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.