Inquiring minds want to know...How many countries are using NCP and IDNT?

Participants in the MEDNA pilot survey asked how many countries other than the US are using the NCP and IDNT (Nutrition Care Process Terminology)?  While we don't have a complete answer for exactly how many countries are currently using it or the extent of the use, here are some links to what has been posted on a number of websites relative to the Nutrition Care Process and standardized language in countries other than the US.

The International Confederation of Dietetic Associations (ICDA) has posted their support for the concept of having a global process that describes how dietitians approach nutrition care.  They have a tab on the ICDA home page for the NCPT and states “The Nutrition Care Process being promoted by the International Confederation of Dietetic Associations provides a framework for nutrition and dietetic practice”. 

The European Federation of Associations for Dietitians (EFAD) has also posted a document summarizing their thoughts called the Vision paper: The implementation of a Nutrition Care Process (NCP) and Standardized Language (SL) among dietitians in Europe.  The Professional Practice Committee recommends that all national dietetic associations "support the access and use of a chosen Nutrition Care Process/Dietetic Process (NCP) model and a SL developed for dietitians."  

The DietitiansAssociation of Australia website includes a document, Health Informatics and e-health, outlining their support for the standarized language saying that " A working party has now been formed to facilitate the the implementation of Nutrition Care Process Terminology (NCPT, formerly IDNT) in Australia" 

British Dietetic Association includes the statement that "The BDA has approved the adoption, with adaptations, of the international Nutrition Care Process Terminology (NCPT) as the preferred standardised language (terminology) for use in electronic records" in their document Nutrition and Dietetic Process Terminology.  Another document Model Process for Nutrition and Dietetic Practice states "The BDA believes that the implementation of the Process for Nutrition and Dietetic Practice is important as it enables you to show how you deliver effective and quality nutrition and dietetic services".

Dietitians of Canada discusses the need for NCP and Standardized language in a public policy statement called Canadian Perspectives on the Nutrition Care Process and International Dietetics and Nutrition Terminology .  They state  " The Nutrition Care Process (NCP) and International Dietetics and Nutrition Terminology (IDNT) are recommended by the International Confederation of Dietetic Associations for international adoption as a framework for dietetic practice" 

The Swedish Dietetic Association has fully supported the NCP and IDNT/NCPT and has issued a position statement, POSITION STATEMENT - NCP and IDNT,  that  "recommends the implementation of NCP and IDNT" and included a translation of key parts of the model description and terminology in Swedish on the ENCPT. 

Venezuela published an article, Nutrition Care Process and Model from the American Dietetic Association;  useful tool for nutrition transition countries by Marianella Herrera in 2010 

According to a website from Fukuoka Womens University, Professor Yoshinori Katagiri reported being at 2014 member of a Working Group of the Japan Dietetic Association for reviewing Nutrition Care Processes.  

Two documents summarize published research on use of NCP in other countries (Korea and Venezuela). A summary of research evaluating the use of the NCP use in Korea, A Survey on the status of Nutrition Care Process Implementation in Korean Hospitals by Kim and Baek was published in Jul 2013
A description of research conducted in Venezuela for childhood obesity prevention,  Going International:  Using Kids Eat Right to Address Childhood Obesity and Under nutrition Part II   by Marianella Herrera shows how to use INDT in describing their intervention. 

The Academy International Nutrition Care Process website includes a place for countries to share documents.  This tab includes a Venezuela implementation plan (under Documents, Implementation) 

While this list certainly is not inclusive, it gives a glimpse into what other countries are doing relative to the NCP and standardized language. 

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List of Links Embedded in Message:

ICDA - http://www.internationaldietetics.org/

EFAD - http://www.drf.nu/wp-content/uploads/2014/08/EFAD-Prof-Practice-Committee-2014.pdf

http://daa.asn.au/for-health-professionals/daa-committees/health-informatics-and-e-health/

https://www.bda.uk.com/professional/practice/terminology https://www.bda.uk.com/professional/practice/process

http://www.dietitians.ca/Dietitians-Views/Health-Care-System/NCP-and-IDNT.aspx

http://www.dietitians.ca/Downloadable-Content/Public/hospitalcare-position-paper

http://ncpt.webauthor.com/

http://anales.fundacionbengoa.org/ediciones/2010/2/?i=art6)

http://www.fwu.ac.jp/teachersdatabase/detail/english/?masterid=79&gakkaid=203&gakubuid=20

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3728464/

http://files.abstractsonline.com/CTRL/DE/9/B9B/F2E/1E8/41D/F82/583/074/54C/F84/87/a952_1.pdf

http://aincp.webauthor.com/

If I'm new to the Nutrition Care Process (NCP) and IDNT, where do I start?

A recent survey in Middle Eastern countries asked dietitians and nutritionists about their awareness, knowledge and use of the Nutrition Care Process and the standardized terminology.  They also identified questions they would like answered.  One of the questions was:  "If I am new to the Nutrition Care Process (NCP) and IDNT, where do I start?"  

There are a lot of resources available to you at no charge.  Some of these are located on the Academy of Nutrition and Dietetics and are available to you even if you are not a member of the Academy of Nutrition and Dietetics.

One of the first things you may want to do is to check out the Academy's website for Nutrition Care Process information for Health Professionals   It is located at:  health professionals information on the eatright.org website. (http://www.eatright.org/HealthProfessionals/content.aspx?id=7077)  

Another source of information is to the International NCP page, which is free to all and allows for discussion of international implementation issues at http://aincp.webauthor.com/ .  Although the website asks you to "register" there is no fee associated with registration and use of the site at this time.

When you access these sites, a way to get started might be the following:
1) read the article , Nutrition Care Process, Update Part 1, that describes the current model and the content of each of the steps.  This is a comprehensive description of the entire model as well as the steps in the nutrition care process.

