Friday, September 5, 2014

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  Accessed Sep 2, 2014.

4.         Critical Thinking Skills in Nutrition Assessment..  Available at:

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.

Wednesday, September 3, 2014

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)

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 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.

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.

Monday, September 1, 2014

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 is at the CORE of the model.