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.