2) Then read each of the snapshots as a review of the article's high points.  These are intended to be quick and easy references for each of the steps.  This document downloads 4 pages, a one page summary for each of the four steps in the nutrition care process:  Nutrition Assessment, Nutrition Diagnosis, Nutrition Intervention, and Nutrition Monitoring and Evaluation.

3) After getting an overview of the Nutrition Care Process, then you may want to read the article about the standardized language,  Part 2 of the Nutrition Care Process Update.  This article summarizes the way the terminology was created, organized and the basics on how to use it.

4) At this point you may want to find someone who is using it that you can discuss with them, or you may want to start looking at cases to see what it looks like in practice and will likely want to attend a workshop where you use cases to work with applying the NCP and terminology.  You could also read older blog issues on specific topics that you find challenging.

 If this was your question, please let me know if this was helpful.

If a picture is worth a thousand words...what is a "model" worth?

Lets examine the various components of the Nutrition Care Process and model...starting with the CORE of the model...the patient-dietitian relationship.  
Open access has been provided to an article that traces the history of one line of thinking that clearly influenced the formal development of the Academy of Nutrition and Dietetics' Nutrition Care Process and Model.  The article lays out the historical evolution of the dietetics teaching models that occurred at Pennsylvania State University starting in the 1970's and identifies the body of knowledge that was used to articulate some of the key concepts.

For example, this article traces the evolution of the core (center) of the model...the relationship between the dietitian and the client.

In the original hand drawn model the core/center of the model was just the words "dietitian" and "patient" with arrows indicating a two way interaction.   In the 1977 Hammond model the core depicted "The Helping Relationship, Rapport, empathy listening, objectivity, etc" and the concept reflected drew heavily on Dr Steven Danish's work at Pennsylvania State University from the Psychology department.

 In the 1984 Hammond model the core was depicted as a "Partnership" between the clinical dietitian and the patient/client with the two way interaction arrows.  In the 1986 model core was depicted as a "Partnership of Individuals" again listing the clinical dietitian and patient/client as those involved. As Marian Hammond described the thinking at the time, this notation reflected the belief that "each member’s individuality affected the partnership dynamics, process, and, most likely, quality of outcomes."

Later, both the original 2003 and the updated 2008 Academy of Nutrition and Dietetics (then called the American Dietetic Association)  models have the core of the model designated as the "Relationship between the patient/client/group and the dietetic professional".

Occasionally people ask whether the Nutrition Care Process is really patient-centered or client-centered. While it certainly it takes more that one component in a model to truly fulfill the concept of "patient centered-ness",  this evolution clearly shows the intent for the model to recognize the importance of putting the patient/client at the very "core" of the whole process.  

Hammond, M, Myers, E, Trostler, N. Nutrition Care Process and Model:  An Academic and Practice Odessey.  J Academy of Nutr and Diet, 2014.  FREE FULL TEXT LINK

Danish SJ. Developing helping relationships in dietetic counseling. J Am Diet Assoc. 1975;67(2):107-110.

Danish SJ, Ginsberg MR, Terrell A, Hammond MI, Adams SO. The anatomy of a dietetic counseling interview. J Am Diet Assoc. 1979;75(6):626-630.

LaQuatra I, Danish SJ. Effect of a helping skills transfer program on dietitians’ helping behavior. J Am Diet Assoc. 1981; 78(1):22-27.

Are Goals, Expected Outcomes, Indicators and Criteria all the same??

In the Nutrition Care Progress notes, Evidence-Based Practice Guidelines, and references about nutrition care we have several terms that are all used to describe the outcome of our nutrition care.

It can be confusing when trying to discern what is a goal, expected outcome or indicator and criteria.

For each of these terms there are varying definitions, however as we think about how they are being used in the context of nutrition care we can determine how to incorporate them into our work as dietitians.

To illustrate how these might be similar or different we are going to follow the wording used to reflect sodium intake and energy (calories) through one specific condition, Heart Failure.

GOAL
For example within Evidence-Based Nutrition Practice Guidelines (EBNPG) the word "goal" is used generally to refer to the broad statements used to reflect the purpose of the EBNPG.

Example:  In the Heart Failure EBNPG Toolkit it states:
"The goals of nutrition care include a reduction in sodium and fluid intake and the monitoring of calories, protein and nutrient needs."  

The components of the nutrition prescription may also serve as a more specific articulation of these goals. The completed example of a progress note shows the nutrition prescription as 1800 KCal, 2 Gm Na, 2 gm Potassium diet, 65 Gm protein with 1900 ml fluid.

GOAL/EXPECTED OUTCOME
The EBNPG Toolkit in the Intervention step description indicates that the "Goal/Expected Outcome" should include the amount of change anticipated, the timeline for change, they should be clear and concise, client-centered, tailored to what is reasonable and reflect appropriate expectations based on treatment.

Within this context, the sodium level specified in the Nutrition Prescription is a more specific articulation of the broader goal statement.  Thus the goal/expected outcome  for the intervention of either education or counselling is to achieve this specific level of sodium.  In other words, the reason we educate the patient/client is to provide them with the necessary knowledge to select foods that were within the sodium level specified in the nutrition prescription.

