long hours of mom locked in the study. Your be autiful faces always inspired me on. I hope that my example, in turn, will inspire you t o fulfill your dreams and never give up.

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Acknowledgements There are many people without whom this project wou ld not have been successfully completed. I would first like to than k my major professors, Dr. Michael Mills and Dr. Jan Ignash. Without your guidance, e ncouragement, and patience, I would never have made it. I would also like to acknowled ge the other members of my committee Dr. Mercer and Dr. Cobb-Roberts. Thank you for all the advice and support. I would also like to thank my supporters at work – Sherri, Martha, Lynn, Anne, Mila, Kadie, Cheri, Steve and many others. From ch anging my schedule, allowing me to present my latest class project, to never allowing me to quit, your encouragement helped me through this process. Finally, I would like to thank the graduates, super visors, and program directors that participated in the study. I learned so much from each of you and truly appreciate your time and willingness. I would also like to ac knowledge the Commission on Accreditation for Dietetics Education for their sup port of my education and research

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i Table of Contents List of Tables..................................... ................................................... ...............................v List of Figures.................................... ................................................... ............................vii Abstract........................................... ................................................... ..............................viii Chapter One: Introduction......................... ................................................... ......................1 Statement of the Problem........................... ................................................... ...........1 Conceptual Framework............................... ................................................... ..........4 Purpose of the Study............................... ................................................... ..............5 Research Questions................................. ................................................... ..............5 Hypotheses......................................... ................................................... ...................6 Significance of the Study.......................... ................................................... ............7 Delimitations of the Study......................... ................................................... ...........7 Limitations of the Study........................... ................................................... .............8 Organization of Remaining Chapters................. ................................................... .10 Summary............................................ ................................................... .................10 Chapter Two: Literature Review..................... ................................................... ...............12 Dietetics.......................................... ................................................... ....................12 Dietetics Education................................ ................................................... .............13 Competency and Supervised Practice................. ................................................... 15 Technology in Dietetics Education.................. ................................................... ...15

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ii Distance Learning, Dietetic Internships............ ................................................... ..17 Definition of Distance Learning.................... ................................................... .....19 History of Distance Learning....................... ................................................... .......20 Description of Distance Learning................... ................................................... ....20 Theory and Distance Learning....................... ................................................... .....21 Equivalency Theory................................. ................................................... ...........22 Prevalence of Distance Learning in Higher Education ..........................................24 Prevalence of Distance Learning in Healthcare Educa tion....................................25 Clinical Judgment.................................. ................................................... .............26 Benefits of Distance Learning...................... ................................................... ......28 Barriers in Distance Learning...................... ................................................... .......29 Distant Learning Students.......................... ................................................... .........31 Faculty Attitude and Satisfaction.................. ................................................... ......32 Student Outcomes & Satisfaction.................... ................................................... ...34 Summary............................................ ................................................... .................38 Chapter Three: Methodology........................ ................................................... .................40 Quantitative Research............................. ................................................... ............42 Design........................................... ................................................... ..........42 Procedure........................................ ................................................... ........42 Instrument....................................... ................................................... ........43 Participants..................................... ................................................... .........44 Analysis......................................... ................................................... ..........47 Qualitative Research.............................. ................................................... .............49

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iii Design........................................... ................................................... ..........49 Procedure........................................ ................................................... ........50 Interviews....................................... ................................................... .........51 Participants..................................... ................................................... .........52 Analysis......................................... ................................................... ..........53 Ethical Issues..................................... ................................................... .................54 Biases, Assumptions and Negotiation of Entry....... ..............................................54 Summary............................................ ................................................... .................55 Chapter Four: Results............................. ................................................... .......................56 Research Question 1................................ ................................................... ...........56 Pass Rate Descriptive Statistics................... ..............................................56 Pass Rate Inferential Statistics................... ................................................57 Research Question 2................................ ................................................... ...........59 Research Question 3................................ ................................................... ...........66 Research Question 4................................ ................................................... ...........73 Traditional and Distance Learning Graduate Intervie ws...........................74 Traditional and Distance Learning Program Directors Interviews............83 Traditional and Distance Learning Graduate Supervis or Interviews.........87 Summary............................................ ................................................... .................94 Chapter Five: Conclusions......................... ................................................... ....................96 Discussion of Findings for Research Questions...... ..............................................96 Implications and Recommendations for Future Practic e.....................................100 Recommendations for Future Research................ ...............................................103

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iv Conclusion......................................... ................................................... ...............103 References......................................... ................................................... ............................105 Appendices......................................... ................................................... ...........................114 Appendix A: Program Information and Registration E xam Pass Rate Review..115 Appendix B: Graduate Survey on Preparedness for Pra ctice..............................116 Appendix C: Supervisor Survey on Preparedness for Practice..... .......................117 Appendix D: Program Director Interview Guide...... ..........................................118 Appendix E: Graduate Interview Guide.............. ...............................................120 Appendix F: Supervisor Interview Guide............ ...............................................122 About the Author................................... ................................................... .............End Page

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v List of Tables Table 1. Study Phases.............................. ................................................... .......................41 Table 2. Participation by Programs................. ................................................... ................45 Table 3. Research Question Analysis................ ................................................... .............49 Table 4. Frequency Table of Program Pass Rates..... ................................................... .....56 Table 5. Pass Rate Mean Percentages and Normality T ests..............................................5 7 Table 6. Parametric t-test and Non-Parametric Test Results for Pass Rates.....................58 Table 7. Parametric t-test Results for Survey Resul ts in Distance Graduates versus Traditional Graduates.............................. ................................................... ............61 Table 8. Parametric t-test Results for Survey Resul ts in Distance Supervisors versus Traditional Supervisors............................ ................................................... ...........69 Table 9. Graduate Interview Question #1............ ................................................... ...........74 Table 10. Graduate Interview Question #2........... ................................................... ..........75 Table 11. Graduate Interview Question #3........... ................................................... ..........76 Table 12. Graduate Interview Question #4........... ................................................... ..........77 Table 13. Graduate Interview Question #5........... ................................................... ..........78 Table 14. Graduate Interview Question #6........... ................................................... ..........79 Table 15. Graduate Interview Question #7........... ................................................... ..........79 Table 16. Graduate Interview Question #8........... ................................................... ..........80 Table 17. Graduate Interview Question #9........... ................................................... ..........80 Table 18. Graduate Interview Question #10.......... ................................................... .........81

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vi Table 19. Graduate Interview Question #11.......... ................................................... .........81 Table 20. Program Directors Interview Question #1.. ................................................... ....83 Table 21. Program Directors Interview Question #2.. ................................................... ....84 Table 22. Program Directors Interview Question #3.. ................................................... ....85 Table 23. Program Directors Interview Question #4.. ................................................... ....85 Table 24. Program Directors Interview Question #5.. ................................................... ....86 Table 25. Program Directors Interview Question #6.. ................................................... ....86 Table 26. Supervisors Interview Question #1........ ................................................... .........88 Table 27. Supervisors Interview Question #2........ ................................................... .........88 Table 28. Supervisors Interview Question #3........ ................................................... .........89 Table 29. Supervisors Interview Question #4........ ................................................... .........89 Table 30. Supervisors Interview Question #5........ ................................................... .........90 Table 31. Supervisors Interview Question #6........ ................................................... .........91 Table 32. Supervisors Interview Question #7........ ................................................... .........91 Table 33. Supervisors Interview Question #8........ ................................................... .........92 Table 34. Supervisors Interview Question #9........ ................................................... .........92

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vii List of Figures Figure 1. Survey Participation..................... ................................................... ...................46

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viii Comparison of Student Outcomes in Distance Learning versus Traditional Dietetic Internships Lauri Wright ABSTRACT One way in which higher education is responding to technology advances, demographics changes, and economic pressures is thr ough the development of distance learning. Distance learning represents one of the most prominent trends in higher education today. Understanding the impact of this technologically driven change on student outcomes is unmistakably important. One ex ample of this trend in higher education is the distance learning internship in di etetic training programs. The purpose of this study was to compare student outcomes in dista nce learning dietetic internships to student outcomes in traditional dietetic internship s. The pass rate of the registration exam for dietitians, levels of perceived preparation for practice, and evaluation of curricular experiences were compared. The study was divided i nto three phases. The first phase of the study was the recruitment of dietetic internshi p directors and program information, including registration exam pass rate. The second phase of the study consisted of surveys on preparedness for practice to the graduates and s upervisors. The third phase of the study involved interviews of traditional and distan ce program graduates, their supervisors, and internship directors on curricular experience and preparation. No significant difference was found in pass rates for the registration exam. Significant differences were found in constructs of dietetic pr actice based on surveys with graduates and their supervisors. Common themes from intervie ws with graduates, their supervisors,

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ix and program directors confirmed survey results show ing graduates of traditional dietetic internship were prepared at a higher level of pract ice, competence and clinical judgment. The results of this research do not support equival ency in preparation for practice between distance and traditional dietetic internshi ps.

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1 Chapter One Introduction One way in which higher education is responding to technology advances, demographics changes, and economic pressures is thr ough the development of distance learning. Distance learning, in fact, represents o ne of the most prominent trends in higher education today. With over one-half of all institu tions of higher education providing some form of distance learning, our traditional con cepts of education are being challenged. Distance learning represents a change in the fundamental orientation of the learning environment (Allen et al, 2004). Underst anding the impact of this technologically driven change on student outcomes i s unmistakably important. However, it is still unclear what the outcomes of distance l earning are. One example of this trend in higher education is th e distance learning internship in dietetic training programs. Traditionally contr olled on-site at hospitals and universities, dietetic internships are now being pr ovided at a distance. No comparative data is available on the effectiveness of this new version of dietetics education against its traditional counterpart. This study compares stude nt outcomes in distance learning dietetic internships to student outcomes in traditi onal dietetic internships. Statement of the Problem Higher education is facing many complex challenges from the external environment. Within the societal context of rapid technological change and shifting

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2 market conditions, higher education is being asked to increase education opportunities, to improve the quality of student learning, and to con tain or reduce the rising costs of instruction (Twigg, 2003). Many educational instit utions are answering these challenges by developing distance learning courses and program s. While educators are rapidly developing courses and programs, there is limited k nowledge about student outcomes in distance education (Woo & Kimmick, 2000). According to the U.S. Department of Education’s “Pr ojections of Education Statistics to 2012,” enrollment in degree-granting colleges and universities is projected to increase more than 15% by 2012 (DiMaria, 2003). Fu rthermore, tuition at public fouryear colleges rose 9.6% in 2002, the highest rate i n a decade, and is expected to continue to rise at a rate greater than the rate of inflatio n (Young, 2002). Tuition increases reflect the budget difficulties colleges are facing as a re sult of the nation’s economic setbacks and continued reduction in state appropriations for higher education. In addition, there has been an unprecedented call by government, socie ty, and taxpayers for more accountability in the higher education system. Con sequently, higher education is being asked to provide increased access without an increa sed budget and to demonstrate the quality of the education provided. With the advancement of computer technology, specif ically with the availability and extensive usage of the Internet, there has been a dramatic change in the way our society delivers information. These advances in in formation technology and telecommunication have also brought significant cha nges to higher education. Distance learning has become an important alternative to tra ditional methods of education. In a recent survey, the National Center for Education St atistics found that over one-half of

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3 higher education institutions now offer distance ed ucation courses (National Center for Education Statistics, 2003). Distance learning exp ands the ability of institutions to reach students and, in turn, provides convenience and fle xibility to students. Although this new mode of education is in its relative infancy, it ho lds enormous promise for students and institutions. There is much dispute, however, about how well distance learning works and under what conditions it may provide similar or sup erior instructional results to more traditional teaching modes. Dietetic education mirrors this trend in higher edu cation. Thirty-three percent of undergraduate programs in dietetics offer some cour sework via distance education (Commission on Accreditation for Dietetics Educatio n, 2005). Thirteen of the 264 dietetic internship programs are now offered at a d istance, with this number expected to increase. The dietetic internship is a post-gradua te clinical practicum required for eligibility to sit for the registration exam for di etitians. Supervised clinical practice is critical in the dietetic education model, providing an opportunity for students to apply scientific principles, develop clinical judgment, a nd to gain confidence in performing skills (Skipper & Lewis, 2005). The Commission on Accreditation for Dietetics Education (CADE) establishes the required outcomes for the internship in the form of core competencies. Dietetic internships are tradit ionally based in hospitals and clinical settings. Interns complete their required practice hours in the accredited hospital with an internship director developing and overseeing the l earning experiences in coordination with the CADE core competencies. Distance learning dietetic internships differ from traditional dietetic internships in that interns de velop their own learning experiences at affiliate hospitals geographically distanced from t he accredited institution and internship

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4 director. The distance learning dietetic internshi ps have enjoyed immense popularity with students, but there has been no collective eva luation of student outcomes in this new type of program. Conceptual Framework Apple (1991, p. 75) observed that “new technology is not just an assemblage of machines and their accompanying software. It embod ies a form of thinking that orients a person to approach the world in a particular way.” Therefore, distance learning does not simply represent replacing traditional classrooms w ith computers and software. Rather, technology must coincide with teaching practices ba sed on how students learn best (National Council for Accreditation of Teacher Educ ation [NCATE] Task Force on Professional Development, 1997). The conceptual framework for this research study is the Equivalency Theory. It may be premature to consider the Equivalency Theory a theory yet, but the ultimate goals do align with the goals of this research. This the ory advocates designing a collection of equivalent and appropriate learning experiences for distance and local learners with the goal of facilitating equivalent learning outcomes f or each student (Keegan, 1995 and Simonson, 1995). The more equivalent the learning e xperiences of distant learners are to those of local learners, the more equivalent will b e the outcomes of the educational experiences for all learners. The more equivalent the outcomes of distance learning, the more acceptance distance education will have from t eachers, learners, and the public. This theory aligns most closely with the purpose of this study and the goals of distance dietetics education.

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5 Purp ose of the Study With the formation of this new type of dietetic int ernship, it was important to examine educational processes and outcomes. Theref ore, the purpose of this study is to compare outcomes in distance learning dietetic inte rnships to traditional dietetic internships. Specifically, the pass rate of the re gistration exam for dietitians and levels of perceived preparation for practice was compared in the quantitative portion of this study. Graduates’ and supervisors’ perception of students’ preparation for practice and graduates’ curricular experiences was further evalu ated in the qualitative portion of this study. A pragmatic framework was chosen for this s tudy. A pragmatic framework supports the use of both qualitative and quantitati ve research methods in the same research study (Tashakkori & Teddlie, 2003, p. 21). The rationale for choosing a pragmatic framework is that “methods should be mixe d in a way that has complementary strengths and non-overlapping weaknesses,” (Tashakk ori & Teddlie, 2003, p. 299). Research Questions The following research questions were addressed in the quantitative portion of this study: 1. Does the registration exam pass rate differ between distance learning and traditional dietetic internships? 2. Do graduates of distance learning and traditional d ietetic internships differ in their assessment of graduates’ preparatio n for practice? 3. Do supervisors of graduates of distance learning an d traditional dietetic internships differ in their assessment of graduates ’ preparation for practice?

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6 In the qualitative portion of this study, the foll owing research question was addressed: 1. How do graduates, their supervisors, and program di rectors of dietetic internships evaluate interns’ curricular experience and preparation for practice? Hypotheses It was hypothesized that there is no significant d ifference in registration exam pass rates between students who complete distance l earning dietetic internships and students who complete traditional dietetic internsh ips. Additionally, it was hypothesized that there is no significant difference in perceive d levels of preparation between graduates of distance learning internships and graduates of t raditional dietetic internships. Finally, it was hypothesized that there is no significant di fference in supervisors’ perceived level of preparation between students who completed dista nce learning dietetic internships and students who completed traditional dietetic interns hips. H1: There is no significant difference in registra tion exam pass rates between students who complete distance learning dietetic internships and students who complete traditional dietetic internships. H2: There is no significant difference in graduate s’ perceived levels of preparation between those completing a distance learning intern ships and those completing a traditional dietetic internship. H3: There is no significant difference in supervis ors’ perceived level of preparation between students who completed distance learning di etetic internships and students who completed traditional dietetic internships.

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7 Significance of the Study Distance learning is among the fastest growing tre nds in higher education today (Siegel, Jennings, & Conklin, 1998). Distance lear ning provides education to students not otherwise attainable by traditional methods for social, professional, economic, and geographic reasons. There is also some research th at suggests distance learning may reduce the cost of education (Mattheos, N., Schitte k, M., Attstrom, R., and Lyon, H. C., 2001). More than one-half of the institutions of h igher education in the United States offer distance learning courses and programs, and t his figure is expected to rise (National Center for Education Statistics, 2003). Case repor ts on distance learning outcomes have been enthusiastic, but controlled studies are neede d to better evaluate the effectiveness of distance learning courses and programs, and the typ e of educational experiences and environments in which distance learning is at least equivalent in outcome to traditional forms. Distance learning is being utilized in diet etics education as well. Thirty-three percent of undergraduate dietetic programs offer di stance learning courses (CADE, 2005). No studies are currently available on the e ffectiveness of this new type of dietetics education component. Therefore, the prop osed study will add to the body of literature on distance learning, particularly as an educational methodology in dietetics education and for internships. The study will also aid the field and accrediting body of The American Dietetic Association to determine the effectiveness and appropriateness of this new form of internship. Delimitations of the Study Delimitations are factors used to intentionally na rrow the scope of a study (Creswell, 1998). All studies contain delimitation s. This study is limited to one

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8 discipline, that being dietetics. Only one type of education experience was studied – the dietetic internship. Finally, this study is confin ed to three student outcomes – registration exam pass rates, curricular experience as it relate s to preparation, and perceived competency for practice. Limitations of the Study Limitations are potential weaknesses of a study. T hreats to internal and external validity exist in all quantitative and qualitative studies. Thus, limitations pertinent to this mixed methods study are presented. First, threats to internal validity are presented. This is followed by threats to external validity. Despi te the limitations, the use of mixed methods may enhance the inference quality, or the i nternal validity, and trustworthiness/credibility (Cook & Campbell, 1979, p. 37). Internal validity is defined as “the condition that observed differences on the dependent variable are a direct result of the indep endent variable, not some other variable” (Gay & Airasian, 2000, p. 345). One thre at to internal validity in this study is the differential selection of participants, or sele ction bias. There may be substantive differences between dietetic interns enrolled in th e distance education internships and the dietetic interns enrolled in the traditional intern ships, which may affect the effectiveness they derive from the internship. These differences could include differences in undergraduate preparation, work experience, and ski lls or attitudes of those who adopt new technology and are willing to work independentl y. These differences may influence performance in the internship and/or on the registr ation exam for dietitians. Matching bias is another threat to internal validity in this study. Traditional dietetic internships were matched by size, geography, institution type, and defined emphasis area to distance

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9 learning internships. This matching of similar cha racteristics poses a threat to internal validity because those individuals not matched may possess variables that may be related to the observed findings of the study (Onwuegbuzie & Teddlie, 2003). Researcher bias is another possible threat to internal validity in thi s study. “Researcher bias may occur during the data collection stage when the researche r has a personal bias in favor of one technique over another” (Onwuegbuzie & Teddlie, 200 3, p. 77). Although the researcher does have opinions concerning traditional versus di stance learning dietetic internships, the threat should be minimized because the research er is not implementing the intervention. Other threats to internal validity i n this study include instrumentation (i.e., reliability/validity of the registration exam), and mortality (i.e., non-responders). External validity refers to “the extent to which th e results of a study can be generalized to and across populations, settings, an d times” (Johnson & Christensen, 2000, p. 200). A threat to external validity in this stu dy is population validity. Population validity refers to the extent to which findings fro m the sample can be generalized to the population. Because some members of the target pop ulations did not respond to this study, population validity is a threat. Also, inte rnship conditions can vary widely by fields and sites. Ecological validity is another t hreat to external validity in this study. Ecological validity refers to “the extent to which findings from a study can be generalized across settings, conditions, variables, and context s” (Onwuegbuzie & Teddlie, 2003, p. 80). It may be difficult to generalize the findin gs of this study for dietetics education to other allied health internships and residencies due to the fact that only one unique discipline is being studied.

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10 Among the most cited criticisms of qualitative rese arch are the presumed lack of reliability and validity of its findings (McRoy, 19 96). Lincoln and Guba (1985) proposed criteria for judging the soundness of qualitative r esearch and offered these as an alternative to more traditional quantitative criter ia. The criteria include credibility, transferability, and dependability. Credibility, m ost similar to internal validity in quantitative research, involves establishing that t he results are believable. Transferability, most similar to external validity in quantitative research, refers to the degree to which the results are applicable to other settings. Dependability, most similar to reliability in quantitative research, refers to how true the interpretation is to the data. Ultimately, qualitative research soundness is achie ved when the written account or description represents accurately the features of t he communication observed. These threats to the validity and generalizability were a ddressed by the use of purposeful sampling and member checks as discussed in the meth ods chapter. Organization of Remaining Chapters The remaining chapters present information relevant to this study. Chapter 2 is a review of existing research on distance learning in higher education. Chapter 3 details the methodology to be used in this study. Specific ally, this chapter includes a discussion of the participants, ethical considerations, instru ments, procedures, research design, and data analysis. The results of the research are pre sented in Chapter 4. Finally, conclusions and implications are offered in Chapter 5. Summary Distance learning is a growing trend in higher edu cation. Dietetics education mirrors this trend with 33% of undergraduate dietet ics programs offering distance

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11 learning and 13 dietetic internships now being offe red at a distance. Despite the popularity of distance learning, little information is available on student outcomes. The purpose of this study was to compare student outcom es in distance dietetic internships to those in traditional dietetic internships.

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12 Chapter Two Literature Review Distance learning is instruction delivered over a d istance to one or more individuals. Distance education in higher education has been in existence for over a century but a new form using the Internet has resul ted in an explosion in its use. The following chapter will begin with a discussion of d ietetics education and a new distance learning dietetic education program. This will be followed by the definition, history and description of distance learning, theories, and pre valence in higher education, benefits, barriers, the distance learner, faculty attitude, o utcomes in distance learning, and a discussion on clinical judgment. Dietetics Nutrition is the study of the food substances vita l for health and how the body uses these substances (Wardlaw and Smith, 2005). D ietetics is the profession that utilizes nutrition to promote health and prevent diseases. A registered dietitian is a food and nutrition expert who has met the minimum academic a nd professional requirements to qualify for the credential “RD” (American Dietetic Association, 2004). In addition to national registration, many states have licensure l aws for dietitians. State requirements are generally met through the same education and tr aining required to become an RD. The requirements to become a registered dietitian a re as follows: 1) Earn a bachelor's degree with course work approved by Commission on A ccreditation for Dietetics Education. Coursework typically includes food and n utrition sciences, foodservice

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13 systems management, business, economics, computer s cience, sociology, biochemistry, physiology, microbiology, and chemistry; 2) Complet e an accredited, supervised, 6-to12-month internship or experiential practice progra m at a health-care facility, community agency or foodservice corporation; and 3) Pass a na tional examination administered by the Commission on Dietetic Registration. Continuin g professional educational requirements are in place to maintain professional registration. The American Dietetic Association (ADA) is the nat ion's largest organization of registered dietitians (American Dietetics Associati on, 2004). The majority of registered dietitians work in the treatment and prevention of disease, often in hospitals, doctor’s offices and clinics, or other health-care facilitie s. In addition, a large number of dietitians work in community and public health settings, acade mia and research. A growing number of registered dietitians work with food and nutrition industry and businesses, journalism, sports nutrition, corporate wellness pr ograms, and other non-traditional work settings. According to the U.S. Bureau of Labor St atistics, dietitians held about 49,000 jobs in the year 2002 and employment of registered dietitians is expected to grow about as fast as the average for all occupations through the year 2012 because of increased emphasis on disease prevention, a growing and aging population, and public interest in nutrition (U.S. Bureau of Labor, 2004). Dietetics Education Dietetics is a collegiate career study similar to social work, nursing, physical therapy and pharmacy (Stark and Lattuca, 1997). In these professional studies, the major conveys a knowledge base of skills, attitudes, and behaviors needed for entry to the field.

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14 Collegiate career education also concentrates on pr eparing students for ambiguous situations calling for informed, complex judgment. Dietetics education is a dynamic and complex proces s that translates the science of nutrition into application and practice (Commiss ion on Accreditation for Dietetics Education, 2004). Dietetics education programs pro vide opportunities for students to acquire the necessary knowledge, skills, judgment a nd competencies for dietetics practice. The Commission on Accreditation for Diet etics Education (CADE) is ADA's accrediting agency for education programs preparing students for careers as registered dietitians (American Dietetics Association, 2004). CADE is recognized by the Council on Higher Education Accreditation and the United St ates Department of Education as the accrediting agency for education programs that prep are dietetics professionals. CADE exists to serve the public by establishing and enfo rcing eligibility requirements and accreditation standards that ensure the quality and continued improvement of dietetics education programs (American Dietetics Association, 2004). There are two required components of dietetics educ ation: didactic education and supervised practice (Commission on Accreditation fo r Dietetics Education, 2004). Didactic education provides the foundation knowledg e necessary to function as a professional and on which practitioner competencies are built (Commission on Accreditation for Dietetics Education, 2004). This foundation knowledge is obtained in the undergraduate degree in dietetics. Supervised practice provides the practitioner skills, judgment, and competencies essential to perform the specialized functions of a dietitian and is obtained in the hospital-based internship. The Commission on Accreditation for Dietetics Education requires a minimum of 900 super vised practice hours within the

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15 dietetic internship. The general path of study to become a dietitian, then, is an undergraduate degree in dietetics followed by a hos pital internship. An alternative to this path is the coordinated undergraduate program. The re are 51 coordinated programs that synchronize didactic education with the supervised practice (CADE, 2005). This study will not include coordinated programs because of th e difficulty in distinguishing the supervised practice component from the didactic com ponent of the program. Competency and Supervised Practice Competency is having adequate abilities and qualit ies to function. The health care environment mandates that entry-level practiti oners possess knowledge and problem-solving skills that are competent and high quality (Forker, 1996). Health care trends challenge dietetics educators as well to pre pare competent professionals. In response, ADA developed competencies to address the changing roles of dietitians and to ensure students are well-prepared for practice (Bru ening and Pfeiffer, 2002). Dietetic educators must explore innovative ways for students to achieve these competencies (Gates and Sandoval, 1998). Competencies are based upon both objectivist and constructivist criteria, including such skills as a ssessment, critical thinking, cooperative work, and effective communication skills. Competen cies are ultimately designed to assure competent skills and clinical judgment. Ind icators of competency used by dietetic internships include students’ standardized test sco res, grade point averages, attainment of course objectives, performance on registration exam s, and job placement. Technology in Dietetics Education There is limited research available on the use of technology to enhance dietetics education. Those few studies have indicated that c omputer-aided instruction is an

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16 efficient, convenient and effective method for prom oting competency in health professionals, including dietetics students (Engel, Crandall, Basch, Zybert, and WylieRosett, 1997; Raidl, Wood, Lehman, and Evers, 1995; Lyons, Miller, and Milton, 1998). Instructional technology has been used in many ways in dietetics education, including videotapes, correspondence, audiovisual conferencin g, and online instruction. The use of instructional technology enhancements in dietetics education has been demonstrated to have many benefits. Strauss and Dahlheimer (1998) studied the effectiveness of incorporating multimedia technology into lectures o n anatomical and physiological concepts using a pre-test/post-test format and cros s-over design. Students in the enhanced lectures had higher post-test scores, indi cating that enhanced lectures are effective in teaching difficult concepts. Turner, Evers, Wood, Lehman, and Peck (2000) studied the impact of computer-based simulations on the performance of dietetics interns in initial clinical rotations. Repeated-measures a nalysis of variance and linear regression were used to compare performance ratings between in terns receiving computer-based simulations and those receiving the standard orient ation. The study demonstrated that the interns who received computer-based simulation had a higher rate of skill development. Raidl, Wood, Lehman, and Evers (1995) studied the e ffects of a computer-assisted instruction program on learning clinical reasoning skills in undergraduate dietetics students. Four hundred-thirteen students from thir ty dietetics programs participated and were divided into two groups – one given a standard drill-and-practice and the other group given a new computer-assisted tutorial. The students given the computer-assisted tutorial scored higher on a simulation test, demons trating enhanced clinical reasoning skills. Finally, Litchfield, Oakland, and Anderson (2002) examined the use of online

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17 technology to develop competency in dietetics educa tion. Seventy-five dietetic interns from three different programs were divided into tho se with and without online instruction, to which preand posttest key featu re exams were administered and registration exam scores were compared. The author s found that those dietetic interns with online instruction had greater improvement on key-feature exams in two of three content areas. There was no statistical difference in performance on the registration exam between the two groups. In summary, a variety of i nstructional technologies are being utilized in dietetics education with success, havin g been shown to improve student outcomes including post-test scores, rate of skill development, clinical reasoning skills, and attainment of clinical competencies. Distance Learning, Dietetic Internships Within the supervised practice component of dietet ics education, there is a new type of program – the distance learning dietetic in ternship. Traditional internships and distance learning internships are both accredited u nder the standards of the Commission on Accreditation for Dietetics Education, require d ietetic interns to participate in a computerized matching process, and include a minimu m of 900 practice hours. The purpose of distance learning and traditional dietet ic internships is to provide supervised practice to interns so they achieve the skills, cli nical judgment, and competencies needed for entry-level dietetic practice. The distance le arning dietetic internships, however, differs from traditional dietetic internships in tw o ways. The first difference is in proximity of dietetic interns to the accredited ins titution. Traditional dietetic interns are placed by the internship director into pre-approved practice sites, either within the accredited institution itself, as in a hospital-bas ed internship, or within proximity of the

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18 accredited institution and internship director, as in a university-based internship. Distance learning-dietetic interns, on the other ha nd, obtain their own practice sites and are separated from the accredited institution and i nternship director, often by hundreds of miles. The distance learning internship directors communicate via email with the intern and his or her preceptor throughout the program and physically visit the intern and preceptor on-site one time during the program. The distance learning internship directors rely heavily on the preceptor’s evaluation of the i ntern’s competence. The second difference in distance learning dietetic internship s from traditional dietetic internships concerns the learning experiences. In traditional dietetic internship, the learning experiences are planned and standardized by the int ernship director in order for interns to obtain all competencies adequately. For example, a ll interns in a traditional internship are required to attend an interventional study eval uating a patient’s ability to swallow in order to satisfy the competency on “being familiar with diagnostic procedures and adjusting diets accordingly.” In this way, little variability exists between interns in the learning experiences obtained at a traditional inte rnship. In the distance learning internships, interns are given the list of competen cies prescribed by CADE and it is their responsibility to find the practice sites and creat e their own learning experiences to obtain those competencies. To continue the example, a dis tance intern may not have swallow studies available at the site he or she chose to in tern so he or she reads about the procedure rather than actually viewing the procedur e. In this way, the learning experiences are highly individualized, exhibit grea t variability, and present more chance of an intern not adequately obtaining a competency. Currently, there are thirteen distance

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19 learning dietetic internships approved by CADE, the first originating in 1995. There is no collective data available evaluating the effecti veness of distance learning internships. Definition of Distance Learning Distance education in the most general sense of the term is instruction delivered over a distance to one or more individuals located in one or more venues (Phipps & Merisotis, 1999). The newest form of distance educ ation is web-based education, which can be defined as “an approach to teaching and lear ning that utilizes Internet technologies to communicate and collaborate in an educational co ntext. This includes technology that supplements traditional classroom training with web -based components and learning environments where the educational process is exper ienced online” (Blackboard, 2002, p. 6). Web-based teaching and learning are changing t he face of higher education and rapidly becoming commonplace in colleges. Web-base d courses are being developed at a hastened pace, and faculty are working feverishly t o develop the skills needed to instruct in an on-line environment. Distance education appe ars to be a phenomenon that is here to stay. Ronald Phipps and Jamie Merisotis of the I nstitute for Higher Education Policy note in their 1999 report on distance education, “T echnology is having, and will continue to have, a profound impact on colleges and universi ties in America and around the globe. Distance learning, which was once a poor and often unwelcome stepchild within the academic community, is becoming increasingly more v isible as a part of the higher education family” (Phipps & Merisotis, 1999, p.12) Terminology varies, but for the purpose of this study, the terms distance education distance learning, and the newest form, online education, will be used interchangeabl y. Within this study, distance learning dietetic internship does not refer to web-based ins tructors; rather, distance learning

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20 dietetic internship refers to clinical experiences completed at a distance from the internship director and accredited institution. History of Distance Learning Distance learning is not a new concept. The earlie st form of an extended classroom, or distance education, was paper-based c orrespondence. As early as 1840, Isaac Pittman was teaching shorthand in England by correspondence (Curzon, 1977). Through the early and middle 1900’s, correspondence courses grew (Curzon, 1977). As technology changed, so did the methods of transferr ing information. Correspondence courses were replaced by courses using radio and te levision. In 1973, Moore introduced the theory of independent study, suggesting that su ccessful teaching can take place even though teacher and learner are physically separated during the learning process (Galusha, 1997). By the 1980’s, laboratory-based independent study programs, cable-television courses, mailed videos with course materials, and t eleconferencing were the newer mechanisms being utilized (Curzon, 1977). These fo rms of distance education were just the beginning of what we are experiencing today. T he advent of the Internet and World Wide Web has now brought us to the new frontier of online education. Description of Distance Learning At its most basic level, distance education takes place when a teacher and student(s) are separated by physical distance and t echnology is used to bridge the instructional gap (Reinert, & Fryback, 1997). Ther e is a wide range of technological options available in distance education. The optio ns fall into four categories: voice, video, data, and print (Willis, 2003). Voice techn ology is an instructional audio tool that includes telephone, audioconferencing, tapes, and r adio. Video technology tools include 19

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21 slides, videotapes, films, and images combined with audioconferencing. Data technology utilizes computers to send and receive information electronically. Computer applications are varied and include the following: (a) computerassisted instruction (CAI), which uses the computer as a teaching machine; (b) computer-ma naged instruction (CMI), which uses the computer to organize instruction and track students; and (c) computer-mediated education (CME), involving applications that facili tate delivery of instruction and communication such as electronic mail and fax (Will is, 2003). Print technology is generally the foundation of courses and includes te xtbooks, syllabi, and study guides. Theory and Distance Learning Theory is a set of hypotheses logically related to one another for explaining and predicting occurrences (Simonson, Schlosser & Hanso n, 2002). Theory is important to the study of distance education because it guides p ractice and research. Holmberg (1995), however, suggests that distance education h as been characterized by a trial and error approach, with little consideration given to a theoretical basis. The earliest theories of distance education were based on correspondence study and were derived from European models of education. All of these classic al theories emphasize the notion that distance education is a fundamentally different for m of education. These traditional theories fall into three categories independence and autonomy, interaction and communication, and industrialization of teaching. The first theories of distant learning, independence and autonomy, are based on works from Wedemeyer (Keegan, 1986) and Moore (1994) who emphasize learner independence and the adoption of technology as a way of implementing independence. The theories als o emphasize increased learner responsibility for the learning experiences. The s econd category of distance learning

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22 theory is interaction and conversation. Holmberg’s (1989) theory of distance learning, which he calls a “guided didactic conversation,” fa lls into this category. In his theory, “distance teaching supports student motivation, pro motes learning pleasure and makes study relevant to the individual learner and his/he r needs, creates feelings of rapport between the learner and the distance education inst itution, facilitates access to course content, engages the learner in activities, discuss ions and decisions and generally catering for helpful real and simulated communication to and from the learner” (Holmberg, 1989, p. 123). Peters’ (1988) Theory of Industrializatio n of Teaching proposed that distance education could be analyzed by comparison with the industrial production of goods. He concluded that for distance teaching to be effectiv e, the principle of division of labor is a critical element. While these classical theories a ttempted to explain early distance learning, they failed to keep abreast with the dyna mic nature of distance learning and did not incorporate principles of American education. Equivalency Theory Advances in telecommunications, which have allowed the creation of a virtual classroom by electronically linking the instructor and students, have significantly altered the practice of distance education in the United St ates. As a result, a new theory on distance learning, called the Equivalency Theory, h as emerged. In addition to reflecting advances in technology, the new theory is also base d on the U.S. system of education, which emphasizes characteristics such as the use of regular classroom teachers to facilitate the teaching and learning process, local control, small class size, rapport between teacher and learner, and personalized learn ing (Simonson, Schlosser & Hanson, 2002). In contrast to the classical theories, the Equivalency Theory argues that distance

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23 education is a variation of education, not a distin ct field of education. This theory is based on the works of Keegan (1995) and Simonson (1 995) and includes the following key elements: equivalency, learning experiences, ap propriate application, students, and outcomes. Central to this theoretical approach is the concept of equivalency. Education at a distance should be built on the concept of equ ivalent learning experiences. The second key element of this theory is the concept of learning experience. Distance educators are responsible for designing learning ev ents that are individualized, appropriate, and provide equal value for learners. The goal of instructional planning then is to make the sum of experiences for each learner equivalent. The next key concept is the idea of appropriate application. This concept implies that learning experiences, suitable to the needs of the individual learner and the learning situation, should be available and that the availability of learning exp eriences should be proper and timely. Students, the fourth key concept of the Equivalency Theory, are the ones involved in the formal learning activities and they should be defin ed by their enrollment in a course or program, not by their location. The final key conc ept of this theory is outcomes. Outcomes of learning experiences are those changes that occur because of the students’ participation in the education. The theory details two categories of outcomes: instructordetermined and learner-determined. Instructor-dete rmined outcomes are generally the stated course goals and objectives and reflect what the learner should be able to accomplish after the learning experience that they could not do before the learning experience. Learner-determined outcomes are less s pecific and relate to what the learner hopes to accomplish as a result of participation in the education event. Learnerdetermined outcomes include enrollment in a followup course or application of newly

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24 learned skills to a job. The Equivalency Theory ar gues that in order for distance learning to be accepted, instructorand learner-determined outcomes should be equivalent. In sum, the Equivalency Theory advocates equivalent le arning experiences and student outcomes in distance education. The Equivalency Theory was chosen as the conceptua l framework for this study for two reasons. First, the Equivalency Theory can serve as a standard of reference for the study. The purpose of the study was to compare outcomes in distance learning dietetic internships to traditional dietetic intern ships. The theory supports equivalency in student outcomes and in this way, can serve as a st andard of reference. The second reason the Equivalency Theory was chosen as the con ceptual framework is its similarity to the goals of dietetics education. The Commissio n for Dietetics Education advocates for dietetic internships to provide equivalent lear ning experiences in all practice sites. Equivalent learning experiences, in turn, facilitat e achievement of competency for entrylevel practitioners. Because of the standard it ca n provide and its similarity to dietetics education goals, the Equivalency Theory was chosen as the framework for this study. Prevalence of Distance Learning in Higher Education The National Center for Education Statistics surve yed higher education institutions, using the Postsecondary Education Qui ck Information System (PEQIS), on distance education courses offered for the twelve m onth, 2000-2001 academic year (National Center for Education Statistics, 2003). Distance education was defined by the researchers as “education or training courses deliv ered to remote (off-campus) locations via audio, video, or computer technologies” (Nation al Center for Education Statistics, 1999, p. 3). The survey found 56% of higher educat ion institutions offered distance

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25 education courses. Public institutions were more l ikely to offer distance education courses than were private institutions, with 90% of public 2-year and 89% of public 4year institutions as compared to 15% of private 2-y ear and 40% of private 4-year institutions (National Center for Education Statist ics, 2003). An estimated 118,100 different college-level, credit-granting distance e ducation courses were offered, up from 54,470 different courses offered in 1997-1998. (Na tional Center for Education Statistics, 2003). The number of students enrolled in distance -education courses rose from approximately 1,344,000 in 1997-1998 to approximate ly 3,077,000 in 2000-2001. The distribution of distance education course enrollmen ts was consistent with distribution of institutions offering distance learning, with 48% o f the total enrollments at public 2-year institutions and 31% of the total enrollments at pu blic 4-year institutions (National Center for Education Statistics, 2003). Prevalence of Distance Learning in Health-Care Educ ation The prevalence of distance education in health-care programs is variable, with no prevalence rate for programs such as medicine and d entistry currently available (Mattheos et al, 2001). A national survey on dista nce learning in social work education found that 16% of respondents reported the use of d istance learning in their social work program (Siegel et al, 1998). This represented a 5 % growth in distance education over a two-year period. Twenty-two percent of respondents who were not currently using distance learning in their social work programs ind icated that plans were in progress to develop such a system. The largest percentage of u sers (22%) was public institutions, with a student body of more than 20,000. In a stud y of distance learning in nursing education, Reinert & Fryback (1997) surveyed all ac credited nursing programs in the

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26 United States. There was an 80% return rate for a total of 353 schools. Thirty-eight percent of the schools reported offering some form of distance learning and 19% of schools without distance learning programs reported that they were planning future offerings. Distance learning offerings varied from one or two courses to offering entire degrees online. A report by The American Dietetics Association (ADA) found that 93 dietetics education programs, or 33%, offer some co ursework via distance education and that thirteen programs, or 5%, have a distance educ ation option for supervised practice experience (CADE, 2005). According to ADA (2003, p 10), “The Association is sensitive to the needs of nontraditional students a nd encourages programs to employ distance learning.” The introduction of distance l earning in health-care programs has been delayed but it appears it is becoming an impor tant alternative to traditional methods of education (Mattheos, Schittek, Attstrom, Lyon, 2 001). Clinical Judgment One reason distance learning may not be as prevale nt in health-care education is the issue of clinical judgment. Clinical judgment refers to the ability to apply knowledge into expert judgment and action. Clinical judgment is becoming a benchmark of professional competence and student performance in health care professionals (DiVitoThomas, 2005). Clinical judgment has two component s – explicit and tacit knowledge (Epstein, 1999). Explicit knowledge refers to fact s, theories, concepts, and principles. Explicit knowledge is usually acquired from books, electronic media, or instructors. This component of clinical judgment can be quantified, m odeled, and readily communicated. Tacit knowledge on the other hand is more ambiguous and difficult to define. Tacit knowledge includes values, experience, emotions, bi as, and personal knowledge. While

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27 explicit knowledge is taught formally, tacit knowle dge is usually learned in less direct and explicit ways such as during observation and pr actice. The development of both components of clinical jud gment is essential to the preparation of the next generation of professionals Integrated clinical experiences are recognized as the ultimate opportunity to put theor y into practice and develop clinical judgment (Malloy & Denatale, 2001). In fact, the a pprenticeship, mentorship, or internship is an universal and critical component o f all health care education. The interaction and collaboration between mentor and st udent allows for the transfer of expert judgment. Methods such as case studies and process ing between the mentor and students facilitate the acquisition of judgment. What is the relationship between distance educatio n and clinical judgment? Distance education is enhancing and even replacing traditional education venues. There is continuing debate regarding which academic disci plines are suitable for distance learning. Distance learning is well accepted in ma ny disciplines such as liberal arts, humanities, social and political sciences, business and mathematics (Phipps and Merisotis, 1999). It seems special characteristics such as the development of clinical judgment has delayed the introduction of distance l earning to health-care education. One strength of distance education is to deliver a larg e amount of information; in regards to clinical judgment, this actually may be a weakness. As Klas (2004) argued “what we have come to recognize as the information revolutio n is just another way to deliver information. Too often, we confuse information wit h knowledge and knowledge with judgment.” The challenge to distance education, th en, is to find ways to ensure that clinical judgment can be transferred to health care students.

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28 Clinical judgment is a science and an art. The mo re explicit component is often learned from books while the more tacit component o f clinical judgment is learned from observation and experience. It is the apprenticesh ip in health care education that provides the clinical experiences to develop both components of clinical judgment. While technology is providing more information, this may not translate into clinical judgment. Distance learning needs to find ways in which to pr ovide experiences and interaction that facilitate the development of clinical judgment. Benefits of Distance Learning Distance learning, fueled by the World Wide Web, h as opened a whole new venue for teaching and learning. Distance learning is enhancing and even replacing many traditional classroom settings. There are many ben efits of distance learning. The most obvious benefit of distance learning for both stude nts and faculty may be convenience (Hofmann, 2002; Barron, 1999). Distance learning p rovides convenience, flexibility, and the ability to “learn anytime, anywhere.” This ben efit was reflected in a survey on attitudes toward distance learning where faculty ci ted convenience as the primary benefit of distance learning – “being able to teach on a sc hedule and from a location of their own choosing” (National Education Association, 2000, p. 9). Another benefit of distance learning is accessibil ity. Distance education has the potential to provide access to higher education for students who previously may not have been able to participate due to geography, time, jo b and family responsibilities, or finances (Boettcher, 1996). Additionally, the Nati onal Education Association ‘s (2000) survey found similar results, with faculty citing t he ability to reach more students as an added benefit. This is also a benefit for the inst itutions of higher education, with distance

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29 learning opening new markets. After an extensive r eview of the empirical findings in educational and training technology, Fletcher (2001 ) found web-based instruction reduces the cost of instruction by about one-third. Another potential benefit of distance learning is enhanced learning. Olson and Wisher (2002) argue that unique features of distanc e education such as multimedia and multi-sensory formats, self-pacing, active learning and tailored feedback can enhance learning. For example, some students learn from vi sual stimuli, such as video, and others learn best by listening or interacting with a compu ter program. If distance learning courses are well designed, they will likely offer l earners a wide range of choices, thereby providing the optimal combinations of interaction a nd media. A final potential benefit of distance learning per tains to communication. Communication in distance learning can be more equi table and collaborative. Distance learning gives students equal opportunity to partic ipate. Reports have found that students feel more comfortable asking questions electronical ly than in face-to-face situations with an instructor or peers (Gale, 2000). The communica tion is also more collaborative, with chat rooms and electronic mail encouraging students to communicate with their instructor and each other. In summary, distance learning offe rs many advantages for students and faculty. Barriers in Distance Learning Distance learning gives learners and faculty the gr eatest possible control over the time, place, and pace of education. However, there are problems and barriers associated with distance education. These problems and barrie rs encountered by distant learning students contribute to higher dropout rates, as mea sured by course completion rates,

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30 among distance learning students when compared to t raditional students (Sweet, 1986). Similarly, in a study of 231 students in a college health education course, Diaz (2002) found that online students were twice as likely to drop a course, a 13.5% drop rate for online students versus a 7.2% drop rate for traditi onal students. One barrier for the distance student that may contr ibute to higher dropout rates may be the perceived lack of feedback. Because the re is not daily or weekly face-to-face contact with teachers, students may have trouble wi th self-evaluation, motivation, and study pacing. The isolation that can result from t he distance learning process can complicate the learning process for students and le ad to higher drop out rates. Other barriers for distance students that may contr ibute to higher dropout rates are lack of support and services. Students may be phys ically separated from the institution and lack support such as technical assistance, tuto rs, and advisors. Further, students may experience technical issues including incompatible software, unavailable servers, and even lack of technical skills. All of these factor s present barriers to learning and may contribute to student drop out. Specific to this s tudy, interns enrolled in distance learning dietetic internships may also experience barriers t o learning such as lack of feedback from the internship director or lack of technical s kills to obtain reference materials electronically. Faculty barriers in distance learning include lack of training in course development and technology, time required for cours e development, lack of institutional support for distance learning in general, perceived threat to tenure, and suspicions about the academic quality of on-line learning (Galusha, 1997). In a study of distance learning in social work education, Siegel et al (1998) found the barriers to distance learning were:

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31 1) philosophic barriers concerning the quality of t he classroom and lack of “face-to-face” interactions; and 2) lack of recognition by adminis trators of the technical support necessary to assist the instructor. In a study of distance learning in nursing education, Reinert and Fryback (1997) interviewed instructors experienced with distance learning to obtain information on their experiences. The autho rs found barriers in distance learning included comfort with technology, faculty contact a nd socialization, and students’ need for structure. They also found the facilitators to distance learning included technical support, workload adjustment to prepare for distanc e learning, and organized but flexible teaching methods. Although no studies have been do ne on barriers to distance learning in dietetics, informal conversations with dietetics ed ucators have supported the philosophic concerns about the quality of the education. Distance Learning Students Moving courses from the traditional classroom to a distance format has the potential to shift human interaction, communication learning paradigms, and assessment techniques. Distance education places the onus on students to initiate the learning process. Students must be responsible to read the material, explore the links, participate in the discussion, ask questions, learn the objecti ves, and set aside the time to learn. Therefore, the student must be self-disciplined, mo tivated, responsible, and active in the learning process. Online students are becoming an entirely new subpop ulation of higher education learners. Many distance education students are old er. Adult learners tend to be practical problem solvers. Their life experiences make them autonomous, self-directed, and goaland relevancy-oriented; they need to know the ratio nale for what they are learning

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32 (Howell, Williams, & Lindsay, 2003). Distance lear ners generally have jobs and families. As such, they have many conflicting resp onsibilities and need the flexibility distance learning allow. Distance learners general ly have completed more college credit hours, more degree programs, and have a higher allcollege grade-point average than traditional students (Diaz, 2002). For example, Di az (2002) found that online students received twice as many A’s and half as many D’s and F’s in their completed coursework as compared to students taking traditional coursewo rk. Still, researchers have found that these students feel insecure about their ability to succeed in distance learning, possibly because these students are less traditional learner s (Dortch, 2003; Diaz, 2002; Knapper, 1988). Distant students have a variety of reasons for taking courses, from taking courses to broaden their education, to obtaining credential s to qualify for a better job. They are motivated by professional advancement, external exp ectations, the need to better serve others, social relationships, stimulation, and pure interest in the subject (Howell, Williams, & Lindsay, 2003). Knowing the characteri stics and demographics of the distance learners helps instructors and institution s better meet the students’ needs and improve their chances of success. Faculty Attitude and Satisfaction The National Education Association recently conduc ted a survey of members in higher education on attitudes toward distance educa tion (National Education Association, 2000). Members were contacted by phone, with a tot al response of 532 members. The results of the survey indicated that, overall, facu lty members were more positive and less divided over distance learning than is commonly bel ieved. Attitudes toward distance education were more favorable among those who had t aught distance learning courses,

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33 72% of whom were positive, compared to 51% of respo ndents who had not taught distance learning classes. Several common concerns emerged from the survey. First, faculty feel it is crucial to have reliable technol ogy, support, and mentoring. Next, faculty routinely report that developing and teachi ng distance learning courses is more time intensive than traditional courses – thus rais ing doubts about whether distance learning courses are more cost-effective. Finally, while distance learning affords greater interaction, many faculty are concerned that the in teraction lacks a human face. In summary, the results of the survey indicated that t he faculty have some concerns but are generally optimistic about distance learning (Natio nal Education Association, 2000). The 1999 National Study of Postsecondary Faculty ( NSOPF:99) was sponsored by the U.S. Department of Education’s National Cent er for Education Statistics (National Center for Education Statistics, 1999). The Gallup Organization conducted the third cycle of NSOPF, which included 960 degree-granting postse condary institutions and an initial sample of 28,704 faculty and instructional staff fr om these institutions. NSOPF:99 was designed to provide a national profile of faculty, including their professional backgrounds, responsibilities, workloads, salaries, benefits, and attitudes. The fall 1998 study found that those faculty who participated in distance education appeared to interact with students, or be available to them, more than t heir non-distance counterparts. Fulltime faculty teaching distance classes held slightl y more office hours per week than their peers who did not teach distance education classes or non–face-to-face classes. And because they taught more for-credit classes, while average class size was comparable, faculty teaching distance classes had more student contact hours per week than those not

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34 teaching such classes. Furthermore, full-time facul ty who taught distance classes were more likely than other faculty to communicate with their students via e-mail. A major factor in the success of distance learning is a strong faculty commitment. Although similar to other aspects of faculty work, a growing body of research and experience has demonstrated that a strong faculty c ommitment is directly related to levels of personal and professional satisfaction (Thomas, 2002). According to Thomas (2002, p 6), “faculty satisfaction results when those teac hing in online programs receive the personal rewards, institutional support and profess ional recognition they need to feel positive about what they do and to do their jobs we ll.” Student Outcomes and Satisfaction When comparing student outcomes in distance learnin g courses to traditional courses, a “no significant difference” trend has em erged. Thomas Russell’s (1999) compendium of more than 355 comparative research st udies suggests that students in technology-based courses learn as well as their oncampus, face-to-face counterparts. Phipps and Merisotis (1999), however, contend that there are shortcomings to the original research on the effectiveness of distance learning. Their analysis found the following shortcomings: 1) much of the research does not cont rol for extraneous variables and therefore cannot show cause and effect; 2) most of the studies do not use randomly selected subjects; 3) the validity and reliability of the instruments used to measure student outcomes and attitudes are questionable; and 4) man y studies do not adequately control for the feelings and attitudes of the students and faculty. The “no significant difference” compendium was based on research prior to 1999 and did not include distance learning classes that utilized internet technology.

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35 Newer research studies have also concluded that cog nitive factors such as learning, performance, and achievement in online cl asses are equivalent to those observed in traditional classes. In a more recent meta-analysis, Allen et al (2004) summarized the quantitative literature comparing th e performance of students in distance education versus traditional classes. The authors concluded that the average effect (average r = .048, k = 39, N = 71,731) demonstrated that distance learning students slightly outperformed traditional students on exams and course grades. The examination of several moderating features such as channel of d elivery and course content fail to produce a homogeneous solution. Therefore, the aut hors concluded that the results demonstrated no clear decline in educational effect iveness when using distance education technology. Gagne & Shepherd (2001) compared the p erformance of students in a distance education version to the performance of st udents in the on-campus version of an introductory accounting graduate class. The study found no difference between student performance as measured by multiple choice and comp lex problem solving exam format. Carr (2000) found that undergraduates enrolled in i ntroductory psychology performed better in distance education courses. Students par ticipating in the web-based version of a psychology course consistently scored five percenta ge points higher on the final exam and general knowledge psychology test than those in the lecture course. The author attributed the results to the structure of the cour ses – lecture course students tended to study the night before the exam while web-based stu dents have to space out studying in order to complete the weekly assignments. However, the two groups were not comparable since the lecture course students did no t receive weekly assignments. Schoech (2000) reported that the grades and perform ance of students enrolled in a

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36 graduate social work course taught in a distance fo rmat were consistent with previous outcomes in traditional courses of similar content. The author concluded that the Internet provides an environment rich enough to teach at a l evel of quality consistent with a faceto-face classroom. The newer research comparing st udent outcomes in distance learning to traditional classes seem to support the earlier research that concluded “no significant difference” in student outcomes. Unlike student outcomes, the studies on perception s and satisfaction toward distance learning have not shown the same consisten cy. A recent meta-analysis compared distance learning and traditional courses on the basis of the level of satisfaction students experienced (Allen, Bourhis, Mabry et al, 2002). The investigators searched ERIC, SocioInfo, Psychlit, and ComIndex for sources on distance education and satisfaction. The combined sample size was 4702 st udent surveys. The results indicated little difference in satisfaction levels, with only a slightly higher level of satisfaction with the traditional education format than the distance learning format ( r = .031, k = 25). The authors concluded that distance education does not diminish the level of student satisfaction when compared to traditional face-to-f ace methods of instruction. Buckley (2003), however, found less satisfaction with Web-b ased courses. Student learning outcomes and satisfaction were compared in nursing students taking a traditional nutrition course to nursing students taking a web-b ased nutrition course. Fifty-eight students participated in the study. No differences were found in student learning outcomes. The web-based course, however, received significantly lower student satisfaction scores (F=18.53; p=.000). From studen ts’ qualitative comments, the author concluded that the less direct form of communicatio n in the Web-based course

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37 contributed to a sense of isolation and interfered with the desired level of closeness with the instructor. While Carr (2000) found that stude nts enrolled in an introductory psychology course performed better in the distance learning version, the students were generally less happy with the course. In a student -satisfaction survey, the distance learning students consistently reported less satisf action than students in the lecture version. The author surmised that one of the reaso ns for less satisfaction could be due to the distance learning version requiring a greater t ime commitment to complete weekly assignments. Another possible reason for less stud ent satisfaction, the author postulated, may be the lack of instructor contact. Rivera and R ice (2002) compared student performance and student satisfaction in a web-based Management Information Systems course to the traditional course. One-hundred thir ty-four students participated. Exam scores were used to assess student performance and questionnaires were used to assess student satisfaction. While there was no significa nt difference between exam scores, students enrolled in the web-based section were les s satisfied with the course than students enrolled in the traditional section. This was confirmed through the use of a Chi square test of independence, which showed the resul ts as independent at the 0.079 level of significance. Additionally, only 66% of student s in the web-based version said they would sign-up for a similar course in the future as compared to 92% of students in the traditional section. In contrast, Petracchi (2000) reported multisite data addressing the question of how students enrolled in distance learn ing courses perceive their learning experiences. One hundred forty-two students respon ded to a survey regarding their experiences with the technology used in their cours e, their learning environment, the instructor’s teaching skills, and perceived resourc e availability. Respondents were

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38 pleased with their learning experience, with 100% o f students indicating they would enroll in a distance learning course again. Schoec h’s (2000) study on students enrolled in a graduate social work course taught in a distance format found that student satisfaction was similar to traditional courses of similar conte nt, especially when discussion forum and chat rooms were utilized. The results from the studies on student satisfaction are less consistent in their results than the studies compar ing student outcomes in distant learning to traditional methods. These studies do provide r ich data, however, on areas of importance not studied by purely objectivist outcom e studies. Summary Distance education is instruction delivered over a distance to one or more individuals. Distance learning in higher education dates back to at least the middle of the 1800s and has taken many forms, including correspon dence courses and cable-cast. It is the Internet explosion that has led to the rapid in crease in the newest form of distance learning, web-based courses and programs. Approxim ately one-half of higher education institutions offer distance learning courses. The use of distance learning in allied health education programs is slightly less than its overal l use, ranging from 16% to 38%. The primary benefits of distance learning include conve nience and access. Research studies on equivalency of student outcomes have been mixed. No consistent differences in student outcomes or satisfaction have been demonstr ated, but the study designs are haphazard – often evaluating constructivist teachin g methods with objectivist outcomes. Technology enhancements are being utilized in diete tics education with generally positive results. In fact, a new type of dietetic internship has been developed that is offered at a distance. No research is available, h owever, on the effectiveness of this new

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39 dietetics education program. It is hoped that this study will add to the existing body of knowledge on distance learning and dietetics educat ion by examining student outcomes in the distance learning, dietetic internship.

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40 Chapter Three Methodology The focus of this study was on the internship compo nent of dietetics education. Specifically, the purpose of this study was to comp are student outcomes in the newest type of dietetic internship, delivered via distance learning, to student outcomes in traditional dietetic internships. The study employ ed mixed methods. Tashakkori and Teddlie (2003, p. 711) define mixed methods “as a d esign in which mixing of QUAL and QUAN approaches occurs.” The purpose and rationale for conducting a mixed-methods design in this study was complementary, or “to seek elaboration, enhancement, illustration, clarification of the results from one method with the results from the other method” (Greene, Caracelli, & Graham, 1989, p. 259) Specifically, a sequential explanatory design was used. As noted by Tashakkor i and Teddlie (2003, p. 223), “this design is characterized by collection and analysis of quantitative data followed by the collection and analysis of qualitative data.” Tria ngulation was one strategy used during this study to contribute to the richness of the fin dings (Tashakkori & Teddlie, 2003). Triangulation, which is the use of different method s to research the same issue, can assist in enriching findings by providing different perspe ctives (Crane, 2004). In this study, preparedness for practice was studied by both surve y and interview. The following research questions were addressed: a) Does the reg istration exam pass rate differ between distance learning and traditional dietetic internships? b) Do program graduates of distance learning and traditional dietetic inter nships differ in their assessment of their

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41 preparation for practice? c) Do supervisors of grad uates of distance learning and traditional dietetic internships differ in their as sessment of graduates’ preparation for practice? 4) How do graduates, their supervisors, a nd program directors of distance learning and traditional dietetic internships evalu ate interns’ experience and preparation for practice? The study was divided into three phases as noted in Table I. Phase 1 of the study was the recruitment of dietetic internship director s to solicit program pass rate and information. Phase 2 of the study, or the quantita tive phase, was the survey of graduates and their supervisors. Phase 3, or the qualitative phase, was the interviews with graduates, their supervisors, and program directors of traditional and distance learning dietetic internships. Table 1. Study Phases PHASE QUANTITATIVE vs QUALITATIVE PARTICIPANTS INSTRUMENT PROCEDURE Phase 1: RD Pass Rates & Program Information Quantitative Dietetic Internship Directors Review – “Program information & registration pass rate” All 13 DL directors & matched traditional internship directors Phase 2: Level of Perceived Preparation Quantitative Graduates of traditional & distance learning internships and their supervisors Surveys – “Graduate/ Supervisor Survey on Preparedness for Practice” Directors from Phase 1 were mailed surveys for distribution to recent graduates & their supervisors Phase 3: Perceived Preparation & Curricular Experience Qualitative Graduates, Employers & Directors of both types of internships Interview Those indicating willingness to participate on survey were contacted by phone

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42 Quantitative Research Design. The quantitative portion of the research utilized a non-experimental, survey design. According to Ary et al. (2002), sur veys permit the researcher to summarize the characteristics of different groups o r to measure their attitudes and opinions toward some issue. Specifically, a cross-s ectional survey, one in which the information is collected at one point in time, was administered (Creswell, 1998). Weaknesses of survey research designs include a lac k of control, randomization, and manipulation (Gay & Airasian, 2000). Mailed survey s were the data-gathering technique utilized in this survey design. Email surveys were not used in this study in order to protect confidentiality of participants. Procedure. For the quantitative portion of this pragmatic stu dy, the positivist paradigm was employed (Tashakkori & Teddlie, 2003). In this paradigm, research starts with theories and uses deductive logic to move to p redictions of outcomes. Objective data collection and inquiry are goals of this paradigm ( Tashakkori & Teddlie, 2003). This was the theoretical framework that was utilized to obta in the registration exam pass rates and levels of preparation for practice. A non-experimental design was used to gather data on the registration exam pass rates and level of preparation. In Phase 1 of the s tudy, internship directors were recruited to participate in the study. Internship directors were contacted by phone to obtain program information, using the Program Information and Registration Exam Pass Rate Review (Appendix I), and willingness to participate in th e study. All distance dietetic internship directors were asked to participate. Tr aditional internships were then matched to distance learning programs based on size, geogra phy, institution type, and emphasis

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43 area and the directors were asked to participate. In Phase 2 of the study, the participating programs’ graduates and the graduates’ supervisors of the internship programs were surveyed on the graduates’ level of preparation for practice. Because of confidentiality issues, internship directors were asked to mail the surveys, Graduate Survey on Preparedness for Practice (Appendix II), to their graduates. Graduates were also mailed the survey, Supervisor Survey on Preparedness for Practice (Appendix III), to be given to their first supervisor after graduation. The re searcher coded the surveys and the internship directors were asked to record the name of the participants with their corresponding code number. I provided preaddressed envelopes with prepaid postage. All surveys were mailed back to me. I monitored res ponses by code number and then asked the program directors to send follow-up surve ys to non-responders. Instruments. The surveys, Graduate Survey on Preparedness for Practice and Supervisor Survey on Preparedness for Practice were used to collect data for the quantitative portion of the study and are included in Appendices A C. Currently, there is no standardized tool available to gather data on graduates’ and their supervisors’ perception of interns’ level of preparation for pra ctice. However, it is common for dietetic internships to gather these data to assess program outcomes. As such, I reviewed current surveys from dietetic internships and devel oped surveys for use in this study. The surveys address the construct of preparation for pr actice in dietetics by asking questions reflecting key elements of preparedness in dietetic s. I conducted a pilot test consisting of two graduates, their supervisors, and two program d irectors with the developed survey to assess for face validity and revised as recommended

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44 Participants. The participants of this study were the directors o f dietetic internships, graduates of dietetic internships, and supervisors of the dietetic internship graduates. In Phase 1 of the study, the dietetic i nternship directors were contacted by phone. Because there are only thirteen distance lea rning dietetic internships, all directors of the distance learning internships were asked to participate. Therefore, the directors who chose to participate are the population sample for the phenomenon under study. I used homogeneous case sampling to select the tradit ional dietetic internship directors to be in the study. The matched traditional dietetic i nternship directors were then asked to participate. Table II details participation by programs. A tot al of 13 distance learning dietetic internship programs and 15 traditional dietetic int ernship programs were asked to participate in the study. Of the 26 program direct ors contacted: five distance learning programs and seven traditional programs agreed and participated in the study; one distance learning program director refused to parti cipate; four distance learning program directors and three tradition program director did not return calls or emails; one distance learning program did not meet study criteria; and t wo distance learning programs and five traditional programs agreed to participate but no s urveys were received from their program constituents. This represents a 46% partic ipation rate. The traditional programs were matched to the distance learner programs based on size, emphasis area, academic affiliation, and length of the program. The progra ms were not matched by age due to the newness of the distance-learning programs. In fact the average age of the traditional programs was 18 years old and the average age of th e distance-learning programs was 5 years old.

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45 Table 2. Participation by Programs Participation Status Distance Programs Traditional Programs Total Agreed & Participated 5 7 12 Refused to Participate 1 0 1 Did Not Return Calls/Emails 4 3 5 Did Not Meet Study Criteria 1 0 1 Agreed to Participate but No Surveys Received 2 5 7 Total 13 15 26 Phase 2 of the study consisted of surveys with grad uates and their supervisors. This phase of the study employed purposive sampling Purposive sampling is “sampling in which the researcher uses some criterion or purp ose to replace the principle of canceled random errors” (Tashiorkkori & Teddlie, 20 03, p. 279). Purposive sampling was used to provide maximum insight and understandi ng by selecting cases that best illuminate the question under study (Tashiorkkori & Teddlie, 2003). The dietetic internship directors from Phase 1 were asked to mai l the Graduate Survey on Preparedness for Practice (Appendix II) and the Supervisor Survey on Preparedness for Practice (Appendix III), to all their graduates from the pa st three years. Due to confidentiality issues, graduates were asked to giv e their first supervisor after graduation the Supervisor Survey on Preparedness for Practice This again represented a

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46 convenience sampling method. Only graduates and su pervisors from the past three years were included because of the relative newness of th e distance learning dietetic internships. Three hundred forty-five total surveys were sent to program directors for distribution to graduates. A total of 127 surveys were returned. This represents a 37% response rate. Of the 127 completed surveys receive d: 70 were from distance programs and 57 were from the traditional programs. Of the 70 surveys from the distance programs, 44 were from distance graduates and 26 we re supervisors of distance graduates. Of the 57 surveys from the traditional programs, 37 were from traditional graduates and 20 were supervisors of traditional gr aduates. Figure I is a graphic presentation of the survey participation. Figure 1 Survey Participation TOTAL SURVEYS 127 DISTANCE SURVEYS 70 DISTANCE GRADUATES 44 DISTANCE SUPERVISOR 26 TRADITIONAL SURVEYS 57 TRADITIONAL GRADUATES 37 T RADITIONAL SUPERVISORS 20

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47 There is no information available on the non-respon ders. Communication with program directors, graduates and supervisors sugges t several potential reasons for nonresponse. First, many responders, especially dista nce-learners, indicated a preference for electronic surveys and communication. Despite pilo ting the survey and interview questions among multiple individuals, this preferen ce was only brought to the researcher’s attention after the study had already begun. Another potential reason for program directors not participating is that the stu dy took place during intern selection, a very busy time for program directors. Though the s urvey period was extended, this still may have had a negative impact on the willingness t o participate. Another potential reason for lack of response is the circuitous study design. Surveys were sent to program directors who mailed them to graduates, who in turn gave surveys to their employers. There were many steps where a breakdown in the proc ess could occur by mistake or by choice – for example, a graduate not wanting to giv e a survey to his or her supervisor. A final potential reason for non-response is over-sur veying. It is common for graduates and their supervisors to receive surveys from their int ernship program in an effort to measure program outcomes. The researcher offered to share the program-specific results so these results could be used in lieu of an additional prog ram survey. Analysis. Statistical analyses was performed using SAS (Stat istical Analysis System) software (version 9.1.3, SAS is a registere d trademark of SAS Institute, Cary, NC). Descriptive statistics were generated on popu lation characteristics and include measures of central tendency (mean, median, and mod e), variability (standard deviation, variance, and range), and distribution (skewness an d kurtosis). For research question 1, registration exam pass rate percentages were compar ed using student t-tests and non-

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48 parametric t-test equivalents to test for significa nt differences in pass rates between the two groups (distance learning and traditional). For research questions 2 and 3, preparedness was as sessed using the survey questions A – G on parameters of preparedness: abil ity to communicate, ability to provide comprehensive nutrition therapy, ability to counsel patients, ability to manage foodservice systems, clinical judgment, independenc e, and work ethic. Table 3 summarizes the research questions with their corres ponding measure and analysis. Specifically, responses to questions A G from the Graduate Survey on Preparedness for Practice were used to answer research question 2, graduates ’ assessment of their preparation for practice. Specifically, responses to questions A G from the Supervisor Survey on Preparedness for Practice were used to answer research question 3, supervisors’ assessment of graduates’ preparation f or practice. Survey responses were compared using student t-test s and non-parametric t-test equivalents to test for significant differences in preparedness between the two groups (distance learning and traditional). The independe nt variable was the type of internship. The dependant variables were the preparedness param eters on the survey: ability to communicate, ability to provide comprehensive nutri tion therapy, ability to counsel patients, ability to manage foodservice systems, cl inical judgment, independence, and work ethic. I began by examining the integrity of the data, looking for such issues as data input errors, which may be identified by data in a different format or extreme outliers. I then looked at the data for the three formal assump tions of the student t-test, equality of covariance matrices, independence of vectors and mu ltivariate normality. Significance was set at P<.05.

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49 Table 3. Research Question Analysis Research Question Measure Analysis Does the registration exam pass rate differ between distance learning and traditional dietetic internships? RD pass rate percentages Student t test, non-parametric equivalent tests Do program graduates of distance learning and traditional dietetic internships differ in their assessment of their preparation for practice? Questions A – G on Graduate Survey on Preparedness for Practice Student t test, non-parametric equivalent tests Do supervisors of graduates of distance learning and traditional dietetic internships differ in their assessment of graduates’ preparation for practice? Questions A – G on Supervisor Survey on Preparedness for Practice Student t test, non-parametric equivalent tests How do graduates, their supervisors, and program directors of distance learning dietetic internships evaluate interns’ curricular experience and preparation for practice? Interview questions Constant comparative analysis and developing interpretations Qualitative Research Design. For the qualitative portion of this pragmatic study the constructivist paradigm was employed (Tashakkori & Teddlie, 2003). In this paradigm, research starts with data gathering and uses inductive logic to mov e to inferences or theory. Tashakkori & Teddlie (2003) acknowledge subjective point of vi ew and value-bound inquiry as part of this paradigm. This was the methodology used fo r this phase of study.

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50 The qualitative phase of the study employed a descr iptive research design. The phenomenon studied or focus of inquiry is perceived preparation and curricular experiences from a dietetic internship. Interviewi ng was the data collection method. Procedure. Telephone interviews were conducted to obtain perc eptions of the curricular experiences and preparation for practice The Phase II survey to program directors, graduates, and their supervisors include d a question on willingness to participate in an interview. Individuals from each subgroup were interviewed: a) distance learning dietetic internship graduates; b) initial supervisors of distance learning dietetic internship graduates; c) program directors of dista nce learning dietetic internships; d) traditional dietetic internship graduates; e) initi al supervisors of traditional dietetic internship graduates; and f) program directors of t raditional dietetic internships. The goal was to reach data saturation (Ary, Jacobs, & Razavi eh, 2002.) Foundation questions were sent to participants in advance with the respo nses used to guide the interview as described in the Qualitative Instrument section. I conducted the interviews of the graduates, their supervisors, and program directors and attempted to play a neutral role. Probes and member checks were also used. Appropriate approvals were obtained as explained in the Ethical Considerations section. I began examining my biases and assumption s, brainstorming, creating questions for the interviews, and negotiating entry into the research as explained in the final section. Member checks, or questions to confirm tha t interpretations and themes were accurate, were employed during the interviews. Als o, at the end of the interviews, I asked the participants whether I had accurately des cribed their experience. After

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51 conducting the interviews, content analysis was use d to interpret the data. I first categorized interview responses into different them es as described in the analysis section. Interviews. Interviews were used to collect data for the qualit ative portion of this study. Interviews provide detailed information on overall themes and consisted of oneto-one interaction between the researcher and the p articipant (Tashakkori & Teddlie, 2003). The use of interviews in this study provided perceptions on the curricular experiences and preparation for practice. I conduc ted semi-structured interviews. Program directors, graduates, and graduate supervis ors from distance learning dietetic internships were interviewed by phone regarding the ir perceived preparation and curricular experiences in the dietetics internship program. The interviews were recorded. Interviewees were informed that their names and tit les would not be used in the study and all audiotapes and records would be destroyed at th e conclusion of the study. After arranging dates and times convenient for the partic ipants, I sent the preliminary, openended questions to the interviewees prior to the sc heduled interviews. This allowed interviewees more time to reflect upon their experi ences and the questions served as a guide during the interview. The interview guides a re included in Appendices D, E, and F. The interviews with the graduates began with in troductions and warm-up questions such as which program the graduate attended and why This was followed by the two open-ended, preliminary questions sent to the parti cipants in advance: (1) “How would you describe your internship experience?” and (2) “ How well did your internship prepare you for practice?” The interviews with the supervi sors of dietetic internship graduates began with introductions and warm-up questions such as how long the supervisor has been at his or her current worksite and a descripti on of the facility. This was followed by

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52 the two open-ended questions sent to the participan ts in advance: (1) “How well was this employee prepared to practice in their current posi tion?” and (2) “How does this employee’s preparation compare to other employees?” The interviews with the program directors of dietetic internships began with how lo ng the internship director has been in charge of the program and a description of the prog ram. This was followed by the two open-ended questions sent to the participants in ad vance: (1) “How would you describe the internship curriculum?” and (2) “How well are y our graduates prepared to practice in their first dietitian position?” Again, these ques tions were provided to interviewees in advance to allow them time to formulate their respo nses. These questions served as a beginning for the interviews, with the interviewees ’ responses integrated into more probing questions. Follow up questions were also i ncorporated and included “Did you/the graduate meet the core competencies for ent ry-level dietitians?” “Would you recommend this internship?” “How would you assess the graduate’s clinical judgment?” “What are the strengths of the internship?” “What a re the weaknesses of the internship?” I paraphrased and summarized respondent’s comments as a form of member check. The interview concluded with a debriefing, “I have no f urther questions. Do you have anything you want to bring up or ask about?” Inter views were primarily informal and lasted on average for forty-five minutes. Participants. Phase 3 consisted of interviews with graduates, the ir supervisors, and program directors of distance learning dietetic internships. The Phase 2 survey to graduates and supervisors included a question on wi llingness to participate in an interview. A sample or selection from those indica ting willingness was contacted for interviews. Therefore, convenience sampling was us ed for this phase of the study.

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53 Interviews were conducted from February 28, 2006 un til May 8, 2006. I conducted the interviews by phone with all conversa tions being recorded. Informed consent was obtained from all participants. A tota l of 43 interviews were completed: 3 traditional program directors, 3 distance program d irectors, 10 traditional graduates, 6 traditional supervisors, 11 distance graduates, and 10 distance supervisors. The goal was to reach data saturation, or the point at which no new information is forthcoming from additional participants (Ary, Jacobs, & Razavieh, 2 002). Analysis. After the interviews, the data was organized and pr epared for analysis. All interview notes were transcribed. I then revie wed the transcripts to identify keywords and passages used frequently by interviewees. Some data analysis occurred during the interview, as suggested by Bogdan and Biklen (1998) but detailed analysis began with coding a posteriori or after the data from the surveys and interviews is collected (Tashakkori & Teddlie, 2003). Coding is “the proce ss of organizing the material into chunks before bringing meaning to those chunks” (Ro ssman & Rallis, 1998, p. 171). The constant comparison method, which combines inductiv e category coding with simultaneous comparison of units of meaning obtaine d, was the strategy used for identifying themes in this study (Ary et al, 2002, p. 267). Thus, the keywords and phrases were used to group together related text fr agments from the transcripts, and these, in turn, were reviewed to develop themes within the data. Because of the large numbers of interviews, qualitative software, Ethnograph, wa s used. Finally, the connections, important differences, and common aspects among the themes were interpreted and generalizations made.

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54 Ethical Issues Participation was on a voluntary basis. I obtained informed consent and provided participants with risks and benefits of participati on. Participants were not exposed to discomfort, deception, or risks during this study. Further, the confidentiality and privacy of participants was maintained. No cultural and lan guage barriers as encountered. I had approval from University of South Florida’s Institutional Review Board (IRB # 104254). All surveys and interview data is l ocked in my office. Also, I performed the transcribing and data entry. Transcripts do not include any names and titles. In addition, all interview tapes were destroyed after transcription. Biases, assumptions and negotiation of entry As a researcher, I have participated in quantitativ e research but have no prior experience in qualitative research. I have complet ed one course on mixed methods research. Thus, readers should be aware of the res earcher’s limited experience in qualitative methods. I am a dietitian who has worked in clinical practi ce for 16 years. For 15 of those years, I served as a preceptor for dietetic interns in a traditional dietetic internship. I am now a dietetic internship director. In addition, I have taught nutrition courses using traditional educational methodology at a community college for 11 years. Recently, I began teaching nutrition courses via distance learn ing for a local university and community college. These experiences provide me wi th insight into both teaching modalities. In addition to this work and teaching experience, I am also a site visitor for the Commission on Accreditation for Dietetics Educa tion. As such, I felt comfortable asking dietetic educators to participate in this re search.

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55 I expected to find no significant differences betwe en traditional program graduates and distance learning program graduates o n the traditional registration exam pass rates. The registration exam for dietitians i s the traditional measure used in dietetics education to assess student outcome. The exam, how ever, is an objectivist measure and therefore may not capture more affective outcomes s uch as clinical judgment and feelings of competency. The level of preparation from the s urveys and description of preparation and curricular experiences from the interviews will be used to assess more affective outcomes and also help judge the equivalency of cur ricular experiences and student outcomes. I anticipated the distance learner progr am graduates would report feeling slightly less prepared than traditional program gra duates. Regardless, I was open-minded to participants’ responses from the survey and inte rviews. Summary A mixed methods design was employed to study stude nt outcomes in distance learning versus traditional dietetic internships. Phase I of the study was the recruitment of dietetic internship directors and obtaining prog ram information including registration exam pass rates. Phase II of the study was the qua ntitative collection of internship directors’, program graduates’, and their superviso rs’ level of perceived preparation by survey. Phase III of the study was the qualitative phase and consisted of interviews with internship directors, program graduates, and their supervisors on perceived preparation and curricular experience. Results were analyzed a s summarized in Table 3 for significant differences in student outcomes between the two types of dietetic internships.

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56 Chapter Four Results Research Question One The first research question was “Does the registrat ion exam pass rates differ between distance learning and traditional dietetic internships?” To address this question, pass rates were obtained from participating dieteti c internships programs using the “ Program Information and Registration Exam Pass Rate Review. ” Pass Rate Descriptive Statistics Responses were received from 5 distance programs and 7 traditional programs. The pass rate percentage frequencies for each type of program are presented in Table 4. Table 4. Frequency Table of Program Pass Rates Pass Rate Percentage Distance Traditional Total 90-100 1 3 4 80-89 1 2 3 70-79 2 1 3 60-69 1 1 2 Totals 5 7 12 The five distance programs had a mean pass rate per centage of 77.00% with a standard deviation of 10.44 and a variance of 109.0 0. A test of normality indicated that

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57 this sample was not representative of a normally di stributed population (p <.0001). The seven traditional programs had a mean pass rate per centage of 83.86% with a standard deviation of 14.55 and a variance of 211.81. A tes t of normality indicated that this sample was also not representative of a normally di stributed population (p <.0001). The mean pass rate percentage and associated descriptiv e statistics are presented in Table 5. Table 5. Pass Rate Mean Percentages and Normality Tests Program Type N Mean % Std Dev Variance Skewness Kurtosis t-Value Pr > |t| Distance 5 77.00 10.44 109.00 -0.69 1.91 16.49 < .0 001 Traditional 7 83.86 14.55 211.81 -0.74 -0.70 15.24 < .0001 Pass Rate Inferential Statistics. The sample mean of the registration exam pass rate for the traditional program participants was 6 .86 percentage points higher than the sample mean for the distance program participants. This corresponds to a medium effect (d = .54). Even though the sample means differed, I did not want to conclude the population means differ without a formal test of th e null hypothesis. The null hypothesis was tested with a t-test, which makes the assumptio ns of independence, equal variance, and normality. The assumption of independence was not violated because participants were not assigned to control or treatment groups by the researcher, but rather by their acceptance into the internship. The F-test (p > .5 419) for equal variance was not significantly different so the equal variance assum ption was not violated and as such, I selected the t-test result corresponding to equal v ariances. It is conceivable that the samples did not come from normal distributions but the t-test is robust for violations of the normality assumption. The results of this t-te st showed a t-value = -0.90 with a Pr >

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58 |t| = 0.3911. This test indicated I am unable to r eject the null hypothesis that the two means are equal. The corresponding conclusion is th at there no significant difference in the population mean pass rates between the traditio nal programs and the distance programs. Due to the small sample size, a non-parametric t-te st equivalent (SAS npar1way) was conducted providing both a two-way analysis of variance and a Wilcoxon Rank Sums test. These tests require no assumptions abou t the samples and have been shown to be almost as powerful as a t-test (Cody and Smith, 2006). As Table 6 indicates, both the non-parametric two-way analysis of variance (p > .3 911) and the Wilcoxon Rank Sums tests (p > .3901) agreed with the parametric t-test that there is no statistically significant difference in means on pass rates for distance and traditional programs. These nonparametric results would indicate that the original t-test was valid. Table 6. Parametric t-test and Non-Parametric Test Results f or Pass Rates Distance versus Traditional Programs Test Means Value P > |t| t-test Distance = 77.00 Traditional = 83.86 t = -0.9000 0.3911 two-way ANOVA Distance = 77.00 Traditional = 83.86 F = 0.8035 0.3911 Wilcoxon Rank Sums Distance = 5.30 Traditional = 7.36 Z = -0.8948 0.3901 There are several possible explanations for the la ck of significant difference between the two groups on the registration exam. T he primary reason there might not have been a significant difference in pass rates be tween traditional and distance learning

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59 internship is small sample size (n=12). Without a large sample, there was not enough power to detect potential differences. A second re ason there might not have been a significant difference in pass rates between the tw o groups is lack of sensitivity in the measurement instrument. The registration exam for dietitians is a purely objectivist outcome measure, testing knowledge of nutrition sci ence and dietetics. It is difficult in this multiple-choice format, however, to test appli cation and clinical judgment. Therefore, the registration exam pass rate may not be a sensitive enough measure of competency to practice as a dietitian. The final r eason there might not be a significant difference in pass rates between the two groups is because of a similar knowledge base. Dietetic students acquire most of the knowledge bas e required for the registration exam in the undergraduate program. That knowledge is th en applied and refined during the dietetic internship. The dietetic students in this study all came from traditional undergraduate dietetic programs. The differences b etween groups came later, in the type of internship. Therefore, the similarity in underg raduate programs, where the knowledge base is acquired for the registration exam, may acc ount for the lack of significant differences between graduates of the two groups in registration exam pass rates. Regardless of the test sensitivity or similar knowl edge base, the study demonstrated equivalency in the registration exam pass rates bet ween the two types of internships. Research Question Two The survey entitled Graduate Survey on Preparedness for Practice was used to answer the research question: “Do program graduate s of distance learning and traditional dietetic internships differ in their assessment of their preparation for practice?” The surveys asked graduates for their undergraduate gra de point average (GPA) and to rank

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60 the perceived level of competence using a Likert sc ale of 1 to 5, with 1 representing poor and 5 representing excellent, on the following ques tions: question A ability to communicate effectively and problem solve; question B ability to provide comprehensive nutrition care in a variety of settin gs; question C ability to counsel patients, individually and in groups; question D ability to use techniques and tools to effectively manage foodservice systems; question E clinical judgment; question F independence and self-direction; and question G w ork ethic and professionalism. Results of the survey questions are presented in Ta ble 7. Overall, traditional graduates had a significantly higher GPA than dista nce graduates. Traditional graduates ranked themselves significantly higher on their abi lity to communicate, ability to provide nutrition therapy, clinical judgment, independence, and work ethic. There was no significant difference on the ability to counsel pa tients and ability to manage foodservice systems.

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61 Table 7. Parametric t-test Results for Survey Results in Dis tance Graduates versus Traditional Graduates Survey Question N Mean Equality of Variance tvalue Pr > |t| 2-way ANOVA Wilcoxon GPA 44 distance 37 traditional 3.31 3.67 0.0020 -4.75 <.0001* < .0001* .0002* Question A: Ability to communicate 44 distance 37 traditional 4.34 4.62 0.1768 -2.02 0.0465* 0.0465* 0.0301* Question B: Ability to provide nutrition therapy 44 distance 37 traditional 3.91 4.35 0.8328 -2.72 0.0081* 0.0081* 0.0094* Question C: Ability to counsel patients 44 distance 37 traditional 3.95 4.27 0.7974 -1.72 0.0885 0.0885 0.0711 Question D: Ability to manage foodservice systems 44distance 37 traditional 3.82 4.11 0.2696 -1.52 0.1336 0.1336 0.0985 Question E: Clinical judgment 44 distance 37 traditional 3.86 4.38 0.2702 -3.25 0.0017* 0.0017* 0.0033* Question F: Independence 44 distance 37 traditional 4.66 4.89 0.0001 -2.21 0.0304* 0.0386* 0.0420* Question G: Work ethic 44 distance 37 traditional 4.70 4.89 0.0038 -2.02 0.0467* 0.0500 0.0333* Indicates significance at the .05 level

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62 Student t-tests were conducted comparing GPA and qu estion responses specifically for distance graduates versus traditio nal graduates to answer the research question. The same three assumptions for t-test (i ndependence, equal variance and normality) applied as discussed earlier. The GPA s ample mean for the traditional program graduates was .36 point higher than the GPA sample mean for the distance program graduates. This corresponds to a medium ef fect (d=1.04). A t-test was conducted to test the null hypothesis. The F-test (p = 0.0020) for equal variance was significant; therefore non-equal variance was assum ed and I selected the t-test result corresponding to unequal variances. The results of this t-test showed a t-value = -4.75 with a Pr > |t| = < .0001. This test indicated tha t I am able to reject the null hypothesis that the two means are equal. The corresponding co nclusion is that traditional program graduates have a statistically significant higher G PA mean than the distance program graduates. Both the nonparametric two-way analysis of variance (p < 0.001) and the Wilcoxon Rank Sums tests (p = 0.002) agreed with th e parametric t-test that traditional program graduates have a significantly higher GPA t han distance program graduates. For question A, ability to communicate effectively and problem solve, the sample mean for the traditional program graduates was .31 point higher than the sample mean for the distance program graduates. This corresponds t o a small effect size (d=.45). A t-test was conducted to test the null hypothesis. The F-t est (p = 0 .1768) for equal variance was not significant; therefore equal variance was assum ed and I selected the t-test result corresponding to equal variances. The results of t his t-test showed a t-value = -2.02 with a Pr > |t| = 0 .0465. This test indicated that I a m able to reject the null hypothesis that the two means are equal. The corresponding conclusion i s that traditional program graduates

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63 scored themselves significantly higher on their abi lity to communicate effectively and problem solve than did the distance program graduat es. Both the nonparametric two-way analysis of variance (p = 0.0465) and the Wilcoxon Rank Sums tests (p = 0.0301) agreed with the parametric t-test. For question B, ability to provide comprehensive nu trition care, the sample mean for the traditional program graduates was .44 point higher than the sample mean for the distance program graduates. This corresponds to a medium effect size (d= .60). A t-test was conducted to test the null hypothesis. The F-t est (p = 0 .8328) was not significant; therefore; equal variance was assumed and I selecte d the t-test result corresponding to equal variances. The results of this t-test showed a t-value = -2.72 with a Pr > |t| = 0 .0081. This test indicated I am able to reject the null hypothesis that the two means are equal. The corresponding conclusion is that the tra ditional program graduates scored themselves significantly higher on ability to provi de comprehensive nutrition care than did the distance program graduates. Both the nonpa rametric two-way analysis of variance (p = 0.0081) and the Wilcoxon Rank Sums te sts (p = 0.0094) agreed with the parametric t-test. For question C, ability to counsel, the sample mean for the traditional program graduates was .32 point higher than the sample mean for the distance program graduates. This corresponds to a small effect size (d= .38). A t-test was conducted to test the null hypothesis. The F-test (p = 0 .7974) was not signi ficant; therefore equal variance was assumed and I selected the t-test result correspond ing to equal variances. The results of this t-test showed a t-value = -1.72 with a Pr > |t | = 0 .0885. This test indicated I am unable to reject the null hypothesis that the two m eans are equal. The corresponding

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64 conclusion is that traditional program graduates di d not differ from the distance program graduates in their ratings on ability to counsel. Both the nonparametric two-way analysis of variance (p = 0.0885) and the Wilcoxon Rank Sums tests (p = 0.0711) agreed with the parametric t-test. For question D, ability to effectively manage foods ervice systems, the sample mean for the traditional program graduates was .29 point higher than the sample mean for the distance program graduates. This corresponds t o a small effect size (d= .34). A t-test was conducted to test the null hypothesis. The F-t est (p = 0 .2696) was not significant; therefore equal variance was assumed and I selected the t-test result corresponding to equal variances. The results of this t-test showed a t-value = -1.52 with a Pr > |t| = < .1336. This test indicated I am unable to reject t he null hypothesis that the two means are equal. The corresponding conclusion is that traditi onal program graduates did not differ from the distance program graduates in their rating s on ability to effectively manage foodservice systems. Both the nonparametric two-wa y analysis of variance (p = 0.1336) and the Wilcoxon Rank Sums tests (p = 0.0985) agree d with the parametric t-test. For question E, clinical judgment, the sample mean for the traditional program graduates was .52 point higher than the sample mean for the distance program graduates. This corresponds to a medium effect size (d= .73). A t-test was conducted to test the null hypothesis. The F-test (p = 0 .2702) was not signi ficant; therefore equal variance was assumed and I selected the t-test result correspond ing to equal variances. The results of this t-test showed a t-value = -3.25 with a Pr > |t | = 0.0017. This test indicated that I am able to reject the null hypothesis that the two mea ns are equal. The corresponding conclusion is that traditional program graduates sc ored themselves significantly higher on

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65 clinical judgment than did the distance program gra duates. Both the nonparametric twoway analysis of variance (p = 0.0017) and the Wilco xon Rank Sums tests (p = 0.0033) agreed with the parametric t-test. For question F, independence, the sample mean for t he traditional program graduates was .52 point higher than the sample mean for the distance program graduates. This corresponds to a medium effect size (d= .73). A t-test was conducted to test the null hypothesis. The F-test (p <.0001) was significant; therefore non-equal variance was assumed and I selected the t-test result correspond ing to unequal variances. The results of this t-test showed a t-value = -2.21 with a Pr > |t| = 0 .0304. This test indicated that I am able to reject the null hypothesis that the two means are equal. The corresponding conclusion is that traditional program graduates sc ored themselves significantly higher on independence than did the distance program graduate s. Both the nonparametric two-way analysis of variance (p = 0.0386) and the Wilcoxon Rank Sums tests (p = 0.0420) agreed with the parametric t-test. For question G, work ethic and professionalism, the sample mean for the traditional program graduates was .19 point higher than the sample mean for the distance program graduates. This corresponds to a small eff ect size (d= .44). A t-test was conducted to test the null hypothesis. The F-test (p = 0.0038) was significant; therefore non-equal variance was assumed and I selected the t -test result corresponding to unequal variances. The results of this t-test showed a t-v alue = -2.02 with a Pr > |t| = 0 .0467. This test indicated that I am able to reject the nu ll hypothesis that the two means are equal. The corresponding conclusion is that tradit ional program graduates scored themselves significantly higher on work ethic and p rofessionalism than did the distance

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66 program graduates. Both the nonparametric two-way analysis of variance (p = 0.0500) and the Wilcoxon Rank Sums tests (p = 0.0333) agree d with the parametric t-test. In summary, results indicated the traditional prog ram graduates rated their preparedness higher on the following competencies a nd areas of practice: 1) ability to communicate effectively, 2) ability to provide comp rehensive nutrition care, 3) clinical judgment, 4) independence and work ethic, and 5) pr ofessionalism. There was no significant difference found on the questions conce rning ability to counsel patients and ability to effectively manage foodservice systems. I speculated that no significant difference was found on ability to counsel patients due to the wording of the question. The term “counsel” denotes a higher-level skill for which many of the entry-level graduates may not have felt as well prepared. The meaning of the survey question was, in fact, ability to “educate” patients, which is mo re of an entry-level skill and one for which graduates may feel more competent. The findi ng of no significant difference regarding the ability to effectively manage foodser vice systems was not surprising. Though CADE considers this to be an entry-level ski ll, it is very common for graduates to feel unprepared because foodservice is not a com mon interest in dietetics practice and it is a skill that takes a great deal of experience to acquire. Overall, the graduate survey results on perception of preparation for practice d id not support equivalency between the two types of internships. Traditional internship g raduates rated themselves significantly higher in most constructs of preparedness. Research Question Three The survey entitled Supervisor Survey on Preparedness for Practice was used to answer the research question “Do supervisors of gr aduates of distance learning and

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67 traditional dietetic internships differ in their as sessment of their preparation for practice?” The surveys asked supervisors to rank the perceived level of their employee’s competence using a Likert scale of 1 to 5, with 1 r epresenting poor and 5 representing excellent, on the following questions: question A ability to communicate effectively and problem solve; question B ability to provide comprehensive nutrition care in a variety of settings; question C ability to counse l patients, individually and in groups; question D ability to use techniques and tools to effectively manage foodservice systems; question E clinical judgment; question F independence and self-direction; and question G work ethic and professionalism. T he supervisors of graduates were their first employers after the internship. None of the supervisors worked with the graduates during the internship, only after they had complete d their program and become registered dietitians. Results of the survey questions are presented in Ta ble 8. Overall, traditional supervisors ranked their employees significantly hi gher on their ability to communicate, ability to provide nutrition therapy, ability to co unsel patients, ability to manage foodservice systems, clinical judgment, and indepen dence. There was no significant difference on only one construct – work ethic and p rofessionalism. Student t-tests were conducted comparing survey que stion responses specifically for distance program supervisors versus traditional program supervisors to answer the research question. The same three assumptions for t-tests (independence, equal variance and normality) applied as discussed earlier. For q uestion A, ability to communicate effectively and problem solve, the sample mean for the traditional supervisors was .67 point higher than the sample mean for the distance program graduates. This corresponds

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68 to a large effect size (d = .96). A t-test was con ducted to test the null hypothesis. The Ftest (p = 0 .0029) was significant; therefore non-e qual variance was assumed and I selected the t-test result corresponding to unequal variances. The results of this t-test showed a t-value = -3.35 with a Pr > |t| = 0 .0018. This test indicated that I am able to reject the null hypothesis that the two means are e qual. The corresponding conclusion is that supervisors of traditional program graduates s cored the graduates significantly higher on ability to communicate effectively and problem s olve than did the supervisors of distance program graduates. Both the nonparametric two-way analysis of variance (p = 0.0035) and the Wilcoxon Rank Sums tests (p = 0.008 4) agreed with the parametric t-test.

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69 Table 8. Parametric t-test Results for Survey Results in Dis tance Supervisors versus Traditional Supervisors Survey Question N Mean Equality of Variance tvalue Pr > |t| 2-way ANOVA Wilcoxon QuestionA: Ability to communicate 26 distance 20traditional 3.72 4.54 0.0029 -3.35 0.0018* 0.0035* 0.0084* QuestionB: Ability to provide nutrition therapy 26 distance 20traditional 3.58 4.43 0.0842 -3.53 0.001 0.001* 0.0015* QuestionC: Ability to counsel patients 26 distance 20traditional 3.60 4.38 0.1769 -3.43 0.0013* 0.0013* 0.0035* QuestionD: Ability to manage foodservice systems 26 distance 20traditional 3.15 4.61 0.0077 -7.64 <.0001* < .0001* < .0001* QuestionE: Clinical judgment 26 distance 20traditional 3.46 4.28 0.3248 -3.41 <.0014* 0.0014* 0.0023* QuestionF: Independence 26 distance 20traditional 3.92 4.68 < .0001 -2.26 0.0305* 0.0477* 0.0500* QuestionG: Work ethic 26 distance 20traditional 4.51 4.85 < .0001 -1.32 0.1970 0.2422 0.2736 *Indicates significance at the .05 level

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70 For question B, ability to provide comprehensive nu trition care, the sample mean for the traditional supervisors was .78 point highe r than the sample mean for the distance program graduates. This corresponds to a large eff ect size (d = 1.08). A t-test was conducted to test the null hypothesis. The F-test (p = 0 .0842) was not significant; therefore equal variance was assumed and I selected the t-test result corresponding to equal variances. The results of this t-test showed a t-value = -3.53 with a Pr > |t| = 0 .0010. This test indicated that I am able to rejec t the null hypothesis that the two means are equal. The corresponding conclusion is that su pervisors of traditional program graduates scored the graduates significantly higher on ability to provide comprehensive nutrition care than did the supervisors of distance program graduates. Both the nonparametric two-way analysis of variance (p = 0.0 010) and the Wilcoxon Rank Sums tests (p = 0.0015) agreed with the parametric t-tes t. For question C, ability to counsel, the sample mean for the traditional supervisors was .73 point higher than the sample mean for the d istance program graduates. This corresponds to a large effect size (d = 1.11). A t -test was conducted to test the null hypothesis. The F-test (p = 0 .1769) was not signi ficant; therefore equal variance was assumed and I selected the t-test result correspond ing to equal variances. The results of this t-test showed a t-value = -3.43 with a Pr > |t | = 0 .0013. This test indicated that I am able to reject the null hypothesis that the two mea ns are equal. The corresponding conclusion is that supervisors of traditional progr am graduates scored the graduates significantly higher on ability to counsel than did the supervisors of distance program graduates. Both the nonparametric two-way analysis of variance (p = 0.0010) and the Wilcoxon Rank Sums tests (p = 0.0035) agreed with t he parametric t-test.

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71 For question D, ability to effectively manage foods ervice systems, the sample mean for the traditional supervisors was 1.34 point s higher than the sample mean for the distance program graduates. This corresponds to a large effect size (d = 2.19). A t-test was conducted to test the null hypothesis. The F-t est (p = 0 .0077) was significant; therefore non-equal variance was assumed and I sele cted the t-test result corresponding to unequal variances. The results of this t-test show ed a t-value = -7.64 with a Pr > |t| = <0.0001. This test indicated that I am able to rej ect the null hypothesis that the two means are equal. The corresponding conclusion is t hat supervisors of traditional program graduates scored the graduates significantly higher on ability to effectively manage foodservice systems than did the supervisors of dis tance program graduates. Both the nonparametric two-way analysis of variance (p < .00 01) and the Wilcoxon Rank Sums tests (p < .0001) agreed with the parametric t-test For question E, clinical judgment, the sample mean for the traditional supervisors was .79 point higher than the sample mean for the d istance program graduates. This corresponds to a large effect size (d = 1.06). A t -test was conducted to test the null hypothesis. The F-test (p = 0 .3248) was not signi ficant; therefore equal variance was assumed and I selected the t-test result correspond ing to equal variances. The results of this t-test showed a t-value = -3.41 with a Pr > |t | = < .0014. This test indicated that I am able to reject the null hypothesis that the two mea ns are equal. The corresponding conclusion is that supervisors of traditional progr am graduates scored the graduates significantly higher on clinical judgment than did the supervisors of distance program graduates. Both the nonparametric two-way analysis of variance (p = 0.0014) and the Wilcoxon Rank Sums tests (p = 0.0023) agreed with t he parametric t-test.

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72 For question F, independence, the sample mean for t he traditional supervisors was .50 point higher than the sample mean for the dista nce program graduates. This corresponds to a medium effect size (d = .64). A t -test was conducted to test the null hypothesis. The F-test (p < .0001) was significant ; therefore non-equal variance was assumed and I selected the t-test result correspond ing to unequal variances. The results of this t-test showed a t-value = -2.26 with a Pr > |t | = 0 .0305. This test indicated that I am able to reject the null hypothesis that the two mea ns are equal. The corresponding conclusion is that supervisors of traditional progr am graduates scored the graduates significantly higher on independence than did the s upervisors of distance graduates. Both the nonparametric two-way analysis of variance (p = 0.0477) and the program Wilcoxon Rank Sums tests (p = 0.0500) agreed with the parame tric t-test. For question G, work ethic and professionalism, the sample mean for the traditional supervisors was .18 point higher than t he sample mean for the distance program graduates. This corresponds to a small eff ect size (d = .37). A t-test was conducted to test the null hypothesis. The F-test (p < .0001) was significant; therefore non-equal variance was assumed and I selected the t -test result corresponding to unequal variances. The results of this t-test showed a t-v alue = -1.32 with a Pr > |t| = 0 .1970. This test indicated that I am unable to reject the null hypothesis that the two means are equal. The corresponding conclusion is that superv isors of traditional program graduates did not score the graduates significantly higher on work ethic and professionalism than did the supervisors of distance program graduates. Both the nonparametric two-way analysis of variance (p = 0.2422) and the Wilcoxon Rank Sums tests (p = 0.2736) agreed with the parametric t-test.

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73 In summary, results indicated the supervisors of tr aditional program graduates rated their employees higher on the following compe tencies and areas of practice: 1) ability to communicate effectively, 2) ability to p rovide comprehensive nutrition care, 3) ability to counsel patients, 4) ability to effectiv ely manage foodservice systems, 5) clinical judgment, and 6) independence. There was no significant difference found on the question concerning work ethic and professionalism. I have speculated that no significant difference was found on work ethic and professionalism because these are attitudinal characteristics acquired from observati on of preceptors rather than skills. It was somewhat surprising that the distance learning graduates did not score higher on the question regarding independence since the type of i nternship requires a significant amount of independence and autonomy. This lack of difference could be related to the difference in students’ GPA. Overall, the employer survey on perception of preparation for practice did not support equivalency between th e two types of internships. Supervisors of traditional internship graduates rat ed the graduates significantly higher in most constructs of preparedness. Research Question Four The final research question was “How do graduates, their supervisors, and program directors of dietetic internships evaluate interns’ curricular experience and preparation for practice?” To address this questio n, telephone interviews were conducted with graduates, their supervisors, and program dire ctors of traditional and distance learning dietetic internships. A total of 43 inter views were completed: a) 10 traditional dietetic internship graduates; b) 11 distance learn ing dietetic internship graduates; c) 6 supervisors of traditional dietetic internship grad uates; d) 10 supervisors of distance

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74 learning dietetic internship graduates; e) 3 tradit ional dietetic internship program directors; and f) 3 distance learning dietetic inte rnship program directors. Traditional and Distance Learning Graduate Intervie ws. Twenty-one graduates participated in the interviews. There were a total of 11 questions asked during the graduate interview. The first question was “Why di d you choose the dietetic internship program you attended?” The results are summarized in Table 9. When multiple reasons were cited, they were all coded. The reason for ch oosing the dietetic internship program cited most often by distance graduates was the loca tion (7). As one distance learning graduate said, “I didn’t have a choice, this was th e only type of internship I could do.” The reasons for choosing the dietetic internship pr ogram cited most often by traditional dietetic internship graduates were reputation (6) a nd location (6). Table 9. Graduate Interview Question #1 Codes Distance Graduates Traditional Graduates Flexibility 1 0 Awarded prior experience credit 2 0 Location 7 6 Master’s credit 1 2 Reputation 0 6 Curriculum emphasis 1 1 The next question was “How well did the internship prepare you for your first job?” The results are summarized in Table 10. D istance graduates most often reported feeling “adequately prepared” for practice (5). Th ree distance graduates felt “well

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75 prepared,” while three distance graduates reported feeling “not prepared.” Traditional graduates most often cited feeling “well prepared” for practice (7). Two traditional graduates felt “extremely prepared.” One traditiona l graduate only felt “adequately prepared” and no traditional graduates reported fee ling “not prepared.” Table 10. Graduate Interview Question #2 Codes Distance Graduates Traditional Graduates Extremely Prepared 0 2 Well Prepared 3 7 Adequately Prepared 5 1 Not Prepared 3 0 The next question was “What was your first job afte r the internship?” Graduates reported working in a variety of areas: c linical, specialty positions such as renal and intensive care, long-term care, community administration, research, and other (private practice and grocery store consultant). T he results are summarized in Table 11. Distance dietetic internship graduates most often r eported working in clinical (4) and specialty positions (2), including renal and intens ive care. Traditional dietetic internship graduates most often reported working in clinical ( 5) and long-term care (3) positions.

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76 Table 11. Graduate Interview Question #3 Codes Distance Graduates Traditional Graduates Clinical 4 5 Specialty – renal, intensive care 2 0 Long-term care 1 3 Community 1 0 Administrative 1 1 Research 1 0 Other 1 1 The next question was “What do you see as the progr am’s strengths?” The results are summarized in Table 12. When multiple reasons were cited, they were all coded. Supportive & responsive faculty (8), flexibility (6 ), and organization (4) were the strengths most often reported by distance graduates Variety of experiences (5), supportive & responsive faculty (4), preceptors (3) and thorough preparation (3) were the strengths most often reported by traditional gradua tes.

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77 Table 12. Graduate Interview Question #4 Codes Distance Graduates Traditional Graduates Thorough Preparation 0 3 Variety of experiences 1 5 Flexibility 6 0 Learner-driven 1 0 Organized 4 0 Supportive & Responsive Faculty 8 4 Didactic curriculum 2 0 Preceptors 1 3 Emphasis 0 1 The next question was “What do you see as the progr am’s weaknesses?” The results are summarized in Table 8. When multiple r easons were cited, they were all coded. Weaknesses most often reported by distance graduates were: need for prior work experience (3), need for motivation/initiative (3), expensive (3), lack of communication & support (2), preceptors (2), and lack of collabor ation/interaction (2). Weaknesses reported by traditional graduates were the need for specialty training (4), which included pediatrics and eating disorders, and curriculum (2) Two traditional graduates reported “no weaknesses.”

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78 Table 13 Graduate Interview Question #5 The next question was “How do you rate your clinica l judgment?” The results ranged from excellent to good, fair or poor and are summarized in Table 14. Distance graduates most often reported having good (5) or fa ir (5) clinical judgment. Traditional graduates most often reported having excellent (6) or good clinical judgment (4). Codes Distance Graduates Traditional Graduates Lack of communication & support 2 0 Didactic Curriculum 3 2 Intern needs prior experience 1 0 Intern needs motivation/initiative 3 0 Expensive 3 1 Preceptors 2 0 Lack of interaction/collaboration 2 0 Need more specialties 0 4 Too long 0 1 No master’s credit 0 1 None 0 2

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79 Table 14. Graduate Interview Question #6 Codes Distance Traditional Excellent 0 6 Good 5 4 Fair 5 0 Poor 1 0 Question seven was “Would you recommend this intern ship program?” The answers were yes/no and are presented in Table 15. All (11) distance graduates said they recommend their internship program, but 9 of 11 rec ommended with certain conditions, such as an experienced, mature, disciplined, or ass ertive learner. As one distance graduate said, “These programs are not for traditio nal students who need a lot of structure. You have to have experience and be very assertive.” All (10) traditional graduates said they would recommend their internshi p program, none with conditions. Table 15. Graduate Interview Question #7 Codes Distance Graduates Traditional Graduates Yes 11 10 No 0 0 Question eight was “Did you experience any technica l or logistical problems during the internship?” The answers were yes/no an d are presented in Table 16. Five distance graduates reported difficulties that inclu ded securing practice sites and non-

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80 functioning discussion boards. The other distance graduates (6) did not experience problems. None of ten the traditional graduates re ported problems. Table 16. Graduate Interview Question #8 Codes Distance Graduates Traditional Graduates Yes 5 0 No 6 10 The next question was “Do you feel you had a compar able preparation to other entry-level dietitians?” The answers ranged from “ above average preparation”, “comparable preparation”, “less prepared” to “not p repared” and are summarized in Table 17. Distance graduates most often reported “comparable preparation” (5) or “less prepared” (5). Traditional graduates most often re ported “above average preparation” (7) or “comparable preparation” (3). Table 17. Graduate Interview Question #9 Codes Distance Traditional Above Average Preparation 1 7 Comparable Preparation 5 3 Less Prepared 5 0 Not Prepared 0 0 The next question was “Did you feel competent to p ractice?” The answers were once again yes/no and are presented in Table 18. N ine distance graduates reported feeling “competent” to practice, while only 2 gradu ates reported feeling “not competent”

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81 to practice. All 10 traditional graduates reported feeling “competent” to practice. Knowing the subject of the research, one of the tra ditional graduates said “I don’t feel I would have been successful without such a structure d environment.” Table 18. Graduate Interview Question #10 Codes Distance Traditional Competent 9 10 Not Competent 2 0 The final question was “Did you feel prepared for t he registration exam?” The answers were yes/no and are presented in Table 19. Ten of eleven distance graduates felt prepared for the exam; while only 1 distance gradua te reported feeling unprepared for the exam. All 10 of the traditional graduates felt pre pared for the registration exam. Table 19. Graduate Interview Question #11 Codes Distance Traditional Yes 10 10 No 1 0 In summary, interviews with graduates revealed seve ral themes. The first theme concerned the reason for selecting the internship p rogram. Distance graduates chose their internship based on location. Many of the distance graduates were older and had family commitments that prohibited them from relocating. Traditional graduates also chose their internship program based on location, but more for location familiarity rather than family commitments. Another reason traditional graduates chose their internship is reputation of

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82 the program. A second theme concerned practice are a. Most of the graduates are working in clinical nutrition areas. More distance graduates, however, are working in specialty positions, which may contribute to their feelings of being less prepared for practice. The next theme was how prepared for prac tice graduates felt. All graduates felt prepared for practice but traditional graduates gen erally reported feeling more prepared. Most graduates felt their clinical judgment was ade quate but traditional graduates typically rated their judgment at a higher level. All graduates felt competent for practice and prepared to take the registration exam for diet itians. However, distance graduates felt less prepared than other entry-level practitio ners and traditional graduates felt better prepared than other entry-level practitioners. The distance graduates feelings of being less prepared and competent may be influenced a lac k of confidence from their selfperception as older students. The fourth theme rel ated to strengths and weaknesses of the program. Both groups of graduates reported support ive and responsive faculty as a strength of the program. Distance graduates also f elt the flexibility of the program was a strength. Several distance graduates actually said it was the flexibility of the program that allowed them to complete an internship. Tradi tional graduates felt the variety of experiences was an additional strength of the progr am. There were no commonalities in program weaknesses. Distance graduates reported ma ny more program weaknesses. The weaknesses were related to: 1) the nature of distan ce learning, such as need for learner initiative, lack of communication, and lack of inte raction; and 2) the newness of the programs (7 years average), such as the curriculum and preceptors. Most traditional graduates reported no weaknesses, which may be rela ted to the fact that most of the traditional programs were well established (18 year s average). The one weakness voiced

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83 by the traditional students is the desire for speci alty training, which is not an entry-level skill. The final theme concerned recommendation o f the internship program. All graduates recommended their programs, but distance graduates recommended their programs for only certain types of learners – more self-directed, experienced learners. In fact, many distance graduates felt that traditional dietetic students might actually be at a disadvantage in the distance environment. Some tra ditional graduates actually said they didn’t feel they would have been successful in a di stance internship. Overall, the interviews with graduates indicate that all graduat es feel prepared and competent for practice but traditional graduates seem to feel bet ter prepared for practice. Traditional and Distance Learning Program Directors Interviews. Six program directors participated in the interviews – 3 from t raditional programs and 3 from distance learning programs. A total of nine questions were posed to the traditional and distance learning program directors during the interviews. T he first question was “How competent/ prepared are your graduates?” Results r anged from “well prepared” to “prepared” and are presented in Table 20. Distan ce program directors felt their graduates were either “well prepared’ (1) or “prepa red” (2). Traditional program directors also felt their graduates were either “we ll prepared” (2) or “prepared” (1). Table 20. Program Directors Interview Question #1 Codes Distance Traditional Well Prepared 1 2 Prepared 2 1

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84 The next question was “What do you feel are the str engths of your program?” When multiple answers were given, all were coded. Results are presented in Table 21. Distance program directors felt the strengths of th eir programs were preceptors (2) and flexibility/individualization (1). Traditional pro gram directors cited their preceptors (2), variety (2), specialty rotation (1) and program emp hasis (1) as the strengths of their programs. Table 21. Program Directors Interview Question #2 Codes Distance Traditional Preceptors 2 2 Flexibility 1 0 Variety 0 2 Specialty Rotation 0 1 Program Emphasis 0 1 Question three asked “What do you feel are the wea knesses of your program?” Results are presented in Table 22. Distance progra m directors cited non-traditional students (2) and quality control (1) as the weaknes ses of their program. Traditional program directors listed the need for more pediatri c experiences (2) and the need for more didactic modules (1) as their program weakness es.

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85 Table 22. Program Directors Interview Question #3 Codes Distance Traditional Non-traditional students 2 0 Quality Control 1 0 Need for more pediatrics 0 2 Enhanced didactic modules 0 1 The next question was “How do you assure equivalent learning experiences for interns?” Results are presented in Table 23. Dis tance program directors all (3) reported using leveling experiences such as worksheets, comp rehensive exam, or online modules to assure equivalency. Traditional program directo rs all (3) reported using the same rotation sites to assure adequacy. Table 23. Program Directors Interview Question #4 Codes Distance Traditional Leveling experiences 3 1 Same rotation sites 0 3 The next question was “How would you rate your gra duates’ clinical judgment?” Results are presented in Table 24. Distance progra m directors rated their graduates’ clinical judgment as “above average” (1) or “entrylevel” (2). Traditional program directors rated their graduates’ clinical judgment as “above average” (2) or “entry-level” (1). No director, either distance or traditional, felt their graduates’ clinical judgment was “below average.”

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86 Table 24. Program Directors Interview Question #5 Codes Distance Traditional Above Average 1 2 Entry-level 2 1 Below Average 0 0 The final question was “How do your graduates comp are to other entry-level practitioners?” Results are presented in Table 25. Distance program graduates felt their graduates were “above average” (1) or “comparable” (2). All traditional program directors felt their graduates were “above average” (3). No director, either distance or traditional, felt their graduates’ clinical judgmen t was “below average.” Table 25. Program Directors Interview Question #6 Codes Distance Traditional Above Average 1 3 Comparable 2 0 Below Average 0 0 Despite the small numbers, interviews with program directors revealed several themes. The first theme concerned preparation for practice. All program directors felt their graduates were prepared/competent for practic e but traditional directors felt their graduates were “well prepared” and had “above avera ge” competency for practice. All program directors felt their graduates had at least entry-level clinical judgment, but traditional directors felt their graduates had “abo ve average” clinical judgment. And all

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87 program directors felt their graduates were at leas t comparable to other entry-level practitioners but traditional program directors fel t their graduates performed above entrylevel practitioners. The next theme addresses prog ram strengths and weaknesses. Both traditional and distance program directors felt the strength of their program is preceptors. An additional strength listed by traditional direct ors was variety of experiences. There were no similarities in program weaknesses. Distan ce directors felt the nature of the nontraditional student is the main weakness of their p rogram. Most of the distance students were older, had more family and work commitments, a nd had been out of school longer. Although these characteristics are typical of dista nce learners, they may have a negative impact on completion of the program. The program w eakness listed most often by traditional program directors was the need for more pediatric training, which again is not an entry-level practice skill. Overall, program di rectors were very proud of their internship programs and felt their students were pr epared for dietetic practice, but traditional program directors felt their graduates had above average preparation. Traditional and Distance Learning Graduate Supervis or Interviews. Sixteen supervisors participated in the survey. There were a total of 8 questions on the Supervisor Interview. The first question was “how well prepared was this employee for practice?” Answers ranged from “well prepared” to “prepared”, to “needed more training” and are presented in Table 26. Three dis tance supervisors felt their employee was “well prepared,” five supervisors felt their em ployee was “prepared”, and two supervisors felt their employee “needed more traini ng.” Five traditional supervisors felt their employee was “well prepared” and only one sup ervisor felt their employee “needed more training.”

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88 Table 26. Supervisors Interview Question #1 Codes Distance Traditional Well Prepared 3 5 Prepared 5 0 Needed more training 2 1 The next question was “How did the graduate’s train ing compare to other entrylevel dietitians?” Answers ranged from “above aver age,” to “comparable,” or “below average” and are presented in Table 27. One distan ce supervisor felt the employee was “above average,” seven felt the employee was “compa rable,” and two felt the employee was “below average.” As one distance supervisor sa id, “I would hire either type of graduate but feel the distance learning graduates n eed a little more work.” Five of the traditional supervisors felt their employees were “ above average,” and only one felt their employee was “below average.” Table 27. Supervisors Interview Question #2 Codes Distance Traditional Above Average 1 5 Comparable 7 0 Below Average 2 1 “Was the graduate competent to practice,” was the next question asked. Answers are presented in Table 28. Nine of the distance superv isors felt the graduate was competent,

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89 while one did not feel the graduate was competent f or entry-level practice. All six of the traditional supervisors felt the graduates were com petent for entry-level practice. Table 28. Supervisors Interview Question #3 Codes Distance Traditional Competent 9 6 Not Competent 1 0 The next question asked the supervisors to list th e graduate’s strengths. When more than one strength was listed, all were coded. Results are presented in Table 29. The strengths listed most frequently by distance su pervisors were independence/maturity (5), counseling skills (2), and clinical skills (2) The strengths listed most frequently by traditional supervisor were independence/maturity ( 3) and clinical judgment (2). Table 29. Supervisors Interview Question #4 Codes Distance Traditional Independent/maturity 5 3 Counseling skills 2 1 Clinical skills 2 1 Clinical judgment 0 2 Program emphasis 1 1 Flexibility 1 0 The next question was “In what areas could the empl oyee have been better prepared?” Results are presented in Table 30. The areas for improvement most frequently cited by supervisors of distance graduat es were medical nutrition therapy skills

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90 (4) and the need for more training in specialty are as such as critical care and renal disease (4). Two of the distance supervisor felt there wer e no areas for improvement. Four of the supervisors of traditional graduates felt there were no areas for improvement. The only areas of improvement cited by traditional supe rvisors were medical nutrition therapy (1) and the need for more training in specialty are as (1). Table 30. Supervisors Interview Question #5 Codes Distance Traditional Medical Nutrition Therapy skills 4 1 More specialty training 4 1 No weaknesses 2 4 Counseling 1 0 Work ethic 1 0 Question six was “How would you rate your employees ’ clinical judgment?” Answers ranged from “above entry-level” to “entry-l evel”, or “below entry-level” and are presented in Table 31. Supervisors of distance gra duates rated their clinical judgment as “above entry-level” (4) and “entry-level” (5). Onl y one supervisor rated the distance graduate’s clinical judgment as “below entry-level. ” Supervisors of traditional graduates rated their clinical judgment as “above entry-level ” (4) or “entry-level” (2). No traditional supervisor felt the graduates’ clinical judgment was “below entry-level.”

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91 Table 31. Supervisors Interview Question #6 Codes Distance Traditional Above entry-level 4 4 Entry-level 5 2 Below entry-level 1 0 The next question asked the supervisor to cite the internship program’s strengths based on their experience with the program graduate Results are presented in Table 32. Distance supervisors most often (6) cited independe nt, self-directed graduates as the program strength. Traditional supervisors most oft en cited above entry-level preparation (3) and a variety of experiences (2) as the interns hip program’s strengths. Table 32. Supervisors Interview Question #7 Codes Distance Traditional Independent/self-directed 6 0 Above entry-level preparation 0 3 Variety of experiences 1 2 Flexibility 1 0 Director 1 0 Structure 1 0 Specialty 0 1 Question eight asked the supervisor to cite the int ernship program’s weaknesses based on their experience with the program graduate Results are presented in Table 33.

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92 Distance supervisors most often cited the need for more clinical training (9) as the program weakness. Most traditional supervisors (4) felt there were “no program weaknesses.” When weaknesses were reported, tradit ional supervisors reported the need for more clinical training (1) and the need for mor e specialty training (1). Table 33. Supervisors Interview Question #8 Codes Distance Traditional Need more clinical training 9 1 Need more specialty training 0 1 Need more monitoring, structure 1 0 No program weaknesses 0 4 The final interview question was “Would you recomme nd this dietetic internship program?” Answers were yes/no and are presented in Table 34. Supervisors of distance program graduates most often recommended the progra m (9); only one supervisor did not recommend the program. “The graduate needed to muc h catch-up work.” All (6) of the supervisors of traditional graduates recommended th e program. Table 34. Supervisors Interview Question #9 Codes Distance Traditional Yes 9 6 No 1 0 In summary, interviews with supervisors of dietetic internship graduates revealed several themes. The first theme concerned preparat ion for practice. All supervisors felt

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93 the graduates were prepared and competent for pract ice, but traditional supervisors rated their graduates “well prepared” and “above average” competency while distance learning supervisors rated their graduates as “average” comp etency. The distance learning supervisors’ responses may have been biased by unde rlying preconceptions about distance internships. Traditional supervisors also ranked graduates’ clinical judgment higher. The next theme related to graduate strengt hs and weaknesses. The common graduate strength cited by all supervisors was inde pendence/maturity. It was expected that the distance graduates would have this listed as a strength, since they tend to be older and more experienced, but it was a surprise that th is was a strength listed for traditional graduates, since they tend to be younger and inexpe rienced. It may be that the internship programs develop students’ maturity. Divergent gra duate strengths were: 1) distance supervisors also ranked the graduates higher in ent ry-level skills such a clinical and counseling; 2) traditional supervisors ranked their graduates higher in the more advanced level skill of clinical judgment. Alternatively, s upervisors of distance programs cited areas for graduate improvement as the need for more medical nutrition therapy while traditional supervisors cited no areas for graduate improvement. The final theme involved program strengths and weaknesses. Based o n their experience with the distant graduate, their supervisors felt the programs’ stre ngth was independent graduates, while supervisors of traditional graduates felt the progr ams strengths were above entry-level preparation and a variety of experiences. Supervis ors of distance graduates felt the program’s primary weakness was the need for more cl inical training, while the most supervisors of traditional graduates cited no progr am weaknesses. As one supervisor said, “Graduates need to be able to hit the ground running.” While distance graduates

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94 may be very independent, they may not have the clin ical skills necessary to “hit the ground running.” The implications of the overall f indings from the interviews with supervisors is all graduates seem to be prepared at the entry-level, but traditional graduates seem to have more advanced preparation an d skills from their supervisors’ perspective. Summary This research project was governed by four question s. The first research question was “Does the registration exam pass rates differ b etween distance learning and traditional dietetic internships?” The results of the study found no significant difference in the pass rates between the traditional programs and the distance programs. The second research question was “Do program graduates of dist ance learning and traditional dietetic internships differ in their assessment of their pre paration for practice?” The study results indicated the traditional program graduates rated t heir preparedness significantly higher on the following competencies and areas of practice : ability to communicate effectively, ability to provide comprehensive nutrition care, cl inical judgment, independence and work ethic, and professionalism. There was no sign ificant difference found on the questions concerning ability to counsel patients an d ability to effectively manage foodservice systems. The next research question wa s “Do supervisors of graduates of distance learning and traditional dietetic internsh ips differ in their assessment of their preparation for practice?” The study results indic ated that supervisors of traditional graduates rated their preparedness significantly hi gher on the following competencies and areas of practice: ability to communicate effectiv ely, ability to provide comprehensive nutrition care, ability to counsel patients, abilit y to effectively manage foodservice

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95 systems, clinical judgment, and independence. Ther e was no significant difference found on the question concerning work ethic and professio nalism. The final research question was “How do graduates, their supervisors, and progr am directors of dietetic internships evaluate interns’ curricular experience and prepara tion for practice?” The overall findings from the interviews with graduates indicat ed that all graduates felt prepared and competent for practice, but traditional graduates f elt better prepared for practice. The overall findings from the interviews with program d irectors were all program directors felt their students were prepared for dietetic prac tice, but traditional program directors felt their graduates had above average preparation. The overall findings from the interviews with supervisors were all graduates seem to be prepared at the entry-level, but traditional graduates seem to have more advanced pr eparation and skills from their supervisors’ perspective.

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96 Chapter Five Conclusions The purpose of this study was to compare outcomes i n distance learning dietetic internships to traditional dietetic internships. S pecifically, the pass rate of the registration exam for dietitians, levels of perceived preparatio n for practice, and evaluation of curricular experiences were compared. The study wa s divided into three phases. The first phase of the study was the recruitment of die tetic internship directors and program information, including registration exam pass rate. The second phase of the study consisted of surveys on preparedness for practice t o the graduates and supervisors. The third phase of the study involved interviews of tra ditional and distance program graduates, their supervisors, and internship direct ors on curricular experience and preparation. This chapter will integrate the discussion of the d ata collected and analyzed with the theoretical underpinnings of the Equivalency Th eory, and consists of three sections. A discussion of findings for each research question is included in the first section of this chapter. The second section presents the implicati ons for practice. Recommendations for further study are featured in the third section. Discussion of Findings for Research Questions In this study, there were four research questions guiding the comparison of student outcomes in distance learning dietetic inte rnships to student outcomes in traditional dietetic internships.

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97 Pass rate data was used to answer the research ques tion, “Does the registration exam pass rate differ between distance learning and traditional dietetic internships?” The registration exam for dietitians is a national, val idated test. Program pass rate is the primary objective measure used to evaluate student outcome in dietetic education. Student t-test demonstrated no significant differen ce in total pass rates between traditional dietetic internships and distance diete tic internships. A larger sample size or specific information on domain scores may have dete cted more differences between groups. The answer to this research question is pa ss rates do not differ between traditional and distance dietetic internship progra ms. Therefore, results of this research question support equivalency between traditional di stance learning graduates using this objective measure. This finding, however, is most l ikely attributed to similar undergraduate training rather than the difference i n internship program types. GPA and question responses from the surveys were us ed to answer the research questions “Do program graduates of distance learnin g and traditional dietetic internships differ in their assessment of their preparation for practice?” and “Do supervisors of graduates of distance learning and traditional diet etic internships differ in their assessment of graduates’ preparation for practice?” Although developed for this study, the study survey was based on surveys used in the f ield and was specific for major areas and skills of dietetic practice. Student t-tests w ere conducted comparing the responses from traditional internship participants with dista nce internship participants overall, as well as comparing traditional graduate with distanc e graduates and traditional supervisors with distance supervisors. Survey numbers were lar ger so the measure had a greater power to detect differences. Overall comparison de monstrated traditional program

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98 graduates had a significantly higher GPA. In the c omparison of traditional graduates with distance graduates, traditional graduates scor ed themselves significantly higher than distance graduates on all constructs of preparation except ability counsel patients and ability to effectively manage foodservice systems. In the comparison of supervisors of traditional graduates with supervisors of distance graduates, supervisors of traditional graduates scored traditional graduates significantl y higher on all constructs of preparation except professionalism. The answer to both of thes e research questions is that graduates and their supervisors differ in their assessment of graduates’ preparation, with traditional graduates ranked significantly higher in virtually all areas of preparation. Therefore, the results for these two research questions do not sup port equivalency in preparation for practice. Interviews were conducted to answer the final rese arch question, “How do graduates, their supervisors, and program directors of dietetic internships evaluate interns’ curricular experience and preparation for practice?” All graduates were very positive about their curricular experiences. Tradi tional graduates felt preceptors and the variety of experiences were the strengths of their programs. Distance graduates also felt preceptors were the strength their program, as well as the flexibility of the program. In fact, the flexibility of the distance program allow ed these graduates access to a dietetic internship that they didn’t have through traditiona l programs. All of the graduates recommended their respective programs, but distance graduates recommended their programs only for self-directed, experienced learne rs. All graduates felt prepared for entry-level dietetic practice. Traditional graduat es, however, felt they were better prepared for practice, were more competent than oth er entry-level practitioners, had a

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99 higher level of clinical judgment, and were better prepared for the registration exam than the distance graduates reported. Results from the interviews with the graduates’ supervisors were similar to the results of the grad uate interviews. All supervisors listed independent graduates as a strength of the program. Supervisors of traditional graduates also listed clinical judgment, advanced practice tr aining, and variety of experience as strengths of the traditional programs. There were no similarities in perceived program weaknesses. Supervisors of distance program gradua tes felt clinical training was a weakness of the distance programs. Supervisors of traditional graduates cited no program weakness. Supervisors of distance graduate s felt their employees were prepared and competent for entry-level practice with the cor responding clinical judgment. Supervisors of traditional graduates, however, felt their employees’ clinical judgment, preparation and competence were above entry-level p ractice. Results from interviews with the program directors reflected themes found i n interviews with graduates and their supervisors. All program directors, distance and t raditional, felt preceptors are the strength of their programs. Directors of distance programs cited certain student qualities as the weakness of their programs while directors o f traditional programs cited limited pediatric experience as the weakness of their progr ams. Distance program directors felt their graduates were prepared and competent at the entry-level of practice. Traditional program directors felt their graduates’ clinical ju dgment, preparation, and competence was above entry-level practice. Therefore, the ans wer to this study question is that traditional graduates, their supervisors, and progr am directors differ from distance graduates, their supervisors, and program directors in their evaluation of interns’ curricular experience and preparation for practice. All interview participants evaluated

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100 graduates as prepared for entry-level practice but traditional graduates were evaluated as prepared at a higher level of dietetic practice. T he results for this research question, then, do not support equivalency in preparation for pract ice either. In conclusion, the results of this research do not support equivalency in preparation for practice between distance and tradi tional dietetic internships. Although there was no significant difference in pass rates f or the registration exam, significant differences were found in constructs of dietetic pr actice based on surveys with graduates and their supervisors. Common themes from intervie ws with graduates, their supervisors, and program directors confirmed survey results show ing graduates of traditional dietetic internship were prepared at a higher level of pract ice, competence and clinical judgment. These differences in preparation were despite a com mon undergraduate preparation, which suggests the differences can be attributed to the different type of internship. Implications and Recommendations for Future Practic e This study addressed the equivalency of student out comes in distance versus traditional dietetic internships. Overall, the stu dy results did not support equivalent outcomes between traditional and distance learning internships. One of the primary consumers of dietetics education is the employer of the graduates. Due to issues such as staffing and higher patient acuity, employers are e xpecting graduates’ clinical judgment and competence to be at a level more advanced than entry-level. Traditional internship programs seem to be meeting this expectation while distance programs are not. The question then, is how to build an internship progra m that provides graduates with the appropriate level of clinical judgment and competen ce. Themes from the research can be used to build a distance program that provides equi valent outcomes. One important

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101 theme that was identified from the interviews conce rned equivalent learning experiences. Many traditional program directors reported using l eveling experiences such as case scenarios in lieu of same-site rotations to assure equivalent learning experiences among students within the program. Case scenarios not on ly develop clinical competence, but they also aid in the development of clinical judgme nt. It appears that leveling experiences among internships might help improve eq uivalency of program outcomes between programs. Therefore, one practice recommen dation to assure equivalency of experiences for interns is for all internships to i nclude leveling experiences. Related to this theme is the issue of equivalent pr eceptors. Interviews in this study indicated that preceptors can be a major stre ngth of an internship program. Several programs reported using preceptor training to impro ve compliance with practice expectations. Preceptor training should include me thods to develop clinical judgment such as processing nutritional interventions. In f act, CADE is developing a national preceptor training and certification program. Ther efore, a second practice recommendation is for preceptor training to be stan dard in all dietetic internships. The study results confirmed the literature reviewed on distance learners. This new subpopulation of higher education learners tend to be older, have many conflicting responsibilities, and need flexible learning experi ences. Because of these characteristics and the nature of distance learning, the onus for l earning is placed on the student. Despite this recognition of the characteristics of a distance learner, interviews in this study revealed that these student characteristics a re seen as a program weakness because they can make it more difficult to succeed in an in ternship. The distance learning programs have built ultimate flexibility within the ir programs to help with these

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102 characteristics but more needs to be done. The rec ommendation for future practice, then, is to use the literature on distance learning along with program experience to determine characteristics associated with success in the dist ance learning internships. These characteristics can then be used to develop a scree ning method that ascertains a student’s appropriateness for a distance learning internship programs. One of the reasons this research topic was untaken is a perceived bias by traditional dietetic educators against the distance learning programs. That bias against distance learning programs was also evident in the interviews with employers of internship graduates. This is an important point f or students to be aware of when choosing the type of dietetic internship they wish to complete. The implication is that graduates of distance learning programs may experie nce prejudice when applying for dietitian positions. The Task Force on Dietetics Education is recommendi ng major alterations in the models of dietetics education. Rather than the tra ditional model of a bachelor’s degree in dietetics followed by a dietetic internship, the ne w model calls for the coordination of the internship within the course work, culminating in a master’s degree. All programs will be university-based and have affiliations with hosp ital sites. This new model could foreseeable increase the use of distance learning d ietetic internships because of limitations in the number of clinical sites immedia tely around the university. With an increase use of distance internships, it is critica l that the distance learning dietetic internships assure learning and outcomes equivalent to traditional dietetic internships.

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103 Recommendations for Future Research The major recommended areas for research involve t he registration exam pass rates. The current study only contained overall pa ss rates for 12 programs. Further research with a larger sample size is needed to inc rease the power to detect potential differences between groups. Additionally, research on the domain scores would be beneficial to determine more subtle differences bet ween groups. Another recommendation for further research concern s the age of the internship programs. Age of a program can have a significant impact on the success of the program due to the experience of the preceptors and interns hip director. The distance learning internship programs in this study were younger than the traditional internship programs. Further research is needed to compare student outco mes between distance and traditional programs that are more similar in age. Conclusion In summary, the results of this study did not demon strate equivalency between the two types of dietetic internship in preparation for entry-level dietetic practice. There were no significant differences between the two typ es of internship programs in pass rates. Based on the survey and interview findings, distance-learning graduates appear to be prepared and competent for practice as an entrylevel dietitian. Traditional internship graduates in this study, however, appeared to have a higher level of preparation and competence for practice and clinical judgment. The recommendations for future practice and research provided may help lessen the differenc es found between the two types of internship programs. Overall, this study will aid the field and accrediting body of The

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104 American Dietetic Association to demonstrate the ef fectiveness and appropriateness of this new form of internship.

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105 References Allen, M., Mabry, E., Mattrey, M, Bourhis, J, Titsw orth, S and Burrell, N. (2004). Evaluating the effectiveness of distance learn ing: A comparison using meta-analysis. Journal of Communication 54, 402-420. Allen, M., Bourhis, J., Mabry, E., Emmers-Sommer, T ., Titsworth, S., Burrell, N., Mattrey, M., Crowell, T., Bakkar, A., Hamilton A., Robertson, T., Scholl, J., & Wells, S. (2002). Comparing student satisfacti on of distance education to traditional classrooms in higher education: A meta-analysi s. American Journal of Distance Education 16, 83-97. American Dietetics Association. (2003). Dietetics education and the needs for the future: HOD Report Chicago: ADA. American Dietetics Association. (2004). What is ADA? Retrieved February 5, 2004 from http://www.eatright.org/Public/index_adafaq.cfm Apple, M.W. (1991). The new technology: Is it part of the solution or part of the problem in education? Computers in Schools 8(1), 74-81. Ary, D., Jacobs, L. C., & Razavieh, A. (2002). Introduction to research in education. Belmont, CA: Wadsworth. Barron, A. (1999). A teacher’s guide to distance learning Accessed 2/18/2004 from http://fcit.usf.edu/distance/chp3.htm Blackboard, Inc.(2002.). Product Learning System. Retrieved from http:// www.blackboard.com/docs/wp/LSR6WP.pdf

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108 Galusha, J. M. (1997). Barriers to learning in distance education Accessed 2/22/2004 at http://www.infrastruction.com/barriers.htm Gates, G. and Sandoval, W. (1998). Teaching multisk illing in dietetics education. J Am Diet Assoc 98, 278-284. Gay, L. R., & Airasian, P. W. (2000). Educational research: Competencies for analysis and application (6th ed.) Englewood Cliffs, NJ: Prentice Hall. Greene, J. C., Caracelli, V. J., & Graham, W. F. (1 989). Toward a conceptual framework for mixed-method evaluation designs. Educational Evaluation and Policy Analysis 11 255-274. Hofmann, D. W. (2002). Internet-based distance lear ning in higher education. Tech Directions 62(1), 28-32. Holmberg, B. (1989). Theory and practice of distance education London: Routland. Holmberg, B. (1995). The evolution of the character and practice of distance education. Open Learning, 10, 47-53. Howell, S. L., Williams, P. B., and Lindsay, N. K. (2003). Thirty-two trends affecting distance education: an informed foundation for strategic planning. Online Journal of Distance Learning Administration, 6(3) 34-53. Israel, G.D. (1992). Determining sample size. Florida Cooperative Extension Service Fact Sheet PEOD-6. Johnson, B., & Christensen, L. (2000). Educational research: Quantitative and Qualitative approaches Boston: Allyn & Bacon. Keegan, D. (1986). The foundations of distance learning London: Croom Helm.

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109 Keegan, D. (1995). Distance education technology fo r the new millennium: Compressed video teaching. ERIC ED 389931. Klas, K.J. (2004). Will e-learning improve clinical judgment? BMJ 328, 1147-1150. Knapper, C. (1988). Lifelong learning and distance education. American Journal of Distance Education 2(1), 63-72. Lincoln, Y. S., & Guba, E. G. (1985). Naturalistic inquiry Beverly Hills, CA: Sage. Litchfield, R. E., Oakland, M. J., and Anderson, J. (2002). Promoting and evaluating competence in on-line dietetics education. J Am Diet Assoc 102, 1455-1458. Lyons, J., Miller, M. and Milton, J. (1998). Learni ng with technology: use of case-based physical and computer simulations in professio nal education. Contemp Nurse 7, 3539. Malloy, S.E. and DeNatale, M.L. (2001). Online crit ical thinking: A case study analysis. Nurse Educator 26, 191-197. Mattheos, N., Schittek, M., Attstrom, R., and Lyon, H. C. (2001). Distance learning in academic health education: a literature review Eur J Dent Educ 5, 67-76. McRoy, R.G. (1996) Qualitative research Retrieved March 27, 2004 from httnrrr Moore, M.G. (1994). Autonomy and interdependence. The American Journal of Distance Education 8, 1-5. National Center for Education Statistics. (2003). Distance Education at Degree-Granting Postsecondary Institutions: 2000–2001 Washington, DC: U.S. Department of Education.

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110 National Center for Education Statistics. (1999). Distance Education in higher education institutions Washington, DC: U.S. Department of Education. National Council for Accreditation of Teacher Educa tion [NCATE] Task Force on Professional Development. (1997). Technology a nd the new professional teacher: Preparing for the 21st century classroom. Retrieved March 27, 2004 from http://www.ncate.org/accred/projects/tech/tech-21.h tm National Education Association. (2000). A survey on traditional and distance learning higher education members. Accessed 2/22/04 from http://www.nea.org/he/abouthe/dlstudy.pdf Olson, T. M. and Wisher, R. A. (2002). The effectiv eness of web-based instructions: an initial inquiry. International Review of Research in Open and Distan ce Learning 3(2), 2-17. Onwuegbuzie, A. J., and Teddlie, C (2003). A framework for analyzing data in mixed methods research. In Tashakkori, A. & Teddlie, C. (2003). Handbook of mixed methodology in social & behavioral research Thousand Oaks: Sage. Peters, O. (1988). Distance teaching and industrial production: A comparative interpretation in outline. In Distance Education: International Perspectives New York: Routledge. Petracchi, H.E. (2000). Distance education: What do our students tell us? Research on Social Work Practice 10(3), 362-376. Phipps, R., & Merisotis, J. (1999). What’s the difference? A review of contemporary research on the effectiveness of distance lear ning in higher education Washington, DC: The Institute for Higher Education Policy.

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111 Raidl, M.A., Wood, O. B., Lehman, J. D., Evers, W. D. (1995). Computer-assisted instruction improves clinical reasoning skills o f dietetics students. J Am Diet Assoc 95 (8): 868-873. Reinert, B. R, & Fryback, P. B. (1997). Distance le arning and nursing education. Journal of Nursing Education 36 421-427. Rivera, J.C. and Rice, M.L. (2002). A comparison of student outcomes & satisfaction between traditional & web based course offerin gs. Online Journal of Distance Learning Administration V, 3-15. Rossman, G.B., and Rallis, S.F. (1998). Learning in the field: An introduction to qualitative research Thousand Oaks, CA: Sage. Russell, T. L. (1999). No significant difference phenomenon Montgomery, AL: IDECC. Schoech, D. (2000). Teaching over the internet: res ults of one doctoral course. Research on Social Work Practice 10(4), 467-486. Simonson, M. (1995). Does anyone really want to lea rn at a distance? Tech Trends 40, 12. Simonson, M., Schlosser, C. and Hanson, D. (2002). Theory and distance education: A new discussion. In ASHE Reader Distance Education: Teaching and Learni ng in Higher Education Boston: Pearson Custom Publishing. Siegel, E., Jennings, J. G., & Conklin, J. (1998). Distance learning in social work education: Results and implications of a natio nal survey. Journal of Social Work Education, 34 (1), 71-80.

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112 Skipper, A. & Lewis, N. M. (2005). A look at the e ducational preparation of the healthdiagnosing and treating professionals: Do diet itians measure up? J Am Diet Assoc 105, 420-427. Stark, J.S. and Lattuca, L.R. (1997). Recurring deb ates about the college curriculum. In Shaping the College Curriculum: Academic Plans in A ction Boston: Allyn & Bacon. Strauss, W.V.and Dahlheimer, S.S. (1998). A study o f the effects of computerized multimedia technology on anatomical and physiolo gical concept retention. J Am Diet Assoc 98 (9): 39. Sweet, R. (1986). Student drop-out in distance educ ation: an application of Tinto’s Model. Distance Education 7, 201-213. Tashakkori, A. & Teddlie, C. (2003). Handbook of mixed methodology in social & behavioral research Thousand Oaks: Sage. Thomas, M. (2002). Faculty Satisfaction. Sloan-C View 1(2): 6. Twigg, C.A. (2003). Improving quality and reducing cost: Designs for effective learning. Change, 35 (4), 22-29. Turner, R. E., Evers, W. D., Wood, O. B., Lehman, J D., and Peck, L. W. (2000). Computer-based simulations enhance clinical expe rience of dietetics interns. J Am Diet Assoc 100(2): 183-190. U.S. Bureau of Labor. (2004). Occupational Outlook Handbook 2003-2004. Retrieved February 28, 2005 from http://bls.gov/oco/ocos077.htm Wardlaw, G.M., & Smith, A.M.. (2005). Contemporary Nutrition 6th edition. New York: McGraw-Hill.

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114 Appendices

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115 Appendix A: Program Information and Registration E xam Pass Rate Review Dear Internship Directors, Thank you for your willingness to participate in th is study. I am studying outcomes in distance learning and traditional dietetic internsh ips. Please provide the following information on your program. I. Program Demographics a. Name of Program: b. Location (city and state): c. Number of interns per class: Number of classes eac h year: d. Affiliation (circle one) – hospital university othe r _________ e. Age of Program: II. Program Characteristics a. Type of Program (circle one) – traditional distanc e learning b. Emphasis area (generalist, nutrition therapy, food service, community, sports nutrition, research, other): c. Program Completion Rate: d. Registration Exam Pass Rate for past five years:

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116 Appendix B: Graduate Survey on Preparedness for Pra ctice Please check the appropriate column to indicate how you perceive your level of preparation for professional practice after graduat ing from your internship using the 5point scale shown below. 1. Poor 2. Below Average 3. Satisfactory 4. Above Average 5. Excellent ABILITIES & SKILLS: 1 2 3 4 5 N/A A. ability to communicate effectively and problem s olve B. ability to provide comprehensive nutrition care in a variety of settings C. ability to counsel patients, individually and in groups D. ability to use techniques and tools to effective ly manage foodservice systems E. clinical judgment F. independence and self-direction G. work ethic and professionalism Undergraduate Grade Point Average: ______ Area of Practice: ______a. Clinical Dietetics ______b. Community Practice ______c. Foodservice Systems Management ______d. Education/Research ______e. Other Would you further assist in the study of student ou tcomes in dietetic internship by agreeing to a 30 minute phone interview to discuss your experiences and opinions on the internship? If so, please provide you name and con tact information below. Thanks! Name: Phone: Email: Address:

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117 Appendix C: Supervisor Survey on Preparedness for Practice Please check the appropriate column to indicate how you perceive your employee’s level of preparation for professional practice after grad uating from their internship using the 5point scale shown below. 1. Poor 2. Below Average 3. Satisfactory 4. Above Average 5. Excellent ABILITIES & SKILLS: 1 2 3 4 5 N/A A. ability to communicate effectively and problem s olve B. ability to provide comprehensive nutrition care in a variety of settings C. ability to counsel patients, individually and in groups D. ability to use techniques and tools to effective ly manage foodservice systems E. clinical judgment F. independence and self-direction G. work ethic and professionalism Graduate’s Area of Practice: ______a. Clinical Dietetics ______b. Community Practice ______c. Foodservice Systems Management ______d. Education/Research ______e. Other Would you further assist in the study of student ou tcomes in dietetic internship by agreeing to a 30 minute phone interview to discuss your experiences and opinions on the internship? If so, please provide you name and con tact information below. Thanks! Name: Phone: Email: Address:

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118 Appendix D: Program Director Interview Guide BRIEFING: Thank you for your willingness to participate and b e interviewed. I am studying outcomes in distance learning and traditio nal dietetic internships. This interview will take approximately 30 minutes. INTRODUCTION: Introduction of interviewer. Ask the participate to introduce themselves. WARM-UP : How long have you been in charge of the program? Ca n you give an overview of your program? PRELIMINARY QUESTIONS : We are going to start first with the two questions I sent you in advance. QUESTION #1 Could you describe the internship curriculum? QUESTION #2 How well are your graduates prepared for practice i n clinical, food service and community? FOLLOW-UP QUESTIONS What do you see as the program’s strengths? What do you see as the program’s weaknesses? Describe areas of the curriculum that could be impr oved. How do you assure equivalency of learning experienc es among interns? Do you feel your students are competent to practice ?

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119 Appendix D: (Continued) How would you rate the graduates’ clinical judgment ? How do you feel your graduates’ skills compare to o ther graduates?

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120 Appendix E: Graduate Interview Guide BRIEFING: Thank you for your willingness to participate and b e interviewed. I am studying outcomes in distance learning and traditio nal dietetic internships. This interview will take approximately 30 minutes. INTRODUCTION: Introduction of interviewer. Ask the participate to introduce themselves. WARM-UP : (Graduate) Which program did you attend and when. Why did y ou choose the program? PRELIMINARY QUESTIONS : We are going to start first with the two questions I sent you in advance. QUESTION #1 Describe your internship experience. QUESTION #2 How well did the internship prepare you for your fi rst job? What was your first job? FOLLOW-UP QUESTIONS What do you see as the program’s strengths? What do you see as the program’s weaknesses? Describe the most beneficial learning experience th at prepared you for practice. Describe areas of practice that you needed more lea rning experiences. How would you rate your clinical judgment upon grad uation? Describe any technical or logistical problems encou ntered during the internship.

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121 Appendix E: (Continued) Describe areas of the curriculum that could be impr oved. Would you recommend this internship? Why or why no t? How would you compare your preparation compared to other entry-level dietitians? Did you feel competent to practice? Have you taken the registration exam? If so, did y ou feel adequately prepared?

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122 Appendix F: Supervisor Interview Guide BRIEFING: Thank you for your willingness to participate and b e interviewed. I am studying outcomes in distance learning and traditio nal dietetic internships. This interview will take approximately 30 minutes. INTRODUCTION: Introduction of interviewer. Ask the participate to introduce themselves. WARM-UP : How long have you been at this facility? Can you t ell me about the facility and your department? PRELIMINARY QUESTIONS : We are going to start first with the two questions I sent you in advance. QUESTION #1 How well was this employee prepared for practice? QUESTION #2 How does their preparation compare to other newly h ired graduates of internship programs? FOLLOW-UP QUESTIONS Overall, was the graduate competent for practice? In what areas was the graduate strongest? In what areas could the graduate have been better p repared? Were there any skills that need remediation?

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123 Appendix F: (Continued) How would you rate the graduate’s clinical judgment ? From you experience with this graduate, what do you see as the program’s strengths? From you experience with this graduate, what do you see as the program’s weaknesses? From you experience with this graduate, would you r ecommend this internship? Why or why not

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About the Author Lauri Ysseldyke Wright received her bachelor’s degr ee in dietetics from The Ohio State University. She completed the combined dietetic internship/master’s degree program at Louis Stokes Veterans Hospital/Case West ern Reserve University in Cleveland, Ohio. Ms. Wright worked as a clinical d ietitian at the James A. Haley Veterans Hospital in Tampa, Florida for over 15 yea rs where she specialized in Infectious Disease. She conducted research on The Incidence of Malnutrition and Nutrition-Related Complications in AIDS Patients and The Impact of Nutrition Education on the Nutritiona l Status, Knowledge and Attitude of HIV+ Patients In 2004, Ms. Wright began the dietetic internship at the Bay Pines VA in St. Pete rsburg, Florida. She is an adjunct nutrition instructor for Hillsborough Community Col lege, Manatee Community College, and University of South Florida.


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Comparison of student outcomes in distance learning internships versus traditional dietetic internships
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ABSTRACT: One way in which higher education is responding to technology advances, demographics changes, and economic pressures is through the development of distance learning. Distance learning represents one of the most prominent trends in higher education today. Understanding the impact of this technologically driven change on student outcomes is unmistakably important. One example of this trend in higher education is the distance learning internship in dietetic training programs. The purpose of this study was to compare student outcomes in distance learning dietetic internships to student outcomes in traditional dietetic internships. The pass rate of the registration exam for dietitians, levels of perceived preparation for practice, and evaluation of curricular experiences were compared. The study was divided into three phases. The first phase of the study was the recruitment of dietetic internship directors and program information, including registration exam pass rate. The second phase of the study consisted of surveys on preparedness for practice to the graduates and supervisors. The third phase of the study involved interviews of traditional and distance program graduates, their supervisors, and internship directors on curricular experience and preparation. No significant difference was found in pass rates for the registration exam. Significant differences were found in constructs of dietetic practice based on surveys with graduates and their supervisors. Common themes from interviews with graduates, their supervisors, and program directors confirmed survey results showing graduates of traditional dietetic internship were prepared at a higher level of practice, competence and clinical judgment. The results of this research do not support equivalency in preparation for practice between distance and traditional dietetic internships.
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