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A nutrition counseling workshop:Integrating counseling psychology intonutrition practiceSr M. CARROLL ISSELMANN, EdD, RD; LINDA S. DEUBNER, MA, RD;MARYANNE HARTMAN, MA, RD

ietetics practitioners often find them-selves in the role of counselor. Often,however, they lack knowledge oftheo-

ries of counseling psychology as well as theability to translate theory into practice.Historically, counseling skills have not beenan academic or professional experiencerequirement for dietitians.

In the past two decades, authors havedescribed the need for nutrition counsel-ing skills in the dietetics practitioner (1-4).Severalhow-to books about nutrition coun-seling were published during the early1980s (5-8). In spite of the acknowledgedneed, many dietetics professionals com-pleted their academic programs and pro-fessional experience without developingspecific skills in nutrition counseling. Dan-ish et al (9) highlight the need to educatepractitioners who are not trained in nutri-tion counseling; they believe that themechanism for developing competency iscontinuing education. Dietitians have iden-tified a need for additional training to im-prove their interviewing and counselingskills (10).

Because nutrition counseling has cometo be regarded as an entry-level compe-tency, and because many students andpractitioners lack that skill, we developeda continuing education workshop in nutri-tion counseling.

WORKSHOP DESIGN,OBJECTIVES, AND CONTENTIntegration of the disciplines of nutritionand counseling psychology was the pri-mary objective of the workshop design.

L. S. Deubner (corresponding author)is in private practice at 5249Cambrian Rd, Toledo, OH 43623.Sr M. C. Isselmann is chairperson ofNutrition Education, GraduateDivision, Immaculata College,Immaculata, PA 19345-0732.M. Hartman is a nutrition consultantat 1514 Vista Club Cir, Santa Clara,CA 95054. L. S. Deubner andM. Hartmanformerly were graduatestudents at Immaculata College.

Achieving integration was also plannedthrough the selection of teaching meth-ods. The anticipated outcome was the de-velopment of nutrition counseling skills.Other authors have surveyed the counsel-ing strategies used by the registered dieti-tian (11), provided a model for developingdiscrete counseling skills (12), provided aschematic model for the counseling ses-sion (13), and studied the effect of thecounseling environment (14).

Our graduate-level workshop was com-prehensive. It included all four areas ad-dressed previously in the literature. Theworkshop's educational methods and ob-jectives reflected the desire to integratethe cognitive and affective domains oflearn-ing. The objectives were (a) to develop anawareness of one's personal counselingstyle, attitudes, and values related to coun-seling; (b) to develop an introductoryknowledge of counseling theories and tech-niques; (c) to apply knowledge of counsel-ing theories and techniques to the practiceof nutrition counseling; and (d) to identifythe impact of the nutrition counseling en-vironment on nutrition counseling.

I. Self-inventory of counseling attitudesand values

II. Theoretical orientations in psychologyA. Reality theory

1. Key figures2. Major focus3. Philosophy4. Basic assumptions5. Key concepts6. Therapeutic goals7. Client-counselor relationships8. Videotaped or live role-play il-

lustrations of theories in practiceB. Behavior theory (1-8 above)C. Rational-emotive theory

(1-8 above)D. Client-centered theory (1-8 above)

III. Comparison of self-inventory withtheoretical orientations

Workshop participants (n = 40) camefrom a variety of nutrition counseling set-tings. Most of the participants had notpreviously taken a nutrition counselingcourse or workshop. All of the participantsindicated a belief that counseling skillswere important in nutrition practice. Par-ticipants had the opportunity not only toacquire knowledge but also to internalizevalues about the importance of counselingtheory and technique and applications todietetics practice.

The workshop was didactic and experi-ential. The content of the workshop isoutlined in the Figure. Teaching methodsincluded lecture, role-playing, self-assess-ment, small-group discussion, videotapeddemonstrations, and videotaped practicewitheritique. Videotapes of nutritioncoun-seling scenarios were developed to illus-trate the application of each counselingtheory to dietetics practice; the tapes wereshown immediately after each theory waspresented to provide a link between theoryand practice.