 The Heart Failure EBNPG toolkit identifies the following as examples of what could be included as Goal/Expected outcomes for the overall nutrition therapy:

• "Biochemical (sodium and potassium, fasting glucose within normal levels, and creatinine and BUN at upper limits.
• B12, B5, folate, thiamine and magnesium
• Weight change less than 2 lbs overnight or 5 lbs gain in one week
• Physical activity within New York Heart Association (NYHA) functional classification established for patient
• Intake with sodium no more than 2 Gm and fluid intake within 48-64 fluid ounces per day"

Example:  In an actual progress note, the goal listed in the intervention section might be as follows:

"Goal/Expected Outcome:  Increase dietary intake to 90% of estimated energy and protein within  fluid and sodium limits"

INDICATORS/CRITERIA
In the Heart Failure EBNPG toolkit discussion on potential monitoring indicators, the following items are included as examples that might be used from the Food and Nutrition-Related Outcomes.  (Note:  Other potential indicators are included from the other Nutrition Assessment/Monitoring and Evaluation Domains)

"Food and Nutrition-Related Outcomes

• Fluid/beverage intake
• Food intake
• Alcohol intake
• Protein intake
• Carbohydrate intake
• Vitamin intake
• Mineral intake
• Food and nutrition knowledge
• Beliefs and attitudes
• Adherence (self reported adherence score)
• Physical Activity and function"

The Heart Failure toolkit text also lists the Nutrition Prescription as providing the specifics for the goal  as well as being used when identifying the criteria to be used for the indicators.  i.e.you would compare the actual intake against the criteria of the nutrition prescription/goal or reference standard.

Example:  In this case the following might be included as the indicators and criteria.

• Indicator (energy) and criteria (1620 KCal which is 90% of the estimated requirement of 1800)
• Indicator (sodium) and criteria (2 Gm sodium)
• Indicator (Fluid intake) and criteria (between 1900 - 2000 ml per day)

References:

Heart Failure Evidence-Based Nutrition Practice Guideline Toolkit, 2011, Available at:  https://www.eatright.org/shop/product.aspx?id=6442472073

Value of "THINK ALONG" Nutrition Care Process cases

As dietitians throughout the world increasingly use a common nutrition care process and standardized  language to describe and document their care, the value of   THINK ALONG  cases becomes apparent.  I first recall hearing about "think along"  from the late Dr Mary Ann Kight, in the late 1990's.  Dr Kight is the person who first developed the thinking behind the concept of a "Nutrition Diagnosis" in the United States.  She was describing her method for teaching others the logic behind the process of making a nutrition diagnosis.

 If you search the concept of  THINK ALONG, you find that it usually involves reading with another person (many times childhood education) and involves the following things:

• Expressing how you are thinking so another can "follow along" in their own thinking process (and perhaps add to the thinking as you go)
• Allows you to talk about related topics, e.g. other similar experiences, other patients, or research
• Allows you to explain how you are arriving at a given conclusion or interpretation of the material, e.g. how you decided that xxx was the primary nutrition diagnoses needing to be addressed during this patient encounter
• Allows you to engage the other by asking questions that stimulate creative and critical thinking 
• Why does this occur? (explanation)
• What do you think will happen next? (prediction of future)
• Allows both parties engaged to tell about other things they know on the topic e.g. related medical conditions where this also might be true, current research on topic, or historic context of case

So what would THINK ALONGs look like with Nutrition Care Process (NCP) cases?  

Well, the cases might be structured in such a way that some information is presented and then there is a discussion about what this means, then some additional information is provided and another discussion of how it would be interpreted now that there is additional information.  

Or it might be that an entire case is presented with a series of questions afterward to allow the reader to "follow along" with the logic that has been described and either contribute to agreeing or posing alternative interpretation of the data or alternative interventions that might be successful.  

After doing many NCP workshops throughout the world, I have come to the conclusion that I agree with Dr Kight.  The best way to "teach"  the concepts of the NCP and the choice of the standardized terms to describe our dietetics care is a "think along".  

Ideally there is a two way process of presenting a case, engaging in a dialogue about what this "means" and a dialogue about what would be the "best course of action", and finally a dialogue about "how it might be documented".  

The dialogue process among peers is the best way to bring our assumptions to light and allow us to have a truly productive conversation about how we can continually improve our dietetics/nutrition care.  

Nutrition Prescription---is it the bulls-eye or the arrow??

The bulls-eye in the center is the target being aimed at (nutrition prescription), however the arrow (what is implemented) may not always be exactly on target the very first time (either by design or by lack of full understanding of the situation).

The original thinking about the steps in the Nutrition Care Process included a planning portion of the Nutrition Intervention which was referred to as the Nutrition Prescription.  The Nutrition Prescription is intended to "concisely state the patient/client recommended dietary intake of energy and/or selected foods or nutrients based on current reference standards and dietary guidelines and the patient's/client's health condition and nutrition diagnosis."

Planning versus Implementing

The Nutrition Prescription is the place in the nutrition care process where the dietitian uses clinical judgement to integrate all the work completed in the nutrition assessment and nutrition diagnosis into a single concept that reflects optimum nutrient and physical activity for the patient...(the bullseye target)
On the other hand the actual intervention of Food and Nutrient Delivery reflects the actual implementation at this moment (usually in an institutionalized setting).  If the dietitian is in a position to PROVIDE the actual food and or beverages (e.g. institutionalized setting or as outpatient provide supplemental nutrient beverages or vitamin/mineral supplements) then they would select the FOOD AND NUTRIENT DELIVERY for the actual products being provided...(this is the arrow).

Time Lag in Implementation

 Another concept that differentiates the two concepts is timing.  In some cases the dietitian may determine the optimal nutrition prescription, however the actual food and nutrient delivery may need to be gradually implemented.

A classic example is that of a patient in an ICU setting where the dietitian determines that the patient needs 2600 KCal from enteral tube feeding as the nutrition prescription, but this needs to be provided by gradually increasing both the strength and rate until the optimal intake is achieved.  The goal is for the two to eventually be the same, but there will be a time during the course of care when they are in fact different for sound clinical reasons.

