One of the key outcomes---Change in status of Nutrition Diagnoses?

Documenting the status of Nutrition Diagnoses as patient care continues

One of the key decisions that you will make is determining the appropriate method for documenting progress in nutrition diagnoses based upon your patient/client population. 

The choices for documenting the status of a nutrition diagnosis included in the Academy of Nutrition and Dietetics Health Informatics Infrastructure (ANDHII) are as follows:

•        New

•        Continued

•        Resolved

•        Removed

However, in some cases the dietitian may want to know more than just whether it was continued or resolved, they may want to indicate directionality for a continued nutrition diagnoses for example, using a three way description of  improved, declined/worsened, or no change.

One approach, developed by UPMC Presbyterian Shadyside that accomplishes this directionality uses these terms:

•        “Resolved”—nutrition diagnosis no longer exists because it has been addressed

•        “Improvement shown/unresolved”—nutrition diagnosis still exists but signs/symptoms showing improvement. Patient/client making progress

•        “No improvement/unresolved”—nutrition diagnosis still exists, little to no improvement shown, still appropriate for patient/client’s condition

•        “No longer appropriate”—nutrition diagnosis is no longer exists because patient/client’s condition or situation has changed. The focus of nutrition interventions no longer supports the nutrition diagnosis

At this point, there is no clear right or wrong answer to how your institution chooses to record the current status of a nutrition diagnosis.

As you are considering how you want to record your status, you may want to be thinking about the end result or type of reports that you want.   With the increased use of electronic health records any data recorded in a systematic way can be pulled into a report with the assistance of information technology experts.

 With either the system begin tested in the ANDHII or some other method such as that which was originally designed by UPMC Presbyterian Shadyside  you will be able to generate a numerical percent of the number of nutritional diagnoses that were "resolved" and the number that were removed due to the change in patient condition.  

However if you use the ANDHII system it will be difficult to know how to characterize those that are "continued" , e.g. whether they improved, stayed the same, or worsened.

Your report using the ANDHII data might look like:
       Month_____
              Total number of Nutrition Diagnoses identified ________
                                                                       (Sum of all notes/records)
              Total number of Nutrition Diagnoses resolved _________ 
                                                                      (Sum of all notes/records
              Average nutrition diagnoses per patient ______
                                                                      (Sum/patients with notes/records)
              % patients with at least one Nutrition Diagnoses resolved 
              Narrative list of TOP 10 nutrition diagnoses identified
              Narrative list of TOP 5 nutrition diagnoses resolved
              Narrative list of TOP 10 MEDICAL Diagnoses with nutrition diagnoses
                   May want to show Top 10 Medical Dx matched with top 1-2 Nutrition 
                   Diagnoses for Medical diagnoses

 Or it could be something like the following table which shows a total of those that improved added plus that were resolved and situations where the nutrition diagnoses was no longer appropriate (removed) where it was impossible to resolve/improve.
   

               

Etiologies--Are we missing the point? Just Ask Why 5 times???

Using the etiology (root cause) to guide the nutrition intervention is often not fully explored in  nutrition care
process discussions...other that to mention that you should ask "why?" five times to get to the root cause (or lowest level that the dietitian can impact).  More focus has been placed on correctly naming the problem as the Nutrition Diagnoses.

This example that shows the impact of varying etiologies on the choice of nutrition interventions.

Assume the Nutrition Assessment clearly indicates that there is a problem with Excessive Energy Intake (NC 3.3.1).  The person has consistently gained weight for past 2 years, the dietary history shows that the person has routinely consumed MORE than his estimated needs, and the weight status meets the criteria for being overweight.  There is no medical reason to avoid addressing his weight gain/status at this time.

Excessive Energy Intake (NC3.3.1) was selected as the problem/diagnosis.  But let's look at the difference in intervention based on varying etiologies. (See Etiology Matrix in ENCPT website)  In the ENCPT there are 28 different types of etiologies related to knowledge, beliefs and attitudes alone!!.

If the etiology for Excessive Energy Intake is identified as

• "Food and nutrition knowledge deficit" concerning identifying foods/beverages that are highest in energy or being able to identify intake that would be within optimal energy levels (plus BMI or weight data).  
• Then a logical intervention might be providing tailored Nutrition Education - Content-Recommended Modifications to help increase knowledge and understanding.  

However if the etiology is identified as

• "Lack of confidence in ability to make change" 
• Then an intervention providing knowledge/information would not likely change confidence.   However,the intervention most likely to be successful would be a Nutrition counselling approach, perhaps using an Motivational Interviewing strategy based on Stages of change to facilitate the person being able to clearly identify other situations when he/she has been successful, what the barriers are to making these changes, and exploring problem solving for the patient to discuss ways he/she can overcome the barriers and thus be more confident that they can be successful.  

OR

• "Cultural or religious practices that affect ability to" make changes
• Perhaps a Nutrition Counselling approach based on Cognitive-behavioral theory is appropriate, but not focused on changing the religious or cultural beliefs, but Problem solving to identify ways to accommodate the changes within the existing belief structure.  

OR

• "Denial of need to change"  
• Again a nutrition intervention with Nutrition counselling is appropriate, however the focus would likely be on using the Health Belief Model and perhaps Motivational interviewing to facilitate a discussion where the individual came to the realization that there were consequences likely associated with continuing in present course/not making changes that are outweighed by the benefits of making the effort to make changes.

OR

• "Food and nutrition related knowledge deficit concerning" how to prepare appropriate foods based upon nutrition prescription
• Here a nutrition education intervention would be appropriate, however it would not be the "content" of the diet it would likely need to focus on Nutrition Education-Application, Skill Development, and might involve Collaboration and Referral of Nutrition Care to community agencies/programs to find a suitable cooking course that would meet their needs.

It isn't until a person has started working with the NCP and terminology that you truly come to realize that while naming the problem is important, it is even MORE important to properly understand the etiology, the underlying cause.  Only by understanding the WHY the nutrition problem exists can the dietitian design the optimal nutrition intervention to correct the problem.  The same holds true for other types of etiologies (Access, Behavior, Physical Function, Physiologic-Metabolic, Psychological, Social-Personal, and Treatment).  

Citations:

Etiology Matrix in ENCPT, available at https://ncpt.webauthor.com (Available by subscription)

For student assignments that specifically guide students in making the connection between the etiology and the intervention see the Nutrition Care Process and Terminology:  A Practical Approach.  

Cascade of Nutrition Outcomes - One Thing Leads To Another!!

The critical thinking involved in Monitoring and Evaluation, the last step in the Nutrition Care
Process, is the identification of indicators and criteria that will provide evidence that the nutrition intervention of the dietitian is effective.

Outcomes can be thought of as occurring in a cascade, each level of outcome leading to outcomes in the next layer, until you reach the ultimate outcome desired.  This may be visualized as shown using the domains of terminology.

For example, let's take a case of a person with Diabetes Mellitus who received both nutrition education related to how to choose foods according to plan and counselling to ensure readiness to change.
Then one short term  indicator of success for this nutrition intervention may be a change in knowledge about optimal food choices and change in readiness to change that could be measured at the end of the nutrition consultation and again at the beginning of the next appointment.  This change in knowledge and beliefs and attitudes would be expected to lead to a change in behavior around food choices, perhaps in adherence with meal planning/food choice guidance and types of food/meals consumed.  That change would then lead to a change in food or nutrient intake, perhaps change in total carbohydrate intake or total energy intake.  This change over time would likely lead to changes in self monitored blood glucose levels and eventually to change in HBA1C.  These changes could then lead to changes in quality of life measures, perhaps health related quality of life scores or disease specific quality of life scores.

Dietitians often look at the biochemical measures or anthropometric measures and overlook the more immediate short term measures that are related to their intervention  or overlook the more global quality of life measures.

If we miss the opportunity to document  immediate short term measures that are specific to our intervention (changes in knowledge, behavior, and dietary intake), we don't really know if the changes in laboratory values are related to our intervention or whether they are coming from other interventions such as medication changes.

While dietitians do not claim full responsibility for changes in biochemical or anthropometric measures, without the immediate short term measures we lack any evidence that we even contributed to the outcomes!!

Bottom line:  Using the cascade of outcomes diagram helps dietitian think of a range of outcomes that demonstrate effectiveness of nutrition interventions and create a logical argument that nutrition interventions are related to positive health outcomes.