WORKSHOP EVALUATIONSAt the conclusion of the workshop, eachparticipant responded to a questionnairepresented on a Likert scale to evaluatelearning and skill acquisition. Thirty-eightof the 40 participants reported that as aresult of the workshop their knowledge ofcounseling theories increased. Thirty-nineof the participants reported an increasedappreciation for the integration of counsel-ing theories into nutrition practice. Mostparticipants (n = 37) agreed or stronglyagreed that they could realistically usecounseling skills in their work settings.Increased confidence in nutrition counsel-ing skills and the ability to apply these skills

IV. Basic counseling techniques and skillsA. Attending skills

1. Open and closed questions2. Paraphrasing

B. Influencing skills1. Interpretation2. Feedback3. Directives

V. Effects of the counseling environ-ment on counselingA. Hospital-based vs private

practiceB. Environmental problem

identificationC. Problem solving

VI. Videotaped role-plays with critique

VII. Workshop evaluations

Workshop content outline.

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WORKSHOP OUTLINE

TableFollow-up evaluation 6 months after workshop a

uetlion Response

Strongly Agree Neutral Disagree Strongly Notagree disagree applicable

No % No. % No. % No % No. % No. %1. My confidence in my counseling skills has increased over the past

6 months. 17 19 20 56 5 14 0 0 0 0 4 112. I have identified the counseling style in which I am most

comfortable and effective. 5 14 21 58 7 19 0 0 0 0 3 83. 1 am able to adapt my counseling style to meet the needs of the

patient. 6 17 21 58 4 11 2 6 0 0 3 84. 1 am now using more attending and listening skills in my nutrition

counseling sessions. 10 28 16 44 5 14 0 0 0 0 5 14

5. I am now able to recognize when a patient is not attending orlistening during the counseling process. 9 25 17 47 5 14 1 3 0 0 4 11

6. I am better able to acknowledge my feelings that arise during thecounseling process. 6 17 18 50 8 22 0 0 0 0 4 11

7. I am better able to acknowledge the feelings of my patients duringthe counseling process. 6 17 22 61 4 11 0 0 0 0 4 11

8. I have altered the way I conduct the counseling session based onthe recognition of my own or my patient's feelings. 6 17 20 56 6 17 0 0 0 0 4 11

9. I evaluate the counseling environment before beginning thecounseling session. 6 17 17 47 7 19 1 3 0 0 5 14

10. I take steps to correct the environment before beginning thecounseling session. 5 14 15 42 7 19 4 11 0 0 5 14

11. I have requested that management make changes in my work sitecounseling environment that will enhance the counseling process. 2 6 9 25 4 11 10 27 2 6 9 25

12. I need further instruction, encouragement, and/or evaluation toenhance my counseling skills. 11 31 15 42 2 6 4 11 1 3 3 8

aThirty-six workshop participants were interviewed by telephone.

was reported by 34 of the participants, but the counseling environment before begin-the number who strongly agreed (n = 16) ningacounseling session, and slightlymorewas somewhatlowerthanthosewho agreed than half took steps to correct the environ-(n = 21). Most participants (n = 31) ment. Fewer participants (n = 11) re-thought they had begun to recognize their quested that management make changespersonal style of counseling as suggested to enhance the counseling environment.by the course objectives. Role-playing andlearning counseling theory promoted the APPLICATIONSrecognition that in the nutrition counsel- As the body of knowledge and practiceing process, the counselor could apply nowcallednutritioncounselinghas evolved,skills and techniques taken from psycho- it has become evident that more effectivelogical models. This recognition enhanced nutrition counseling occurs if the disci-the value of the patient-counselor relation- plines of counseling psychology and nutri-ship. tion are integrated. Many practicing di-

A 6-month follow-up survey was con- etetics professionals have not been ad-ducted to determine whether the work- equately prepared in nutrition counselingshop participants had opportunities to prac- and need to fill this void in their education.tice and apply the skills acquired in the The variety of educational methods se-nutrition counseling workshop (Table). A lected for the workshop described in thisstandardized telephoneinterviewwas con- article produced an immediate positiveducted using a 12-question survey on a effect on the participant's appreciation ofLikert scale; a 90% response rate was the importance of developingandintegrat-achieved. Participants who were not work- ing counseling skills within nutrition prac-ing were scored as not applicable. tice. More important, a 6-month follow-up