In other cases there may also be gradual progress toward the optimal nutrition prescription based on principles of making small behavior changes to eventually reach optimal lifestyle habits rather than trying to make ALL the changes at once.

Bottom line...they are closely linked or identical depending on the situation.

The Odessy of the Nutrition Care Process

The article chronicling the development of the original Hammond model (1970-1986), has been released as an Article in Press for the Journal of the Academy of Nutrition and Dietetics on October 10th.  The Hammond model was one of the key documents contributing to the Academy's Nutrition Care Process first published in 2003.

For Marian Hammond, this article has been a labor of love.  The article has been over 7 years in the writing and tells the story of the development of the Nutrition Care Process over a 30+  year period.  The figures show the evolution of the Hammond Model diagram from a handwritten diagram into a more formal graphic that was published in 1986.

It describes in detail the references that were synthesized to contribute to all the concepts and components of the various models as well as the thinking that was behind the various changes made in the Hammond Model iterations.

We have requested that this journal article be considered for open access to adequately allow the international community free access to the article, or as a minimum to have it included on the Academy International NCP website.

For those of you who are Academy members or whose library subscribes to the Journal of the Academy of Nutrition and Dietetics...you can access it now...for the rest, it may take a while to work through the details of how to best provide access to the international audience.

Article in Press:  Hammond, M, Myers, E, Trostler, N. Nutrition Care Process and Model:  An Academic and Practice Odessey.  J Academy of Nutr and Diet, 2014 

Reflective Practice: Enabled by the Nutrition Care Process & IDNT

Anne de Looy mentioned the importance of reflective practice at her FNCE session, the Wimpfheimer-Guggenheim International Lecture:  Global Dietetic Alliances - The European Experience.     Reflective practice is the ability to experience a patient care episode, document what happened, reflect, and then make plans for future learning/actions. Other descriptions of reflective practice include the value of  "describing" the events that occurred as a way to make sense of it and contemplate whether you took the "right" action and perhaps identify future theories about better alternative actions.    


The model described by Kolb is only one of the models that describes the reflective process.  However most of the models include the essential components of documenting what occurred, reflecting and making sense of the events and formulating theories about why the events unfolded as they did, and making plans to take further action, either to repeat to see if the results are similar or to try something different to see if the results are better.  This reflection process is discussed extensively in the research about critical thinking.

This same concept, how we describe and discuss our dietetics care, came up on October 2 during the Nordic NCP and Terminology Network meeting in Oslo, Norway.  We identified one of the benefits of implementing the Nutrition Care Process with the companion standardized language as discussing our dietetics practice in a new way.

At the FNCE  Open Session, Nutrition Care Process Case Studies:  Developing PES Statements and Interventions in Atlanta, where Jennifer Wooley and Debra Geary Hook facilitated the session and attendees used the NCP and terminology to describe the care they would likely provide in specific cases.   I was lucky enough to join a table and  participate in the discussion regarding how to provide care for one of the case studies.

Three of the participants started their descriptions of what they would do with " I would talk with the patient about".  Each of the dietitians described slightly different approaches to the conversation that they thought they might have used with a patient similar to the one described in the case.  It became obvious that each of them was coming from a slightly different perspective.

When I used the NCP terminology and asked them whether their focus was Nutrition Education (providing information) or whether it was Nutrition Counselling (supportive process facilitating behavior change) each of them paused to think.  The discussion then centered around whether we thought he didn't KNOW, leading to butrition education or whether he "KNEW but wasn't doing" which would lead to nutrition counselling as the preferred intervention approach.

After discussion, the table explored the option that perhaps he really "knew" and thus needed counseling to facilitate his implementation of the knowledge.  The conversation then moved to identifying which of the counselling Theoretical Basis/Approaches from the IDNT (e.g. Cognitive Behavioral, Health Belief, Social Learning, or Transtheoretical) the planned conversation with the patient reflected.  Each of the dietitians was asked to describe their underlying assumptions that were reflected in the type of conversation they imagined they would have.  They were also asked to frame their "conversation" by identifying which specific strategy they would be focusing on.

While this was a hypothetical exercise,  it demonstrates the concept of reflective practice where the dietitian reflects on what they (would have) done and why.  If this had been an actual case, the dietitians would have been able to also see what the outcome was and then reflect on whether their approach had been successful or whether another approach might have been better.  The use of the NCP as a framework for the discussion and using the specific terms for the nutrition intervention allowed a completely different level of discussion about what type of care would or should be provided to the patient.

It isn't that dietitians haven't always wanted to practice in the most effective way.  It isn't that dietitians haven't sought out research that can identify ways to improve their practice.  But without a unifying structure (the Nutrition Care Process) and the common language (IDNT) to describe what was occurring during the care being provided, we really didn't have a way to effectively record what occurred during our patient interactions,  to effectively discuss and debate about what could improve our practice, or a truly effective way to apply research to our own practice.

Schön, D. (1983) The Reflective Practitioner, How Professionals Think In Action, Basic Books. ISBN 0-465-06878-2.
Sheilds R.W., D. Aaron, and S. Wall (2001), What is Kolb's model of experiential education, and where does it come from?, Questions and Answers on Adult Education, The Ontario Institute for Studies in Education, University of Toronto. Web-page accessed 29 November 2010

Also special appreciation to the other table facilitators at the FNCE session:  Maree Ferguson,  Tina Papoutsakis, Joyce Buhler,  Sandra Spann,   Patti Landers, Cathy Christie,  Paula Ritter-Gooder,  Camella Rising, and   Gretchen Robinson

And a special thank you to Sissi Stove Lorentzen, Lene Thoresen, and Ylva Orevall for coordinating the Nordic NCP and Terminology Network in Oslo.  

