Design

This review followed the methodology proposed by the Joanna Briggs Institute to develop scoping reviews⁵. To maintain research transparency, a protocol was registered with the Open Science Framework (OSF) on 9 November 2020 (https://osf.io/h489y/).

Search Strategy

The search strategy was used in the MEDLINE (PubMed/Ovid), Web of Science (WOS), EMBASE (through OvidSP), CINAHL (through EBSCO Publishing), ERIC (Educational Resource Information Centre) and Scopus databases. The search strategy was designed using natural language and controlled language adapted to each database. The following or similar terms were used in all databases: "Education, nursing", "Nutritional sciences", "Health Knowledge, Attitude, Practice", "Students, nursing", "Diet, food and nutrition". The search was limited to publications in English and Spanish from the launch of the databases until January 2021. In addition, as a secondary search strategy, the reference list of all included bibliographic sources was examined for additional studies.

The following inclusion criteria were determined for this review: 1) Primary empirical studies; 2) Including all undergraduate year-groups taking a nursing degree; 3) Including face-to-face or online teaching interventions, conducted in the classroom or in clinical settings; 4) Reporting on nutrition programmes in the undergraduate nursing curriculum; 5) Reporting on the teaching and/or learning method. The exclusion criteria were: 1) Editorials, opinion articles, proceedings, protocols, and posters; 2) Studies that did not include nursing students or if included, the data were not disaggregated from other types of students; 3) Studies that reported exclusively on postgraduate or continuing education for nursing professionals.

Study Selection

A total of 992 records were identified in the selected database search. These were subsequently imported into the Mendeley® bibliographic reference manager to eliminate duplicates. Out of the remaining references, 670 were excluded after reading the title and abstract, because they did not match the research study objective. The text in 98 articles was read in full, followed by a consensual discussion between at least two of the reviewers. In this screening phase, 78 references were excluded: 41 did not match the context of undergraduate nursing education, 26 did not include nursing students in the sample and 11 did not meet the determined selection criteria. Finally, 2 more articles were obtained secondarily through references from other registers, bring the inclusion total to 22 studies.

The search results and the study inclusion process are shown in the flow diagram with extension for scoping reviews (PRISMA-ScR)⁶ (Figure 1).

Figure 1: PRISMA Flow Diagram. 

Information extraction

After completing the article search and selection, a data extraction template was created: author, year, country of origin; research aim(s); participants, setting and design; learning outcomes, teaching methodology and learning sequence; evaluation method; and main findings. Two reviewers then independently extracted data from all the studies, discussed the results and updated the data extraction tool. Any discrepancies during data extraction were addressed by bringing a third reviewer into the discussion until consensus could be reached.

Summary of results

To understand and classify the content of the articles, several reiterative readings were carried out to produce a narrative synthesis.

There was emphasis on analysing teaching designs for nursing students concerning nutrition. The narrative content synthesis was evaluated again to identify patterns and similarities and differences in the variables. This was useful to determine the most important relationships between the included studies, making it easier to establish definitive categories to meet the objective of this scoping review.

Study Characteristics

The 22 studies included in this review were published from the launch of the databases until January 2021 ^{7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25)(26)(27)(28}.

According to the origin of publication most of them were contextualised in the USA (n=11), although also found in Europe (n=8), Oceania (n=1), Latin America (n=1) and Africa (n=1) (Table 1).

Table 1: Main results of the included articles. 

Table 1 (cont.): Main results of the included articles. 

Table 1 (cont.): Main results of the included articles. 

Table 1 (cont.): Main results of the included articles. 

Table 1 (cont.): Main results of the included articles. 

Table 1 (cont.): Main results of the included articles. 

Table 1 (cont.): Main results of the included articles. 

Abbreviations: (P) Participants, (C) Context, (D) Design, (LO) Learning Outcomes, (M) Methodology, (LS) Learning Sequence.

The studies included in this review considered nursing programmes (n=7) or nursing students (n=15), as the subject of study. Four of the studies are contextualised within interprofessional education, including students from medical, physiotherapy or dietetics degrees^7)(8)(9)(10.

There was great variability in the academic year in which the subject was taught. In 13 studies, the academic year was not specified and in the remaining 9 that did, there was great heterogeneity: in a single academic year; 1st year (n=2); 2nd year (n=1) and 4th year (n=3) and in more than one academic year; (1st and 2nd) - (1st, 2nd and 3rd) - (3rd and 4th), (n=3).

According to the identified research designs, descriptive studies (n=7), comparative studies (n=5), case studies (n=4) and narrative reviews (n=3) stood out, while other types of designs such as research-based studies (n=2) and a quasi-experimental design (n=1) were also found in smaller numbers.

Description of the results of the included studies

Four relevant themes were identified in the study analysis: 1) Review of nursing programmes and curricula; 2) Teaching designs; 3) Assessment of learning; 4) Students' perceptions of the teaching methodology.

Theme 1: Review of nursing programes and curricula

A total of seven studies based their research on the review of nursing programmes or curricula with regard to the nutrition content taught^{11)(12)(13)(14)(15)(16)(17}. Five of them in US institutions,^{11)(12)(13)(14)(15} one in a European institution¹⁶ and one in Brazil¹⁷.

