Compass Group

Weeks 29 – 36: The FINAL 8 in School Nutrition Management

Well, it’s been a long road, but I can finally say with pride rivaled only by exhaustion that I have COMPLETED my dietetic internship!

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School nutrition management was my final rotation, and it was an experience unlike most of the others. Something I enjoyed was getting to work with a team of managers who worked in non-nutrition disciplines. For most of my 8 weeks, I spent time with our Food Service Director, a Manager in Training, our Associate Director, and worked closely with our head chef and catering manager as well. My rotation took place at San Francisco State University.  As I may have explained in previous posts, my internship was completed (love putting that in the PAST TENSE!) through Morrison Chartwells, a subset of Compass Group. Compass Group has a multitude of sectors, which provide food and nutrition services to establishments from hospitals, to schools, to business and industry settings. Morrison is the sector of Compass that serves healthcare establishments, which is where I did my clinical rotations. Chartwells is the sector that serves schools (and Chartwells Higher Ed, to further categorize, serves college campuses). My experience was unique in that I was working with Chartwells Higher Education, which works on college campuses – most other interns in my program were rotating in K-12 Chartwells accounts.

 

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Now that that’s out of the way….

 

My school nutrition rotation taught me a lot about management, and working with a team in which you are often the sole nutrition representative. I did have the opportunity to work with the Regional RD, Laura, who oversees Chartwells Higher Ed accounts. However, this was a long distance relationship, and  Laura did not have a scheduled trip out to SFSU during my time there. She was always available by phone and email, and was a large part of my learning experience in this rotation. Not having an RD present at the site on a daily basis taught me many times over to be proactive and independent.

Chartwells at SFSU incorporates a concept called Balanced Kitchen, which I was so excited to be a part of. Balanced Kitchen focuses on wellness on college campuses. At one point, I conducted an audit to ensure the dining center was meeting the wellness criteria for this concept – and our SF State champs did very well! I remember being a freshman in college, and staying well with healthy foods was such a challenge. It is great to see higher education moving in a direction that promotes the importance of a healthy lifestyle.

 

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Some of the criteria for Balanced Kitchen (aka Balanced U), and what the dining center strives to promote.

 

This was a project-centered rotation. In these 8 weeks, I think I completed upwards of 10 projects – and all of them took some serious time commitment! Some highlights:

 National Nutrition Month Activities:

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Me, beaming in the presence of my food models. Typical.

 

Nutrition Educations:

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Weird shadow on my face… But here I am giving a lesson on eating local and seasonally. My favorite educational tool right now is my local foods wheel. Ask me where you can find one!

 

Participation in Sustainability and Real Food Events:

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IMG_7790 A real local food-focused event!

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Put on a Farmer’s Market

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Enjoyed soo much delicious local produce.

 

Stress Reduction Fair:

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Focused on how to use good nutrition to keep stress in check! So much fun talking to students – and I met someone I’ve communicated with in the blog world! Amazing.

 

and Staff Trainings, and Food Service & Sanitation Audits (not pictured, because not that exciting – bein’ honest, folks).

 

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By the end of my rotation, I had made some strong connections with Compass employees at SF State, and I feel this rotation was the best opportunity to get to know some of the higher-ups who work for corporate! Getting to know some of the big wigs who manage entire regions was not only inspiring, but also allowed me to make an impression, shake some hands, and learn more about Compass as a whole.

 

As this blog is about honesty, I don’t want to leave out how much I struggled to get through this last rotation. With 8 weeks standing between me and RD eligibility, the to do list seemed forever impending. It’s not that the rotation was extremely challenging – I have been SO grateful to be done with clinical, and the stress level was NOT THE SAME here. But I did feel often paralyzed when I looked down at the list of projects to complete, and it even took me a few weeks to get started on some. But as of posting this, my assignments are COMPLETE, and I am awaiting the OK to sign up for my RD board exam (eeek!). This is a good reminder for me that it will all get done if I work toward it, but I have to remember to stay calm, get focused and organized, and just keep moving forward.

 

Well, folks, that wraps it up! Thank you to everyone who continued reading through my experience! I hope I was able to shed some light on the experience of dietetic internships for those of you embarking on this path. If you have questions, or just want to let me know how I’m doing (or how YOU are doing), please drop me a line below, or shoot an email over to thenourishedsoulblog@gmail.com.

 

This may be the end of my 1240+ supervised practice hours, but don’t you worry – there is still plenty of living, studying, and trying not to have panic attacks that I’ll be continuing to write about. Stay tuned, beautiful people! The best is yet to come over here.<3

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Weeks 23-28: Long Term Care and Community Nutrition

 

 

Every time I realize my clinical rotation is completely behind me, I feel completely shocked. Clinical rotations were something I had been anticipating since I came to understand what exactly happens in a dietetic internship. I am so excited to be moving down this path so quickly, and can’t believe the speed at which it’s flying by.

 

Immediately after my clinical rotations, I began the next two weeks in long term care, at a place called St. Paul’s Towers in Oakland, California.

 

Long Term Care: St. Paul’s Tower’s, Oakland, CA

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Older picture, but it’s still this HUGE!

 

St. Paul’s Towers is what is referred to as a Continuing Care Retirement Community, or a CCRC. By definition, CCRCs offer living facilities across all levels of care, which include independent living, assisted living, and skilled nursing (aka SNF). Here is a link to a basic description of each level of care: Long Term Levels of Care.

One of the jobs I worked before starting my dietetic internship was as the Dietary Director of a skilled nursing facility. With this under my belt, I felt I had already gained a fair amount of exposure to the job of a dietitian in a long term care facility. As it turns out, I was correct, but of course had volumes more to learn.

Fortunately for me, St. Paul’s happened to be going into mock survey during my first week there. Mock survey is something that, to those with a bit of knowledge of regulations in skilled nursing, sounds very scary, but is actually a positive thing. To start, I will explain the dreaded SURVEY. Every skilled facility has a survey “window” – for example, the SNF that I worked at had a survey window from April through July, if I recall correctly. What this window means is that any time during these months, surveyors who are usually sent from the state or federal level can show up at a facility and will audit everything from nursing to medical records to dietary and nutrition, looking for any errors  — anything at all you’ve done incorrectly or inadequately over the last year. So, survey itself is definitely SCARY. But MOCK survey is a company’s way of preparing for the true surveyors. During mock survey, the overarching company that runs the facility will send their own representative to audit all of these areas, and act exactly as a surveyor would. It is still terrifying, as each department (very much including nutrition) is looked at on such a microscopic level, that you can basically expect that any mistake you made over the last year will be found, addressed, and acted upon to correct. But, while this induces every self-critical voice in a young dietitian’s mind, mock survey is a good thing, as it is not put in place to get everyone in trouble, but to catch mistakes and assign them a plan of correction before the actual survey happens. Because the thing about a true survey is that if they catch too many mistakes, or just a small number of mistakes that show to cause harm to a large number of residents, the facility can have major penalties, and even be shut down completely.

 

So, it was great to have exposure to this process. When I was at my SNF about a year ago, I never had the… pleasure… of undergoing survey – but we were all constantly on edge, prepping for them to walk through the doors at any moment, so I was familiar with how to prepare for a survey. But getting this additional opportunity to hear everything from the preparation phase through the exit conference where the mock surveyor shares all of her findings with us was very beneficial.

 

A large portion of the week was spent shadowing and observing, but I also got a ton of hands on experience doing kitchen audits, dining room observations, and clinical assessments. My favorite part of my 2 weeks here was how creative my preceptor liked to get to bring a little extra joy to her residents. Mondays she took a little time to make hot chocolate and deliver a cup to any resident who was interested. One day per week she also would deliver fresh baked cookies to each resident. All of these practices that the RD implemented were a great way to add a little excitement to each week, boosted morale for employees (who got sweeties too!) and also acted as a great method for sneaking in some extra calories for those residents experiencing difficulty with weight maintenance!

 

Overall, my Long Term Care rotation was a great experience, and allowed for some unexpected new exposure. Next up was Community Nutrition at WIC!

 

Community Nutrition: WIC (Women, Infants, and Children)

The day after LTC was completed, I jumped in my lil’ Kia Sportage, and enjoyed a solo roadtrip down the California coast to spend the next 3 weeks at Normandie WIC near downtown Los Angeles. WIC is a supplemental nutrition program that serves low income families, assisting with food and providing nutrition education and counseling. The program serves pregnant mommies-to-be, and continues to assist as long as the family remains eligible until the child is 5 years old. Additionally, if the mother miscarries, services are still available up to 6 months after end of pregnancy. Different food packages are provided to these families, a picture of which is below (my WIC rotation was done in California – this is a picture of Florida WIC’s food packages, but they are similar):

 

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Supplemental Food Breakdown

 WIC will provide supplemental nutrition for the mother while she is pregnant, and will continue to do so after her pregnancy if she is breastfeeding. As the image above indicates, food packages vary based on whether the mother reports she is completely breastfeeding, mostly breastfeeding, or only providing some breast milk, or none at all.

 

WIC provides special WIC checks which can be used at participating stores for to obtain these foods. Participants can tell if a store will accept their WIC checks by looking for this image:

 

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During this rotation I learned so much more about the challenges that come with breastfeeding your child – although at the same time, I was reminded of all the incredible benefits both mother and baby receive when breastfeeding is made a part of the child’s first year. I was so happy to be reminded of the preventative benefits of breastfeeding, like decreasing disease risk and risk of obesity and cancer for both mother and the baby. Additionally, the emotional bonding that occurs between mom and child from skin-to-skin contact is truly amazing. And, of course, the nerdy nutrition girl that I am, I would be remiss not to mention the nutritional benefits of breastfeeding right away. WARNING: If you do NOT wish to get nerdy with me, please skip ahead to the next paragraph. Hello? Anyone left? Awesome, I knew I could count on you… So, later on in pregnancy, the mother’s body does begin to produce breast milk. However, the milk at this stage is what is referred to as colostrum – it is a substance that is a bit more yellow in color, and is made up of mostly protein. When you feed your baby right away with this early breast milk, they tend to see an array of benefits. Also, it just so happens that the nutritional makeup of colostrum is just EXACTLY what the infant needs at that early stage of life – now it’s pretty hard to dispute nature in all her perfection, am I right?

 

Now, if you’re just joining us, let me assure you of what a fun time we had in science land…

 

During this rotation, I was required to be very proactive in making sure I got the experience I needed/wanted. It was difficult to gain hands-on experience with counseling and educations due to a few limitations. Firstly, I did not have access to the computer charting system, since I was only at this site for 3 weeks. The computer was pretty imperative in conducting a counseling session, so most of what I did was observation, while providing input when it came time to conducting educations. The second and very significant challenge and limiting factor here was the language barrier. With only 3 years of high school Spanish under my belt, I knew I would not be able to have intellectual conversations about nutrition, nor convey all the information and passion I normally feel capable of communicating. I had been warned that when working at WIC, it is HIGHLY beneficial to be bilingual (at the very least), but I must have underestimated just how beneficial. It took me a few DAYS to be able to even observe anything because everything was being conducted in Spanish, Armenian, Russian, or Korean (and then some…). It was only later in my rotation that I mustered the confidence to decide that I could at least observe in Spanish, at which point I learned that I had a basic enough understanding of the language to at least follow along (although I was correct in feeling I could not communicate on my own…).

 

Given these significant limitations, a lot of the benefits that came from this rotation came in the form of projects that I asked my preceptor to be a part of. I requested to be given assignments, like creating handouts, which I could work on during the day as I was waiting for a counseling or education class in a language I could understand. During the course of my 3 weeks, one handout I created deals with what is safe to eat during pregnancy.

I also got to work on a presentation that I gave to the staff on my last day on a topic of their choosing. The staff requested dietary carbohydrates, weight loss, and calories in food – so I chose to address carbohydrates, and encompass the other two within.

A link to both of the projects is availabe on my online portfolio (click it, click it!!!).

My WIC rotation was a nice break from the hustle that was my clinical rotations. And I so enjoyed my time in Los Angeles, where I got to experience being a nutrition professional in my hometown, and got to spend three whole weeks with family and old friends.

 

Reminder from Mom...

Reminder from Mom…

Surviving 3 weeks of LA traffic, and remembering to BREATHE

Surviving 3 weeks of LA traffic, and remembering to BREATHE

Spending time with some of my oldest friends...

Spending time with some of my oldest friends…

...and the best family.

…and the best family.

And takin' in all the beauty.

And takin’ in all the beauty.

After WIC, it’s hard to believe, but I’m on to my next and FINAL rotation: School Nutrition Management. With about three weeks left at this point, you can expect the summary of that rotation shortly.

 

And a QUICK NOTE to those of you who went through the dreaded DICAS match these past few months: if you matched, CONGRATULATIONS! It’s an incredible accomplishment, and you have many challenges and some incredible learning experiences ahead of you.

 

If you didn’t match, just remember how AMAZING you are. As a reminder, I did not match my first time applying either. And as it turns out, not matching put me exactly where I need to be in my life in so many ways. If you’re lookin’ for a pick me up, check out this post I wrote the night before my first, unsuccesful match, and reposted a year later. And if you just need to remember that the world is good, please view this Buzzfeed post on baby elephants learning to use their trunks — I promise it will at least make you smile.

 

Thanks for tuning in, everyone. And stay tuned for my next and FINAL post as a dietetic intern!

 

Love Yo’self.

Weeks 4-6: Clinical Management and General Medicine

As is likely evidenced by my online absence—it has been a crazy few weeks! So, here’s what I’ve been up to:

Patient Services/Clinical Nutrition Management Rotation

            I learned a serious amount during this 1 week long, jam-packed rotation. Biggest lesson: I don’t believe management is in my near future. The Morrison-Chartwells internship has a strong focus in management, as does the overarching Compass Group of which Morrison and Chartwells are a part. So that’s why I’ve been lucky enough to have the opportunity to experience RD supervisory roles prior to even becoming a registered dietitian. My primary preceptor for this rotation was a highly-qualified RD, MSc, PhD who it seems loves the management side of clinical nutrition. I was able to see into the world of policies and procedures, interdisciplinary meetings, and personnel management. I have had exposure to this in my experience as Dietary Director of my little 56-bed skilled nursing facility before my time at UCSF Medical Center. But the observation and hands-on days I had at Alta Bates in this rotation were on a much larger scale, as a hospital with greater than 500 beds, working with multiple highly-educated people in various disciplines, and helping to oversee a team of brilliant clinical dietitians.

            As valuable as this experience has been, I will reiterate: I don’t see clinical management as my path at this time.  But hey, that’s the beauty of getting to participate in supervised practice before becoming a dietitian, right??

            The Pros: Having the opportunity to work with such qualified people was certainly inspiring.  I also got to meet people in different departments (i.e. pharmacy, human resources, physicians, etc), and also the movers and shakers within various areas of the Food and Nutrition department (i.e. foodservice directors, patient services managers, and the cooks, diet aids, and nutrition assistants that make the entire operation go). I really enjoyed the time getting to know all of these people. I have always felt it very beneficial to gain knowledge of positions other than your own to really understand why things are done the way they are, giving us the ability to do our jobs better (and maybe with less attitude). So there are the positives!

            The Cons: I missed patient care while in this rotation. Management has a major impact on this, of course. But direct patient care is just not something managers get to do much of—it’s one of the things they’re often forced to delegate in such a large operation. In fact, even as a SNF dietary manager, I found that the tasks I had to do relating to patient care fell to the back burner, as they were often the easiest jobs to delegate, and other issues such as food orders and immediately pressing scheduling problems would arise that needed to be dealt with. I also felt my clinical brain was not being exercised as I had hoped. Having a strong clinical background of course allows a clinical manager to do their job with an appropriate knowledge level, but… I wanted to do a dang TPN calculation! …Whoa, never thought I’d say that.

I will admit that this rotation tickled a nerve that begged that horrifying question, not once but a few times: “Am I in the right field? Have I made a mistake?”

Although the question was asked, I think in my little adequately-nourished heart knew this was just a challenging start to an incredible experience. I love what I know so far from the world of nutrition and dietetics, and I don’t feel it is possible that I could ever give it all up. This rotation reminded me that every field—no matter how ideal—will have its moments that even the most die-hard avengers will dread. For me, it appears one of those moments will involve chart audits and patient satisfaction surveys (ick).

Fortunately, the next few weeks reminded me why I DO love nutrition…

On to General Medicine—I finally get to play DIETITIAN!

 

After 3 weeks of rotations that felt entirely different from my expectations, with days of doubt and questions, I finally got to participate in what I feel I can fairly deem SUPERVISED PRACTICE. I arrived at Alta Bates’ Herrick Campus on the outskirts of Downtown Berkeley for my first day of my General Medicine rotation. This campus is primarily a psychiatric hospital with a residential, IOP (intensive outpatient), and PHP (partial hospitalization) eating disorder treatment program. One lone unit up on floor #5 houses the acute rehab department, and this is where I spent my two weeks in Gen Med.

            I saw a variety of types of patients during this time, although the majority were admitted with a stroke diagnosis. Many of these patients, secondary to their strokes (or CVAs – ‘cerebrovascular accidents’), were experiencing difficulty swallowing, otherwise known as dysphagia, which of course puts them at risk for malnutrition. Swallowing difficulty usually leads to patients being placed on diets that range from pureed to ground to chopped, and may be put on thickened liquids to avoid risk of aspiration or choking. Because these diets can cause food to be unappealing, and stroke patients may already have decreased appetite for various reasons, intake can decrease significantly. In the acute rehab unit, the neuropsychologists, speech therapists, dietitians, along with many other disciplines, play major roles in patient recovery, and it was empowering to be a part of a team with such capable hands.

            In addition to our stroke patients, we saw people with an array of complications from improper nutrition. Sometimes coupled with a CVA, patients admitted to this unit often presented with diabetes, heart disease or congestive heart failure, renal disease, and so many more.

Primary Diets Involved in This Rotation:

Carbohydrate Controlled

Renal (Limiting Sodium, Potassium, Phosphorus)

Fluid Restrictions

Modified Texture/Liquid Consistencies

*Many patients were on combinations of these diets—not just one restriction

 

The most impactful situations to me involved patients who had lived with uncontrolled diabetes for years, and had gotten to the point of exhibiting all those dreadful complications that we aimed to warn people against during my first rotation in the Diabetes Center. Meeting with patients who were on hemodialysis multiple times each week for their chronic kidney disease, who sat in front of me with BOTH legs amputated due to uncontrolled blood glucose levels, yet persisted to drive home their points on why their diets should be liberalized was truly eye-opening. What these experiences taught me is that no matter how knowledgeable a practitioner is, a dietitian (or doctor, or nurse, or therapist, etc.) CANNOT create motivation within another person. That truly has to come from within, and sometimes even a bilateral amputation won’t do the trick. So we just have to wait and see if something else does, while in the meantime giving our patients the best in-hospital nutrition care possible, and providing them with any education they will accept.

            I’m now moving on from Herrick, and heading to Ashby Campus. I will be returning to Herrick in January for my Eating Disorders elective rotation—can’t wait!

My time in General Medicine has given me a strong basis to head into my rotations to come, as I learn about some more specialized fields. Renal and Labor/Delivery is next! Stay tuned :).