Standardized Languages: ICF and IDNT -- Different, Similar, or Compatible??

At FNCE there was an excellent session on international issues in implementing the Nutrition Care Process.   Daniel Buchholz and Rubina Hakeem discussed Middle Eastern and European implementation of the Nutrition Care Process (NCP) and standardized languages.  For more than 5 years we have been thinking about how the International Classification of Functioning (ICF) and International Dietetics and Nutrition Terminology (IDNT) relate to each other.

We have noted previously that the ICF dietetics extension developed by the Dutch has a more robust assessment of the some areas of nutrition assessment (particularly descriptions of taste and appetite).  But it wasn't until I heard Daniel and saw the phrase on one of his slides that the light-bulb really came on.

His slide said something to the effect that the ICF-Dietetics was intended to describe the functions of the patient.  At this moment the pieces clicked into place in my mind!!

The two languages have different purposes.  The ICF is describing the patient, and the IDNT describes the care that dietitians provide to the patient.  As a necessity parts of the IDNT also describes the patient (Nutrition Assessment, Nutrition Diagnosis, and Monitoring and Evaluation) since the care provided by the dietitian is based on their assessment of the patients condition and changes in the patient condition reflect whether the care was successful or not.

So the major way of thinking about how the two languages intersected was in contemplating the PURPOSE of the language...

And according to the Page 5 in theWorld Health Organization Family of International Classifications: definition, scope and purpose" the ICF is ONE of several sets of  standardized languages that are intended to be used together.  The other languages are the International Classification of Diseases and Conditions (for diagnoses) and new sets being developed to describe health interventions, the International Classification of Health Interventions (ICHI).

I began playing with how to lay this out in a way that was easy to understand so we could have a more productive conversations.  I am more familiar with the IDNT and welcome comments from those more familiar with the ICF.  Below are some initial thoughts:

Nutrition Care Process Steps	ICF Terminology	IDNT Terminology
Focus of terminology	Describe patient	Describe care provided by dietitian
Nutrition Assessment	Information from WHO Website:  Functioning and disability are classified separately in the International Classification of Functioning, Disability and Health (ICF) Terms describe patient’s functioning using ICF domains.  The WHO generic ICF evaluation checklist captures the following sections:  PART 1 -Impairment of body functions -Impairment of body structures PART 2 -Activity Limitations and Participation Restrictions PART 3 -Environmental Factors PART 4 -Other Contextual Information It includes scoring terms and guidance for each section tailored to the items that are being assessed. The proposed dietetics extension includes specific nutrition functioning.  Specific nutrition assessment data may or may not be included (e.g. gms of carbohydrate intake)	Terms in Nutrition Assessment are intended to reflect the individual nutrition assessment data/factors evaluated by the dietitian in the following domains: -Food and Nutrition History -Anthropometric measurements -Biochemical Data, Medical Tests and Procedures -Nutrition focused physical findings -Client History Dietitians choose how to capture data relative to the assessment data identified (record actual Gms, Servings, gm/dl, weight, etc).  Standard scoring not provided.
Nutrition Diagnosis	Terms blur together with both assessment of body functions, activity limitations, participation restrictions, and environmental factors that could be framed either as assessment of the situation or as the “problem” to be addressed.  Information from WHO website:  Diseases and other related health problems, such as symptoms and injury, are classified in the International Classification of Diseases, now in its 10th revision (ICD-10)	-Diagnosis terms are higher level with combinations of the nutrition assessment data used to determine which problem exists and it is intended to be used to reflect the care being provided in this episode/visit, not overall functioning
Nutrition Intervention -Prescription/plan -Intervention	At present interventions can only be reflected by indicating a desired “change” in status, e.g. change in knowledge, or change in functioning, referred to as the individuals ability to "manage" intake.  Information from WHO website:  A third reference classification, the International Classification of Health Interventions (ICHI), is under development. The individual health experience in general can be described using the dimensions of the ICD and ICF. The needs of the user will determine the number of dimensions, and the level of specificity used. Other classifications needed to describe other aspects of the health experience and the health system have been adopted as related classifications (e.g. ATC/DDD3 classifies therapeutic chemicals).	Terms reflect the nutrition prescription to be pursued and the method used by the dietitian to pursue that optimal nutrition prescription.  Dietitian focused terms:  provide food, nutrition education, nutrition counselling, collaboration with other health care providers
Nutrition Monitoring and Evaluation	Changes in scores associated with selected terms used to describe the patient’s functioning can be used to monitor and evaluate impact of intervention	Changes in selected nutrition assessment terms can be used to monitor and evaluate impact of intervention.

Is all the focus on Critical Thinking "much ado about nothing"?

Why spend all the energy outlining the critical thinking that occurs in each of the Nutrition Care Process steps?

The answer is fairly straightforward.  The critical thinking is one of the key skills that the dietitian contributes to the process!

It is the ability to USE all that unique body of dietetics knowledge that dietitians have learned in their formal education process to gather and assess data, identify problems that need to be addressed,  to select the most important and appropriate interventions in collaboration with the patient/client and healthcare team, make recommendations to clients and healthcare team members, and guide problem solving when situations arise that need additional thought.

When the first article was published in 2003, the term Critical Thinking was formally defined, elaborated, and included in the terms defined in the article. (1)   While it had been used prior to this in educational standards, it had not been formally defined for dietetics.

The 2003 article went further and stated:

"Critical thinking integrates facts, informed opinions, active listening and observations.  It is also a reasoning process in which ideas are produced and evaluated"

"The use of critical thinking provides a unique strength that dietetics professionals bring to the Nutrition Care Process.  Further characteristics of critical thinking include the ability to do the following:

• conceptualize
• think rationally
• think creatively
• be inquiring and
• think autonomously."