Only one study specified that nutrition content was integrated in different subjects¹², but this was not specified in the rest of the studies^{11)(13)(14)(15)(16)(17}.

There is emphasis on the theoretical aspects of nutrition, the significance of teaching about basic nutrients across different life stages and nutrition in cases of illness^13)(15)(17. On the practical side, instruction on fluid and electrolyte management is prioritised^12)(13)(15.

In this review, two teaching contexts were identified: the university classroom and clinical placements. Most studies focused on theoretical classes taught in the classroom^{7)(9)(10)(17)(18)(19)(20)(21)(22)(23)(24)} and some combined traditional theoretical teaching with clinical placements^{8)(25)(26)(27}. Additionally, several studies highlighted the necessity to enhance basic nutrition content in the nursing curriculum, although the most suitable context for this is not specified^(11,12,15.⁾

In addition to delivering theoretical and/or practical content, only two studies specified the faculty responsible for teaching nutrition subjects^13,16. In the work carried out by Weigley,¹³ in US institutions, the subject was traditionally taught by dietetics professionals. More recently, in their study conducted in 31 European countries, Eglseer et al.¹⁶ identified that nurses were responsible for teaching nutrition in more than half of the educational institutions.

Theme 2: Teaching designs

Four studies explicitly identified the proposed learning outcomes for instruction^{9)(10)(18)(23}. Two of them focused on acquiring interprofessional communication skills to address the patient's nutritional needs and develop clinical judgement^9,10. The other two studies established learning outcomes focusing on knowledge acquisition^18,23, identifying different dietary sources of nutrients and implications for nurses¹⁸ and exploring nutritional factors and other health determinants to promote wellness²³.

Eleven studies specified the teaching designs used: lectures;²² lectures reinforced with case-based practice^9,26; lectures supported by computer tools^7,19; clinical practice²⁷; nutrition diary²⁴; one-day nutrition event²⁵; photovoice²³; game-based learning¹⁸; and simulation¹⁰. Three did not explain the methodology and teaching strategies used^8)(20)(28.

Theme 3: Assessment of learning

From the studies included in this review, 4 report on the use of different tests and/or rating scales to assess acquired learning, without specifying whether this was part of the subject evaluation ^{20)(21)(22)(28}.

For this purpose, the following were used: a questionnaire developed ad-hoc by the authors of the research with 30 multiple choice questions²²; the validated Nutrition Knowledge Test (NKT) questionnaire²⁰; a 20-item questionnaire, used in similar previous studies to assess nutrition knowledge in other unspecified countries²⁸. Finally, a specific open-ended question on Mediterranean diet in addition to the KIDMED TEST (Pre-Post) used to assess adherence to the Mediterranean diet²¹.

Within this category, five papers were also found that reported on student learning using lectures as the unique mode of instruction or in combination with other types of strategies^{7)(9)(19)(22)(26}. The use of lectures alone provided an increase in general nutrition knowledge in the intervention group²². Complementing the theoretical teaching with case studies increased the level of learning and was useful to work on interprofessional competencies^9,26). In addition, theoretical classes supplemented with computer tools provided consistent learning, saving instructors time^7,19).

Other studies assessed student participation and motivation in different activities that involved developing learning content^{18)(23)(24)(25}. Students reported a better understanding of nutritional recommendations through keeping a food diary.²⁴ Practical tools such as photovoice gave greater awareness of the barriers and benefits of food provision on campus²³. Organising a collaborative event between university and clinical practice seems to increase student motivation²⁵. Other methodologies such as game-based learning also seem to help improve motivation and learning of nutritional concepts¹⁸. Simulation is another teaching method that, although no differences have been found, is expected to increase clinical judgement and interprofessional communication¹⁰.

Regarding the results of the learning assessment in the studies included in this review, better results were obtained on general knowledge about nutrition^22,28, carbohydrates²⁰ and Body Mass Index (BMI)²². Worse results were obtained for sources of cholesterol^20)(22)(28, sources of water-soluble fibre²⁸, food to prevent and manage cardiovascular disease²⁸, obesity or overweight ranges^22,28, nutrient metabolism²⁸ and physical activity²⁰. According to Vega et al.²¹ slightly more than half of the nursing students did not have congruent ideas about the Mediterranean diet prior to instruction, with a statistically significant increase after instruction.

Theme 4: Students' perceptions of the teaching methodology

Two papers were identified which assessed students' perceptions of the teaching methodology^19,26. Students perceived increased learning regarding eating and hydration, protocols and recognition of malnutrition and identification of relevant interventions when devising cases studies²⁶.

On the other hand, a study that compared face-to-face training and web-based teaching, using the Student Opinion of Instruction (SUMMA) tool, obtained better results in terms of students' perception for the former mode of instruction compared to the latter¹⁹.

Limitations

Among the limitations encountered when conducting this review, it should be noted, firstly, that the study search was limited to English and Spanish, leaving out papers published in other languages that might have been relevant. Secondly, there is the limitation associated with the methodology chosen to meet the objective. Scope reviews do not take into account the methodological quality of the research, so this was not a criterion considered in the inclusion/exclusion criteria when selecting papers for this study. Finally, it should be noted that the scope of professional practice is not homogeneous throughout the world, so teaching may differ according to nursing profession regulations in each area.