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.