It was felt to be so important, that when each of the steps of the nutrition care process  was elaborated in the articles accompanying the Nutrition Care Process and Model, a separate section was devoted to further delineating the critical thinking of the dietitian in each of the steps. (1,2)

In the 2012 standards for dietetics education programs it is mentioned 8 times, usually in relationship to problem solving  (3) For example:  "Critical thinking is the careful attainment and interpretation of information to reach a valid conclusion" (3)  In the formal definitions  critical thinking is defined as "The ability to draw conclusions about issues where there are no clear-cut answers by analyzing, synthesizing and evaluation facts, informed opinions and observations".

The practice paper on nutrition assessment also echoes the importance of critical thinking. (4)  Additional work has been published on critical thinking as it applies to dietetics topics. (5)

Bottom line:  Critical thinking is an important contribution throughout the steps in the Nutrition Care Process that is provided by the dietitian and significantly affects the outcome of the nutrition care process cycle(s).

1.         Lacey K, Pritchett E. Nutrition Care Process and Model: ADA adopts road map to quality care and outcomes management. J Am Diet Assoc. Aug 2003;103(8):1061-1072.

2.         Nutrition care process and modelpart I: the 2008 update. J Am Diet Assoc. Jul 2008;108(7):1113-1117.

3.         ACEND Accreditation Standards for Dietetics Education Programs:  Available at http://www.eatright.org/ACEND/content.aspx?id=57.  Accessed Sep 2, 2014.

4.         Critical Thinking Skills in Nutrition Assessment..  Available at: http://www.eatright.org/Members/content.aspx?id=6442478892

5.        Trostler, N, Myers, E.  Review of critical thinking.  Making decisions to either measure or estimate Resting Metabolic Rate Requirements (RMR).  Top Clin Nutr.  2008:25(4):278-292.

Is the NCP a Process or a Model....or both??

Both!!  as the formal name implies...NUTRITION CARE PROCESS AND MODEL (NCPM)

The 2003 and 2008 revision of the NCPM diagram published by the Academy was intended to reflect both the Nutrition Care Process as well as provide a model that described the context in which the Nutrition Care Process occurred.  Both articles published elaborated on the thinking that was behind each of the components of the Model. (1,2)

NUTRITION CARE PROCESS
Strictly interpreting things.... NCP refers only to the four steps represented in the diagram:  Nutrition Assessment/Re-assessment, Nutrition Diagnosis, Nutrition Intervention, and Nutrition Monitoring and Evaluating.  And there are times when you are focusing just on these steps and it may be appropriate to use a diagram that only represents these activities.

Having said this, it should be recognized by anyone who has truly studied "processes" that this diagram is NOT a typical process flow chart...it is a stylized representation of four large groups of processes...usually referred to as a "block diagram".  The traditional symbols of a process flow chart are not used and it does NOT reflect the actual sequence in which these activities occur when performed.

AND MODEL
However when you refer to the NCPM this refers to all the other components of the Model as well.

Two definitions of a model hold true for the larger diagram.  Webster's dictionary includes these definitions:    a) a set of ideas and numbers that describe the past, present, or future state of something (such as an economy or a business)  and b) an example for imitation or emulation.  Both of these represent what the larger diagram was intended to convey to the public and to the dietetics profession as a whole.

The Model includes two key activities that are often accomplished by persons other than dietitians....the 1) screening, that occurs before the NCP steps where the individuals or populations that would benefit from dietitian intervention are identified, and 2) the outcomes management where data is aggregated and the dietitian's or department's overall performance is evaluated.

The Model also includes other factors that affect the outcomes of the NCP represented by the core and two outer circles encircling the  four NCP steps:

1-core (relationship between dietitian and patient/client/population)  which is the basis of all counseling relationships and critical to any interaction where the dietitian is facilitating change in nutrition-related behavior or making decisions about nutrition care

2- outer circle representing the environmental factors that affected the outcome::  Healthcare systems, Practice settings, Economics, and Social Systems

3- innermost of the two outer circles representing the strengths and abilities that the dietitian him/herself brings to the process: Code of ethics, Dietetics knowledge, Skills and competencies, Critical Thinking, Collaboration, Communication, and Evidence-based practice.

Periodically the Academy engages in a process to update and revise the Nutrition Care Process and Model based on questions that have arisen or new information.  Each time this has involved publication of a formal paper that explains the rationale behind the changes/revisions to the NCP and Model.  We look forward to future revisions to the NCPM and understanding the logic behind the proposed changes.

1.            Lacey K, Pritchett E. Nutrition Care Process and Model: ADA adopts road map to quality care and outcomes management. J Am Diet Assoc. Aug 2003;103(8):1061-1072.

2.            Nutrition care process and model part I: the 2008 update. J Am Diet Assoc. Jul 2008;108(7):1113-1117.

Is the Nutrition Care Process patient centered??

Patient centered...not dietitian centric!!

One of the questions that inevitably comes up is.... whether the Nutrition Care Process is patient centered...or where is the patient in this process?

While the nutrition care process reflects the critical thinking and approach to care that is taken by the dietitian, the model reflects the rest of the system that we work in and shows our relationship to the patient.

Both of the two versions of the Nutrition Care Process and Model published by the Academy included a description of the rationale for each component of the NCPM.  The articles describe the factors that influence and impact the quality of nutrition care provided.

The Lacey and Pritchett 2003 article that described the first model states:   "Central to providing nutrition care is the relationship between the patient/client/group and the dietetics professional."

For symbolic purposes this has been placed at the core, or the very center of the model, specifically identifying the importance of the relationship between dietitian and the person receiving the nutrition care.  