Results of the telephone surveyrevealed survey verified increased confidence infavorable long-term outcomes. Twenty- the development anduse ofnutrition coun-seven of the 36 respondents agreed that seling skills as well as recognition of per-their confidence in their counseling skills sonal counseling styles.had increased. Participants had identified In the initial evaluation, participants in-a counseling style in which they were com- dicated an awareness of the importance offortable and were able to adapt their style the nutrition counseling environment. Nev-to meet the needs of clients. Almost two ertheless, the 6-month follow-up surveythirds of the participants began to evaluate indicated that a significant percentage of

participants did not take active steps to-ward improving their counseling environ-ment. This behavioral aspect of nutritioncounseling deserves increased emphasisin future workshops. Activities could in-clude the development of assertivenessand negotiation skills to help practitionerssecure from management provision of anappropriate nutrition counseling environ-ment.

The following recommendations arebased on the results of our workshop expe-rience:

* Nutritionprofessionals should recognizethat nutrition counseling is more effectiveif theories and techniques of counselingpsychology are integrated into nutritionpractice.* Future workshops should provide ameans for empowering the professionalwith the assertiveness needed to secure anappropriate space and environment foreffective counseling.* Academic institutions, internships, andapproved preprofessional practice pro-grams should include practice-orientedexperiences in teaching nutrition counsel-ing skills.* Future research should address the ques-tion of the most effective time for thislearning to occur in the education of thenutrition professional.

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References1. Ohlson M. The philosophy of dietary coun-seling. JAm Diet Assoc. 1973; 63:13-14.2. Ling L, Spragg D, Stein P, Myers ML. Guide-lines for diet counseling. J Am Diet Assoc.1975; 66:571-575.3. Mason M, Wenberg B, Welsh P. The Dy-namics of Clinical Dietetics. New York, NY:John Wiley & Sons; 1977.4. Danish SJ, Ginsberg MR, Terrell A,Hammond MI, Adams SO. The anatomy of adietetic counseling interview. JAmDietAssoc.1979; 75:626-630.5. Danish S, D'Augelli A. Helping Skills II:Life Development Intervention. New York,NY: Human Sciences; 1983.6. Laquatra I, D'Augelli A, Danish S. HelpingSkills II: Life Development Intervention,Leader's Manual. New York, NY: Human Sci-ences; 1983.7. BuildingNutrition Counseling Skills. vol1. Bethesda, Md: US Dept of Health and HumanServices, National Institutes of Health; 1984.DHHS publication (NIH) 84-2661.

8. BuildingNutrition Counseling Skills. vol2. Bethesda, Md: US Dept of Health and HumanServices, National Institutes of Health; 1984.DHHS publication (NIH) 84-2662.9. Danish S, Lang D, Smiciklas-Wright H,Laquatra I. Nutrition counseling skills: con-tinuing education for the dietitian. Top ClinNutr. 1986; 1:25-32.10. CassellJ. TopClinNutr. 1986; 1:1. Editor'snote.11. Glanz K. Strategies for nutritional coun-seling. JAm Diet Assoc. 1979; 74:431-437.12. Snetselaar LG, Schrott HG, Albanese M,lasiello-Vailas L, Smith K, Anthony S. Modelworkshop on nutrition counseling for dieti-tians. JAm Diet Assoc. 1981; 79:678-682.13. VickeryCE,HodgesPAM. Counselingstrat-egies for dietary management: expanded pos-sibilities for effecting behavior change. JAmDiet Assoc. 1986; 86:924-928.14. Picus SS. Evaluation of the nutrition coun-seling environment of hospitalized patients. JAm Diet Assoc. 1989; 89:403-405.

Attitudes of Ing-teare fe ieestaff toward okler workersCHRISTINE D. ARCHETTI, MA; JENENE G. GAREY, PhD, RD;NEAL F. BERMAS, PhD

The foodservice industry is facing seri-ous labor shortages. The industry hasrelied heavily on 16- to 24-year-olds

(1) to meet its work force needs. Todayless traditional work groups such as dis-abled persons, retirees, and older workersare being recruited (2).

Research has shown that older workersare subject to more stereotyping; hence,they are viewed and evaluated less posi-tively than youngerworkers (1,3-9). Nega-tive stereotypes of older workers can influ-ence managerial decisions, such as selec-tion (6) and promotion (1,3,6), and affectthe career progression of older workers

C. D. Archetti (corresponding author)is thefoodservice manager at theKings Harbor Care Center, Bronx, NY10469. At the time of this study, shewas a graduate student in theDepartment of Nutrition, Food andHotel Management, New YorkUniversity. J. G. Garey is an associateprofessor and N F. Bermas is anadjunct associate professor in theDepartment of Nutrition, Food andHotel Management, New YorkUniversity, New York, NY 10003.

(1,3,4,6). But researchers have found thatolder workers possess many favorablequalities, such as stability (7), dependabil-ity (1,3,7,10), loyaltyto the company (10),and reliability (7) and have better atten-dance records than do younger workers(11). Generally, older workers have feweron-the-job accidents than younger work-ers (11,12), but conflicting results havebeen reported (7,10).

This study examined the attitudes offoodservice personnel in long-term-carefacilities toward workers 55 years of ageand older.

METHODOLOGYTen nursing homes in the New York Cityarea, employing a total of 448 foodserviceworkers, were selected on the basis ofwillingness to participate. The nursinghomes were of varying size (200 to 720beds). All had a self-operated foodservicedepartment headed by a registered dieti-tian and all prepared food on the premises.Eight of the 10 nursing homes offered tray-line and dining room service; two offeredonly tray-line service.

The survey instrument measured atti-tudes of hourly and management food-

service personnel toward older workersusing a 15-item Likert-type questionnaire(Cronbach's = 0.83) (1,3), which hadbeen modified from 24 items (r = .90) (5).The questionnaire also included demo-graphic questions (eg, number of yearswith the facility and opinions on manda-tory retirement).

The foodservice directors agreed duringan introductory telephone call that em-ployees would self-admirister the ques-tionnaire and return it individually. Thequestionnaires included an envelope toensure confidentiality. The instructionsgiven were similar to those used by DeMicco(1). The New York University Human Sub-jects Committee approved the study.

RESULTSOf the 300 surveys distributed, 160 (53%)were completed and 143 (48%) were us-able-from 112 hourly and 31 manage-ment employees equally divided by gen-der. All age groups were represented. Thelargest groups were 18- to 29-year-olds forhourly employees (n = 36) and 30- to 49-year-olds for management employees(n = 22). Sixty-one percent of hourlywork-ers had no more than a high school di-ploma; 50% of management workers had acollege degree. The mean number of yearsworking at the facility was 8.5 and themean number of years working in thefoodservice industry was 11.2.

According to an unpaired t test (t = .396,P = .05), the scores for mean attitude to-ward older workers were similar for hourlypersonnel (49.82, standard deviation[SD] = 7.865) and management personnel(50.45, SD = 7.762) (Table 1). A two-fac-tor analysis of variance of employees(hourly or management) showed a signifi-cant difference in mean attitude score byage (F = 2.804, P = .05) but not by type ofemployee.

On the basis of findings from previousstudies (1,3,5,13,14), we expected a paral-lel increase in mean attitude score as theage of the respondents increased. We foundthat there were slight increases in meanattitude score (with one exception) as theage of respondents increased to age 60(Table 1). Regrouping our respondentsinto general age categories-younger than40, 40 to 49, and 50 and older-yieldedresults similar to those of Bird and Fisher(14) (Table 1).

Seventy percent of the total sample be-lieved that people should retire at a certainage; the most frequent responses were 65years (27%) and 60 years (26%)(mean = 61.37). The respondents said "old"was 70 years (21%) and 65 years (20%)(mean = 64.64).

Table 2 shows the 10 positive and 5negative statements expressing attitudes

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