PROFESSIONAL ACTIVITIES AND PROBLEMS
Dietetic Internship Program, 1948-61
Colonel Katharine E. Manchester, AMSC, USA
In 1947, the Army hospital food service program was placed under the direct supervision of the dietitian. This new responsibility brought into immediate awareness the fact that the educational program for the dietetic interns would have to provide increased opportunity to further develop their skills in administrative and management functions. A serious problem for the civilian dietetic intern was the lack of authority with which to carry out the responsibilities inherent in supervision and direction of military and civilian personnel.
This lack of authority was solved when the commissioning of dietetic interns as Reserve officers was authorized in May 1948 following establishment of the Women's Medical Specialist Corps. The class which entered the internship in September 1948 (Appendix Q, p. 625) was composed of 12 Reserve officers who had been commissioned for the specific purpose of participating in the educational program. At the time of application, they were required to indicate in writing their interest in joining the Regular Army before completion of their 2 years of obligated service. This period of service included 2 months of basic training given to all newly appointed women officers and the 12-month dietetic internship.
The educational program conducted at Brooke General Hospital, Fort Sam Houston, Tex., was revised to provide guidance for the new Army officer as well as to meet the requirements of the American Dietetic Association. The responsibilities of the dietitian were inclusive of all activities within the food service division as well as those of an Army officer. The dietetic intern graduates were almost the sole source of procurement of qualified dietitians for the Army Medical Service. As a result of their educational program as dietitians and Army officers, these graduates proved to be more effective in the accomplishment of their mission. When the graduates requested separation from the service, they were fully qualified to take positions as dietitians in civilian life.?
The program of instruction for the dietetic internship was designed to include the educational requirements of the American Dietetic Association and the additional hours of instruction deemed necessary to cover specific military subjects. The program was reviewed periodically by the Director of the Internship and the Chief, Dietitian Section, Surgeon General's Office, to determine the best instructional program
to meet the needs of the Army Medical Service. In 1948, the trend of reducing classroom instruction from 325 hours to a lesser number in closer alinement with the association's requirements of approximately 125 hours was instituted. The first reduction brought the class hours to 275 which included Army basic orientation information. In the 1959-60 program, 127 hours of classroom instruction were listed. Primary reduction came from areas which could be taught during on-the-job experience.
In addition to classroom instruction, the dietetic intern participated in 50 weeks of on-the-job training designed to provide experience in all phases of hospital dietetics and 40 hours of field trips. On-the-job training and classroom instruction were coordinated to include administration and organization; professional ethics; personnel management and training; menu planning; food procurement, preparation, and service; food conservation and waste control; financial management; equipment management; storeroom management; sanitation; normal infant, child, and adult nutrition; diet therapy; meat and dairy hygiene; nutrition in public health; nutrition education and teaching methods for patients, personnel, and student nurses;1 and commercial food service.
More emphasis was placed on personnel management and gaining experience in using civilian personnel regulations, conducting employment interviews, and orienting new employees to the job (fig. 121). Civilian equipment firms provided consultants to discuss new food service equipment, fabrication of special equipment, and planning layouts of hospital kitchens.
Upon completion of 9 months' training, the intern was given staff responsibilities in which she could apply her new knowledge and gain self-confidence in an operating situation.
The internship director was responsible for the general administration of the internship program, teaching a large number of the classes, conducting the field trips, obtaining outside instructors, and coordinating and planning with the hospital food service supervisor (chief dietitian) on-the-job training in the hospital and affiliated institutions. The chief dietitian was responsible for scheduling training in various units of hospital food service (fig. 122). Staff members were used as food service consultants with emphasis placed on a particular subject during the practical on-the-job assignment. Staff members contributed to the presentations and discussions to relate the practical application to the didactic learning experience.
With each annual evaluation of the educational program, emphasis was placed on integrating the intern program into the hospital food service program to achieve a more complete balance between operation
1Experience in teaching student nurses was gained in a local civilian hospital in cooperation with the nursing staff.
and education. Operation of a food service unit was not to be dependent upon the interns but the interns were to have meaningful experiences which interpreted the didactic training. To accomplish this objective, close coordination among the staff dietitians was required.
During the Korean War, an additional requirement for qualified dietitians dictated the opening of a dietetic internship at Walter Reed General Hospital, Washington, D.C., in September 1951. The program of instruction followed the one in use at Brooke General Hospital. Miss Mable M. MacLachlan, Educational Director, American Dietetic Association, inspected the new internship program, and approval by the Executive Board was confirmed on 12 June 1952. At that time, Miss MacLachlan wrote, "We are very pleased with the possibilities this internship has for developing into one of the outstanding internships. A very fine educational program has been set up and the leadership, interest, and cooperation of the entire staff have contributed to the fine program."
Except for the 1957-58 class, dietetic internship programs were conducted continuously at both hospitals. In 1957, there was an insufficient
number of qualified applicants to permit the appointment of two classes, therefore, the program at Brooke General Hospital was temporarily discontinued.
During the period 1947-62, the following persons were directors of dietetic internships:
Brooke General Hospital
Capt. (later Lt. Col.) Ruby Z. Winslow, September 1947-September 1950
Maj. Nancy L. Huston, September 1950-December 1954
Maj. (later Lt. Col.) Mary Lipscomb, October 1954-September 1957
Lt. Col. Katharine E. Manchester, September 1957-July 1960
Walter Reed General Hospital
Capt. Louise A. K. Frolich, July 1951-53
Maj. (later Lt. Col.) Martha E. Moseman, September 1953-October 1958
Maj. M. Eileen Radke, October 1958-April 1962
Each year the two dietetic internship directors met with the Chief, Dietitian Section, to evaluate the program of instruction and to make revisions to improve the total learning experiences of the intern. Many changes reflected the trends in hospital food service divisions. Two weeks were devoted to an orientation which gave the intern an overall view of the operation of the hospital and the food service division. An understanding of the total operation permitted the student to concentrate more effectively on the detailed learning experiences in various branches and sections of the division. Learning experiences were redistributed into 4-week blocks to facilitate rotation of assignments and planning of integrated activities.
To provide various administrative experiences and to acquaint the intern with the different types of food service in Army hospitals, Brooke General Hospital incorporated two new affiliations in the 1950-51 program; a 2-week affiliation with the food service division of U.S. Army Hospital, Camp Chaffee, Ark., and a 1-week affiliation with the Army Health Nursing Service at U.S. Army Hospital, Fort Hood, Tex. In 1952, the affiliations were concentrated at Fort Hood to conserve time and travel funds. The Walter Reed General Hospital dietetic interns participated in a 2-week affiliation with the Food Service Division, U.S. Army Hospital, Fort Belvoir, Va., and a 1-week affiliation with the Army health nurse at Fort Belvoir. These affiliations were continued until 1956 when temporary duty and travel funds were no longer available for these purposes.
The general outline of the learning experiences as shown in the program of instruction for 1959-60 follows:
Program of instruction
Office, Chief Food Service Division
Production and Service Branch (including branch administration, management of dining hall and kitchen, quantity cookery and recipe testing, and pastry preparation)
Ward Food Service Branch (including branch administration, application of diet therapy to medical treatment of patients, and research in diet therapy)
Food Supply Branch
Teaching and Nutrition Education
Army Health Program
The 127 hours of class instruction included:
Normal nutrition and diet therapy
Nutrition in public health
Nutrition education for student nurses and teaching methods
Nutrition research seminar
Military social work in hospital
The 40 hours of field trips included visits to food service division of an Army station hospital, quartermaster activity, equipment company, civilian hospital, commercial food service operations, meatpacking plant, dairy plant, medical library, medical laboratory, school food service, and produce market (fig. 123).
To improve the learning experiences for the dietetic intern, more meaningful projects and presentations were incorporated into the program. The completed projects were presented to employees, noncommissioned officers, and staff dietitians to make the intern aware of the different educational levels to which teaching techniques have to be adapted.
Nutrition lectures with prepared lesson plans were presented to medical clinical specialists (fig. 124) and student nurses. In-service training lectures were prepared and presented to food service personnel and staff dietitians on safety, security, sanitation, food preparation and cookery, policies and procedures, and other pertinent subjects. Two case studies, medical or surgical, prepared on actual hospital patients by each intern, were presented for in-service educational programs for staff dietitians.
The case method approach was used by the dietetic intern in the preparation and presentation of facts of a personnel problem. The intern studied established civilian personnel policies and division procedures before arriving at recommended action pertaining to the problem. Accident case studies and equipment damage studies were prepared and presented as a means of learning how to gather information, handle reports, and solve problems.
Management improvement, work methods, food and waste studies, nutritional analyses of diets, and recipe standardization were among
the meaningful projects accomplished on various assignments. The inclusion of these particular types of projects in the learning experiences were planned to give the intern confidence in gathering facts, analyzing information, arriving at sound solutions, and implementing changes to improve the efficiency of the operation.
The classroom instruction, learning experiences, and projects were evaluated and integrated to provide a realistic education for the dietetic intern. The intern was given increasing responsibilities throughout the internship and was assigned staff relief when believed capable of successful fulfillment of the assignment. Individual development, as rapidly as possible, was stressed throughout the learning experiences.
In this period, 1948-60, 209 graduates from the internship programs (Appendix Q, p. 625) were awarded the military occupational specialty designation 3420 and were assigned as staff dietitians in Army hospitals throughout the United States. Controlled assignments of the graduates permitted placement of each dietitian in a situation which would enhance professional growth on a continuing basis for the period of obligated military service. These programs were the only internships in the United States where all graduates were se-
lectively placed in situations which were known to the internship director.
The Army dietetic internship programs were strengthened each year by direct feedback to the internship directors. The professional preparation of the internship graduate was evaluated not only by the graduate herself but also by the chief of the food service division to which she was assigned. This latter evaluation was made 6 to 8 months after assignment and indicated the strong and weak points of knowledge of the staff member. The recent graduate evaluated the educational experience in terms of how well the program had prepared her to assume the responsibilities of a staff position. These feedbacks assisted the directors in reevaluating the program and in implementing changes in the curriculum.
The Executive Board, American Dietetic Association was the approving authority for the dietetic internship program. "Minimum Standards for the Hospital Dietetic Internship" were established by the board and served as a guide for development of the curriculum and learning experiences in the program. The Army internship program exceeded these minimum standards in all respects.
Biannual inspection of each internship was conducted by the educational director of the association. In the report submitted to the Dietetic Internship Board, the inspector listed the strong and weak points of the program and made recommendations for improvement of the internship. The final report was submitted to the internship director and the commanding officer of the hospital. A summary of these reports indicated that the strong points in Army training were the interest and cooperation of the hospital administrative and professional staff, the leadership of the internship director and food service staff, the excellent experiences in food service administration, experiences in various size units with different kitchen layouts and equipment, staff responsibility, high standards of food preparation and sanitation, and management responsibility in various assignments. Weak points mentioned in the programs were the high percentage of staff turnover, lack of opportunity for home visits of patients, and limited experience in financial management including overhead costs and cash operations. As these weaknesses were reported, learning experiences were incorporated into the program to correct the deficiencies. Every effort was made to stabilize the staff in the internship program.
Each year the Army internship directors attended the preconvention conference for internship staff and college faculty as required by the American Dietetic Association. The Chief, Dietitian Section, and staff members of the internships attended the conference also. The conference included discussion of new developments in both colleges and internships and progress reports on internship program planning in which there was some deviation from the usual pattern.
The internship directors used this opportunity to report the progress of dietetic interns to interested members of selected college staffs. Military and civilian internship staff members enjoyed exchanging ideas and learning experiences to improve the program.
The establishment of the Army dietetic internship as a military officer training program provided a solution to the problems encountered at the end of World War II. The dietetic intern as an officer was placed in positions of responsibility at a much earlier time than was previously possible when trained as a civilian. Upon completion of the professional educational program, the young officer was exceptionally well prepared to accept and fulfill the responsibilities required of a staff dietitian in the Army Medical Service and to participate in continued research for improvement of the hospital food service program in Army hospitals.