The second article published in 2008 that described the revised model states: "The central core of the model depicts the essential and collaborative partnership with a patient/client"

In other words the entire nutrition care process revolves around the patient who is in the center of it all and involved in all steps of the nutrition care process.

Earlier work completed by Marian Hammond that set the stage for the Academy's model also featured the importance of the relationship between the client and the dietitian.  An upcoming article in the Journal of Academy and Nutrition will show the continued importance of the concept of relationship with the patient throughout all of her iterations as well as how it has been continued in the Academy models.

So the short answer to "Is the nutrition care process patient centered?" is easy to answer....absolutely....just look at the model and you see that the importance of the partnership and relationship between the dietitian and the patient is even more important than the actual steps in the process...it is at the CORE of the model.
    

How specific should PES be??...Like Goldilocks....just right

Like the childhood story of Goldilocks and the three bears, Nutrition Diagnoses and PES statements can be TOO BROAD, or they can be TOO SPECIFIC, or they can be "JUST RIGHT".

Broad Nutrition Diagnoses such as excessive oral intake or inadequate (suboptimal) oral intake are useful when the situation warrants where the intervention is targeted to either less or more of EVERYTHING.  If the intervention is not targeted to one or two specific nutrients, then a broader nutrition diagnosis is warranted.  The nutrition assessment would not need to have as detailed a nutritional analysis of current dietary intake vs estimated requirement that document gaps in specific nutrients when this diagnosis is used.  You may simply have recorded # servings in food categories and use the Pyramid or dietary guideline as the comparative standard.

One example of an appropriate use of a broad nutrition dia
gnosis might be in a long term residential care facility where a resident has consumed one or two teaspoon of each meal for the past two days, Inadequate oral intake might be the best choice.  Since it isn't a long term problem, but one that has just emerged, it may be reflected by a broad Nutrition diagnosis.  This nutrition diagnosis would lead to an intervention focused on increasing intake of ANYTHING.  It would not be reasonable to have multiple nutrition diagnoses, although it would not be technically 'inaccurate', e.g. inadequate energy, inadequate protein, inadequate fat, inadequate carbohydrate, inadequate calcium, inadequate Vitamin C, etc.

 On the other hand, if this were a long term situation where the resident had not been eating over a long period of time and had signs of malnutrition, then this situation would warrant a more specific nutrition diagnosis that reflects the seriousness of the situation, such as malnutrition, or protein-energy.  The nutrition assessment data and comparative standards would need to document the severity of the signs and symptoms that document the discrepancy between estimated requirements and estimated intake which would now lead to an intervention that focused on energy dense and protein rich foods.

Another situation where it may be logical to use a broad nutrition diagnosis might be for a person who has been consuming very large quantities of virtually everything,  The dietitian may choose a broad nutrition diagnosis of excessive oral intake that would lead to an intervention that focused on smaller portions of everything that was consumed.   Again the nutrition assessment data would only need to document portsion sizes or number of servings from pyramid or dietary guideline food categories

However, if you are targeting a specific nutrient with your intervention the it is logical to expect that the nutrition diagnosis would reflect this specific nutrient.  For example if you are modifying protein, sodium, potassium, Vitamin E, or fluid, then your assessment would logically have to include an analysis of that particular nutrient and you would want to use the appropriate comparative standard or nutrient prescription  as the basis to determine whether there is "excessive" or "inadequate" content in the current intake/diet order. In these situations your intervention would the focus on providing or restricting the targetted nutrient.

Bottom line:
The choice of a broad general nutrition diagnosis (suboptimal oral intake) versus a more specific nutrition diagnosis (suboptimal protein intake) is related to the nutrition assessment data available, the intended focus for the nutrition intervention, and corresponding nutrition monitoring and evaluation indicators.

Four steps, but an integrated whole

Although we have the Nutrition Care Process divided into 4 distinct steps, we must always view them as a whole unit, and realize that they do not necessarily happen in tidy neat sequences. 

Dr Kight refered to the "dance" of the nutrition session with a patient/client.  The dance was two steps forward, one step backwards, two steps forward, one step backwards: repeat....

She was referring to the way we have a discussion with a client during a typical dietitian/client encounter.  We gather some information, begin to formulate our preliminary thoughts about what nutrition diagnoses we are dealing with, then we go back into data gathering mode again and gather some more information to confirm our previous thinking, or in some cases decide that perhaps it is actually a different nutrition diagnosis.  In some cases we may already be into providing the nutrition intervention, when the client offers some more information that causes us to re-think our intervention, and perhaps even the nutrition diagnosis that we should be addressing. 

The Nutrition Care Process may be depicted as separate steps, but having all the steps connected is critical to optimizing out ability to help our patients achieve positive nutrition outcomes.

Is there a one "right" PES statement??

Dietitians are concerned about getting the PES statements "right" and are looking for an "answer" to a case that shows the perfect PES statement.

Frequently during NCP/IDNT workshops they are assured that usually there isn't a single "right" PES statement to describe the nutrition problem that they have identified.  And then the discussion goes on to elaborate on how various PES statements could be used to describe the dietitian's judgments about a patient/client's problem that they have chosen to address in their nutrition care.

In some cases, the attendees may interpret this to mean that "anything goes" when it comes to writing a PES statement...this couldn't be further from the truth.  The original point that was being made during the workshop was the importance of focusing on creating PES statements that were as descriptive as possible.  However, the underlying assumption is that the dietitian is competent and has indeed evaluated the nutrition assessment data appropriately and selected one or more appropriate nutrition problem(s) to address--and the focus of the workshop is to help that competent dietitian to best use the IDNT terms available to create one or more PES statements that describe their approach to the nutrition care.