Want to practice NCPT, but not impact patient care??? Case simulations may be part of the answer

As more people both in the US and internationally are exploring and implementing both the Nutrition Care Process and using standardized terminology (eNCPT), more demonstration cases are being developed for use.

Is there a way to develop some common guidelines that can assist those developing cases to make their cases as effective as possible?  And assist educators in selecting the right resource for their needs?

After having the recent experience of  developing the five in-depth cases using two "standardized patients" for our new text, Nutrition Care Process and Terminology:  A Practical Approach, here are some starting thoughts.  Some of these are pretty basic, but it is amazing how they stand the test of time.

• Cases developed to demonstrate the use of the Nutrition Care Process and the Nutrition Care Process Terminology need to reflect the most current terminology.  
• Much to our chagrin, the minute we released our text in early October 2015, there was an update to the ENCPT.  This caused several months of intense review to update the terms used in our cases and activities and publication of an update to address new terms.

• A clear articulation of the exact skills to be learned in a case is essential.  Attention is needed to reflect  all aspects of the interaction between the patient and dietitian to maximize the learning from a case study/simulation.  To help educators select resources, attention to clear learning objectives are essential.  

• Different types of cases needed for different skills
• Starting with a written story that provides all the key elements of the patient's life is entirely appropriate for an objective that deals only with how the dietitian uses data/information to evaluate the situation.  But this would not be sufficient to address the skills needed to review a medical record to extract data nor the interviewing skills necessary to elicit the information from the patients or the communication skills needed to verbally summarize nutrition care.   
• We decided to supplement the written story with a Virtual Learning Environment with video clips and the opportunity for student so submit videos where they "asked" the patent questions, or recorded their opening comments or summary to the patient, or discussed patient progress with the physician.  These types of additional components take a written case a step closer to "real life".  Karen Lacey's forward summarized her opinion on this aspect.  

• The eNCPT Student Companion Guide created by the Academy also includes a basic patient scenario and may be appropriate for the very first introduction to the process and terminology. However the first printing of the Instructor Solution Manual had some information that needed to be more clearly presented (e.g. regarding what was being shown as "prescription"  and "intervention" in the answer keys in the solution manual were co-mingled creating confusion about what the Nutrition Prescription was, what the Nutrition Intervention was, and how to appropriately use the terminology.  The examples provided were not consistent with the descriptions on the eNCPT.)  This guide also includes sample exam questions that can be used to test content knowledge.  It provided a framework for identifying ALL potential nutrition diagnoses based on existence of nutrition assessment signs and symptoms that may be useful as a starting point for less advanced students.  

• There are other aspects of nutrition care that can also be incorporated into different types of simulation.  For example, a simulation that allows the practitioner to explore whether they should be performing a specific task is also needed.  Especially for students who are still learning what is within and what is outside their scope of care.  The "cases" provided by the Academy address some common situations e.g. writing PN and EN orders, ordering laboratory tests, making physical activity recommendations, screening for swallowing difficulties.  These are available to members and for sale to non members addresses this need.   The cases developed by Quality Management from the Academy include the eNCPT as a resource for the cases. 

• Cases are also available that demonstrate various ethical situations, e.g. social media and applying the code of ethics to decisions.  Whenever appropriate these cases should also integrate the framework of the nutrition care process and terminology.  

• Technology continues to evolve at a dizzying pace.  Harnessing the latest to effectively provide learning experiences will be key.  
• The use of Second Life Avatars to allow the students to more fully "experience" doing a Subjective Global Assessment is certainly a unique way used by Dr Alison Steiber.  
• Work completed by Dr Pattie Landers to develop case studies that include the experience of using electronic medical records also provides a different type of simulation experience.   While we know that each electronic medical records is quite unique, being able to see and experience the potential features is essential to ensuring a smooth transition from paper cases/medical records into the world of electronic documentation.

While we know that experiential learning is essential, it will be a challenge to keep these simulations current and to curate the resources available to continually select the most appropriate for the stated objective for the cases.  Just as the case study developers are challenged, so are the educators challenged to continually review and select the materials that most closely meets their classroom/educational program needs.