This in no way means that dietitians, or dietetics students in particular, will always appropriately assess the nutrition assessment data and correctly identify a relevant or the most relevant nutrition problem(s) to address. Certainly if the dietitian or dietetics student has made an error in collecting the nutrition assessment data, has selected an inappropriate standard for comparison, or has not appropriately identified the most critical nutrition problem (in the context of the medical conditions and patients' preferences) this will lead to selection of an inappropriate nutrition diagnoses and therefore a PES statement that is "wrong".  

Assuming that the nutrition assessment has been properly completed, a set of questions/criteria have been developed to assist dietitians in creating documentation that best describes the nutrition problem/diagnoses that they have selected and demonstrates the logical thinking of the Nutrition Care Model.  These questions focus on evaluating each component of the PES statement to see if there are opportunities for improvement in constructing the PES statement.

First look at the Nutrition Diagnosis term (Problem) that has been selected and answer the following questions:'
     
          – Can the dietitian resolve or improve the nutrition diagnosis?     
          – Consider the intake domain as the preferred problem     

Then, look at the wording that has been selected for the etiology and answer the following questions:

          - Is the etiology the “root” cause?     
          – Will dietitian intervention resolve the problem by addressing the etiology?     

           Note :If the dietitian intervention can not directly affect or resolve the stated etiology then can RD
                          intervention at least lessen the signs and symptoms?     

Next look at the Signs and Symptoms and answer the following questions:

          – Will measuring the signs and symptoms indicate if resolved or improved?     
          – Are the signs and symptoms specific enough?     

And finally look at the overall PES statement and ask yourself:

          – Does nutrition assessment data support the nutrition diagnosis, etiology, and signs and symptoms?

Educators who are training dietetics students know that students can have a great deal of difficulty identifying the most relevant nutrition problems to address.  There are other teaching strategies to assist students in first identifying the most appropriate nutrition diagnoses, and then these questions may be useful to help them construct their PES statements.

However the ability to think critically in the nutrition assessment step is a topic unto itself and is definitely a separate critical skill to be developed and honed.  The November 2013 Academy practice paper authored by Pam Charney and Sarah Peterson discusses the critical thinking that is necessary during the nutrition assessment and diagnosis that will lead the dietetics student and dietitian to the appropriate nutrition diagnosis(es).

Bottom line:  Is there a "right" and "wrong" PES statement?  Certainly there are instances where a "wrong" problem/nutrition diagnosis is identified and this will obviously lead to a "wrong" PES statement.  However if we spend too much effort on creating the perfect PES statement we may miss the entire point of providing the right nutrition care.  Just as there is not a "right" nutrition progress note or a "wrong" nutrition progress note, there are some that are more clear and concise than others and better describe the patient care episode...the same is true for the construction of a PES statement.

Our energy is better spent on honing our nutrition assessment skills and diagnostic reasoning to identify the most appropriate nutrition problem and the most effective intervention to improve the nutrition problem than obsessing about getting the perfect PES statement!.

Links of Interest:

Academy Practice Paper- November 2013.  Critical Thinking in Nutrition Assessment and Diagnosis

Nutrition Progress Notes: Form follows function

While the principle of "Form follows function" is widely used in architecture, it is equally applicable as we think about nutrition progress notes.  As we consider the optimal nutrition progress note format and content, it is important to think about the purpose of a nutrition progress note and the intended audiences.  While there may be slight differences in the target audiences between various practice settings, most can be grouped into the following target audiences

• Healthcare Team Members (Physicians, Nurses, and Dietetics practitioners)
• Accrediting Agencies, Regulatory bodies, and legal audiences
• Patients (there is a growing trend to use the medical record as a communication tool with the patient)  

When we think about these target audiences we also think about what is important for each of them::

• Continuity of care (from dietitian visit to dietitian visit, among physicians, nurse and other health care providers)
• Description of and rationale for care (for legal purposes, so enable reviewers to make judgments about whether standards of care were met)

It is important that the nutrition progress note include a clear and concise description of exactly what care was provided, include the rationale or reason for the nutrition care provided or recommended, indicate the anticipated outcomes of care, and indicate the connection or relationship with other aspects of healthcare being provided, considered, or recommended.  The Nutrition Care Process is a logic based problem solving methodology and the IDNT is intended to provide the language that is precise, yet easily understood by the target audiences.

A set of questions was developed to evaluate the nutrition progress note to ensure that the logic of the NCP is captured in the written progress note  This work was originally published in 2005 by Nancy Hakel-Smith, Lewis and Eskidge and has since been adapted and posted on the Academy website in two versions...a simple version and version that can be "scored" to more clearly show improvement over time. The version that can be scored was adapted by Dee Pratt and Sherry Jones.   This questionnaire has also been adapted for international use in Sweden by Lovestam et al to evaluate and compare documentation of NCP in electronic patient records.  Scores from the 14 items used to evaluate the notes placed these notes into three different quality levels (high, medium and low).  These tools are valuable ways to check our documentation to ensure that our care is adequately described.  In some cases the areas for improvement are simply opportunities for clarity in documentation, in other instances this evaluation may highlight areas where the nutrition care itself may be improved.

We continually seek ways to improve our nutrition care and the documentation of the care to ensure that patients and clients receive the best possible care and have the highest possibility of achieving optimal health through nutrition.    

Links of interest

Hakel-Smith, Lewis and Eskridge. Orientation to nutrition care process standards improves nutrition care documentation by nutrition practitioners.  JADA, 2005  PUBMED ID: 16183359

Academy Members Only Link to Brief Chart Audit Tool and Comprehensive Sample Chart Audit Tools:

See "Tools"

 Lovestam, Orrevall, Koochek, Karlstrom, Anderson    Evaluation of Nutrition Care Process documentation in electronic patient records need improvement.  Scand J of Caring Science, May 2013 Abstract: