- Email: [email protected]
Toward International Best Outcomes: The Shared Path of the Nutrition Care Process, Informatics, and Research Translation
RESEARCH Research Editorial
Toward International Best Outcomes: The Shared Path of the Nutrition Care Process, Informatics, and Research Translation Kay Gibbons, APD*, FDAA‡
OCUMENTATION OF CARE IS ESSENTIAL FOR PROfessional communication and good patient management and has presented a challenge over time for most health professions. For registered dietitian nutritionists (RDNs), the use of the Nutrition Care Process (NCP) and Nutrition Care Process Terminology (NCPT)1 offers a structured approach to documentation. However, the increasing use of electronic health records (EHRs), the emphasis on evidence-based practice, funding pressures, and the expectations for efficiencies in time management has placed additional demands on the delivery of nutrition care. A number of developments now come together to offer wider and improved opportunities to provide enhanced nutrition care, to assess practice outcomes, and to demonstrate their effectiveness. There is an undertaking for this partnership of opportunity to be extended internationally, but its potential is yet to be realized. Originating in 2003 with the American Dietetic Association (now the Academy of Nutrition and Dietetics [Academy]), the standardized model for documenting and describing nutrition care, the NCP, linked with the International Dietetics and Nutrition Terminology, has been reviewed and is now adopted as the NCP and NCPT.2 Adoption of the four stages of the NCP and standardized reporting allows comparison of outcomes to substantiate the results of nutrition intervention and care on a much broader scale than individual practitioners or centers can access. Evidence for the quantifiable benefits of nutrition care has traditionally been difficult to gather in the complex health environment of multiple interventions, but the availability of large amounts of
comparable data allows RDNs to assemble this evidence and ultimately to refine the processes and evidence. The importance of evidence-based care as a cornerstone of best practice is well documented, and is included in national health strategies.3 Evidence-based dietetic care is recommended and expected by a number of dietetic associations in addition to the Academy. Evidence-based practice is supported with libraries of material and resources, including the Academy Evidence Analysis Library4 and the Practice-Based Evidence in Nutrition Library, to which a number of dietetic associations contribute.5 Further justification of the role of evidence-based practice in health care and in nutrition care is not required here. Evidence-based care, together with the NCP, NCPT, and nutrition informatics, comprise the foundation of international best practice. The NCP and NCPT can be applied in settings using either paper records or EHRs. A small study comparing documentation over successive 6-month periods, using a manual system followed by an electronic system of reporting, indicated that less time was spent per consultation with the electronic system and a greater number of nutrition diagnoses were resolved using the EHR.6 This observation, without quantitative data, has been reported elsewhere, including in an intensive care setting.7 Inclusion in the decision-making processes, which can ensure the system chosen for the EHR is compatible with the NCPT, allows maximization of the benefits of both the EHR and the NCPT. Where nutrition and dietetic care is not integrated with information systems, potential benefits to both systems may be lost.8 Managing the data produced by the NCP and NCPT is the work of nutrition informatics. Yadrick’s definition of nutrition informatics is the “intersection of information, nutrition and technology” and is about “improving our use of knowledge.”9 An article describing the broad and exciting opportunities offered by informatics acknowledges that the term informatics is often seen as off-putting by RDNs who may not see themselves as technologically skilled.9 In describing the role of nutrition informatics, the article emphasizes that the principles of nutrition care are not challenged by the process, but that RDNs are offered the prospect of the vast new opportunities that combining systematic reporting of the nutrition information relating to patient care with technology can offer. The benefits can influence at all levels—providing fast and detailed information on patient dietary intake and care plans, developing reports to share with patients on their progress, and enabling RDNs to review their care across a patient group or for a department to demonstrate its
ª 2017 by the Academy of Nutrition and Dietetics.
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
ARTICLE INFORMATION Article history: Submitted 10 March 2017 Accepted 25 July 2017
Keywords: Nutrition Care Process Informatics Research translation 2212-2672/Copyright ª 2017 by the Academy of Nutrition and Dietetics. http://dx.doi.org/10.1016/j.jand.2017.07.022 *
APD¼Accredited Practising Dietitian (Australia). FDAA¼Fellow Dietitians Association of Australia.
‡
D
1727
RESEARCH effectiveness. A literature review originating in Australia in consultation with the Academy8 confirmed the view that nutrition informatics has the capacity to “improve efficiencies, reduce costs, support research, and ultimately enhance patient care.” The Academy Health Informatics Infrastructure10 offers RDNs in the United States access to a sophisticated technology to record care and to achieve the promised benefits for themselves, for their patients, and for their organizations. For the field of dietetics, the NCP and NCPT offers the possibility for international collaboration and sharing of practice strengths and research possibilities.8 The International Confederation of Dietetic Associations has a mission to support “national dietetics associations and their members, beyond national and regional boundaries.”11 The goals of International Confederation of Dietetic Associations for 20122106 include “increasing adoption of the international standardized language for nutrition and dietetics.” The International Working Group, part of the NCP Committee of the Academy, was established in 2012 to focus on the growing needs of the international community. The NCP has currently been translated into 11 languages and dialects and the electronic version of the NCPT into nine languages. A number of countries are using and teaching the NCP and NCPT across Europe, Asia, the Pacific region, and the Middle East as well as the Americas, with recommendations for adoption as standard dietetic practice in a number of countries.12 For the realization of best practice internationally, experiences must be shared among professionals in other settings and countries. Publications reporting on progress and activities related to dietetic best practice are able to do so sharing a common language. The article by Lövestam and colleagues in this issue13 offers insight into a Swedish experience with the implementation of the NCP from the perspective of nutrition and dietetics practitioners across a range of practice settings of differing sizes and types. The article stimulates reflection on a number of levels, including the progress of adoption of the NCP into practice and the broader issues of implementing change in a profession where work pressures are great and where the availability of time and funding for practice improvement are not always highly prioritized. A complementary audit of the quality of documentation using the NCP indicated a need for improvement if the full benefits of the NCP are to be realized.14 The article by Lövestam and colleagues13 details the progress toward use of the NCP as experienced by the RDNs involved. The case examples and quotations add life to the findings and will resonate with many practitioners. In a methodology that included semistructured focus groups followed by qualitative analysis, the areas arising as key on thematic analysis were “leadership and implementation strategy, the group and colleagues, the EHR, and evaluation.”13 The themes in the article reflect the categories of the context construct within the Promoting Action on Research Implementation in Health Services (PARIHS) framework for successful implementation.15 A number of models are available and are used within health care and by RDNs in knowledge translation, implementing organizational change, and knowledge transfer. These models include the PARIHS framework,15 Kotter’s schema for organizational change,16 and the Ottawa Model 1728
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
for Knowledge Transfer.17 Although the PARIHS model is used in the context of implementing the NCP and NCPT, the model may have broader use, including changes needed to implement evidence-based practice. The themes identified within the Swedish study13 are also consistent with key steps of Kotter’s approach to organizational change.16 Kotter’s schema16 is used widely and was employed in developing, implementing, and evaluating a package for introduction of the NCP in a group of Australian hospitals that considered measures of pre- and postimplementation knowledge and confidence, and employed a range of strategies, including webinars, e-mail discussion groups, and telephone support.18 The Swedish experience13 confirms the empirical experience that for change to proceed successfully, participants must be engaged and the process cognizant of the local context, including the perceived relevance of the planned change and local barriers to its success. The success of the change, and of future changes in practice, is influenced by personal experience. Among participating institutions in the study by Lövestam and colleagues,13 and at the stage of data collection, little evaluation of the process or outcomes had been undertaken. Where goals were set and evaluated, these related to the early process stage of development of the Nutrition Diagnosis, specifically the problem, etiology, signs, and symptoms statements. Not all facilities employed an EHR and there was no report of progress toward using data in an integrated way. Although recommended as best practice by the Swedish Association of Clinical Dietitians, there are indicators of varied progress toward universal implementation of the NCP in this Swedish group.12 Implementation of the NCP and NCPT in a group of institutions across an extensive geographic area in Australia employing a train the trainer model and use of local champions, reflected increased knowledge and confidence with the process among RDNs compared with preimplementation, but identified the need for ongoing training and support.19 This implementation benefited from support from senior management within the organization, whereas lack of executive support was noted as a concern in some centers in the Swedish study.13 Auditing, accompanied by feedback, is accepted as a useful tool in quality improvement. An audit instrument has been developed for use with the NCP and NCPT to review accuracy of documentation.20 The authors20 emphasize that the tool is not intended for measuring quality of care. The instrument scored highly on content validity and performed in the moderate to high range for inter- and intrarater reliability. Fidelity in recording is essential for merging and comparing information. There is opportunity for validation of the tool in other settings and for international uptake. Several trials have considered utility in specific practice settings. An Israeli group21 considered use of the NCP and NCPT in a geriatric population and determined that a single set of diagnostic codes does not address their specialist population nor their country’s health care system. In a trial in a community nutrition support setting,22 a team found the terminology and process limited for their client group where social context is a key consideration. The recognition of the NCP and NCPT as models in development of local resources is itself a step toward implementation. In contrast, in reviewing November 2017 Volume 117 Number 11
RESEARCH adoption of the NCP, a group of pediatric specialist RDNs identified that a higher proportion of certified pediatric practitioners were using the NCP (81.5%) compared with other practitioners (55.2%). In using the NCP, the challenges of using the standardized language were seen as challenging for pedatrics.23 An ambitious and exciting example of the international application of both Evidence-Based Nutrition Practice Guidelines (EBNPG) and use of the NCP is illustrated in the Diabetes in India Nutrition Guidelines Study.17 With no local evidence-based nutrition guidelines for type 2 diabetes mellitus in India the Academy EBNP guidelines for diabetes were agreed upon as the basis for an intervention project. Twenty-four RDNs were randomized into a control and intervention group of usual care and EBNPG groups. The usual care group used a generic template for data collection and EBNPG group used a purpose-designed template, including the NCP with standardized language. Patient participants underwent follow-up at 6 and 12 months. Results were significantly better on several parameters in the EBNPG group than in the usual care group, with only triglyceride level reduction significantly different between groups at 12 months. RDNs and the authors17 highlighted the complexity of this project using the Ottawa Knowledge Transfer Model, which describes an implementation tailored to local context to implement evidence-based approaches. It has been said that based on the time required for the translation of knowledge to practice, it would take 15.6 years for a new practice to arrive at a 50% use rate.24 A member survey undertaken by the Academy in 2011 to consider the application of nutrition informatics among RDNs indicated increasing adoption, along with the use of NCP and NCPT, in the context of the EHR, compared with 2008.25 The triad of delivery of evidence-based care, implementation of the NCP, and the specialized data management in nutrition informatics provides the field of dietetics with the tools to be more responsive. As data become available, we must be ready to use the lessons learned and integrate them into practice speedily and effectively.
5.
Dietitians of Canada. Practice-based evidence in nutrition. https:// www.pennutrition.com. Accessed June 15, 2017.
6.
Rossi M, Campbell KL, Ferguson M. Implementation of the Nutrition Care Process and International Dietetics Nutrition Terminology in a single-center hemodialysis unit comparing paper vs electronic records. J Acad Nutr Diet. 2014;114(1):124-130.
7.
Simon C, Faut C, Wooley J. Lessons learned in applying the nutrition care process to critically ill patients. Support Line. 2009;31(2):9-13.
8.
Maunder K, Walton K, Williams P, et al. Uptake of nutrition informatics in Australia compared with the USA. Nutr Diet. 2015;72(3): 291-298.
9.
Aase S. You, improved: Understanding the promises and challenges nutrition informatics poses for dietetic careers. J Am Diet Assoc. 2010;110(12):1794-1798.
10.
Academy of Nutrition and Dietetics. Health informatics infrastructure. https://www.andhii.org. Accessed June 12, 2017.
11.
International Confederation of Dietetic Associations. http://www. internationaldietetics.org/About-ICDA/Mission-and-Goals.aspx. Mission and goals. Accessed June 16, 2017.
12.
Academy of Nutrition and Dietetics. About eNCPT. https://ncpt. webauthor.com/. Accessed June 15, 2017.
13.
Lövestam E, Boström A-M, Orrevall Y. Nutrition Care Process implementation: Experiences in various dietetics environments in Sweden. J Acad Nutr Diet. 2017;117(11):1738-1748.
14.
Lövestam E, Orrevall Y, Koochek A, Karlstrom B, Andersson A. Evaluation of a Nutrition Care Process in electronic patient records: Need of improvement. Nutr Diet. 2015;72(1):74-80.
15.
Harvey G, Kitson A. PARIHS revisited: From heuristic to integrated framework for the successful implementation of knowledge into practice. Implement Sci. 2016;11:33-44.
16.
Kotter JP. Leading Change. Boston, MA: Harvard Business Press; 1996.
17.
Myers E, Trostler N, Varsha V, Voet H. Insights from the Diabetes in India Nutrition Guidelines Study: Adopting innovations using a knowledge transfer model. Top Clin Nutr. 2017;32(1):69-86.
18.
Porter JM, Devine A, O’Sullivan TA. Evaluation of a Nutrition Care Process implementation package in hospital dietetic departments. Nutr Diet. 2015;72(3):213-221.
19.
Vivanti A, Ferguson M, Porter J, O’Sullivan T, Hulcombe J. Increased familiarity, knowledge and confidence with Nutrition Care Process Terminology following implementation across a statewide healthcare system. Nutr Diet. 2015;72(3):222-231.
20.
Lövestam E, Orrevall Y, Koochek A, Karlstrom B, Andersson A. Evaluation of a Nutrition Care Process-based audit instrument, the DietNCP-Audit, for documentation of dietetic care in medical records. Scand J Caring Sci. 2014;28(2):390-397.
21.
Rachman-Elbaum S, Porat-Katz B, Kachal J, Stark A. Documentation of the dietetic care process: Developing a sectoral, tailored system. Eur J Clin Nutr. 2016;70(6):753-757.
22.
Charney P. The nutrition care process and the nutrition support dietitian. Support Line. 2007;29(4):18-22.
23.
Auslander M, Enrione E. Assessing practices and perceptions of board certified specialists in pediatric nutrition about the Nutrition Care Process/International Dietetics and Nutrition Terminology. J Acad Nutr Diet. 2013;113(9):A13.
24.
Balas E, Boren S. Managing clinical knowledge for healthcare improvement. Yearb Med Inform. 2000;1:65-70.
25.
Ayres E, Hoggle L. Nutrition Informatics member survey. J Acad Nutr Diet. 2012;112(3):360-367.
References 1.
Bueche J, Charney P, Pavlinac J, Skipper A, Thompson E. Nutrition care process and model part 1: The 2008 update. J Am Diet Assoc. 2008;108(7):1113-1117.
2.
Academy of Nutrition and Dietetics. The Nutrition Care Process. www.eatrightpro.org/resources/practice/nutrition-care-process/. Accessed June 15, 2017.
3.
Thomson K, Davidson P, Swan W, et al. Nutrition care process chains; The “Missing link” between research and evidence-based practice. J Acad Nutr Diet. 2015;115(9):1491-1498.
4.
Academy of Nutrition and Dietetics. Evidence analysis library. https://www.andeal.org. Accessed June 15, 2017.
November 2017 Volume 117 Number 11
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
1729
RESEARCH AUTHOR INFORMATION K. Gibbons is an honorary research associate, University of Melbourne, Melbourne, Australia; a professor, Food, Nutrition, and Dietetics, Victoria University, Melbourne, Australia; an honorary research manager, Murdoch Children’s Research Institute Melbourne, Melbourne, Australia; and an adjunct clinical professor, Australian Catholic University, Melbourne, Australia. Address correspondence to: Kay Gibbons, APD, FDAA, College of Health and Biomedicine, Victoria University, McKechnie St, St Albans, Victoria, Australia 3021. E-mail: [email protected]
STATEMENT OF POTENTIAL CONFLICT OF INTEREST No potential conflict of interest was reported by the author.
FUNDING/SUPPORT There is no funding to disclose.
1730
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
November 2017 Volume 117 Number 11
Toward International Best Outcomes: The Shared Path of the Nutrition Care Process, Informatics, and Research Translation Kay Gibbons, APD*, FDAA‡
OCUMENTATION OF CARE IS ESSENTIAL FOR PROfessional communication and good patient management and has presented a challenge over time for most health professions. For registered dietitian nutritionists (RDNs), the use of the Nutrition Care Process (NCP) and Nutrition Care Process Terminology (NCPT)1 offers a structured approach to documentation. However, the increasing use of electronic health records (EHRs), the emphasis on evidence-based practice, funding pressures, and the expectations for efficiencies in time management has placed additional demands on the delivery of nutrition care. A number of developments now come together to offer wider and improved opportunities to provide enhanced nutrition care, to assess practice outcomes, and to demonstrate their effectiveness. There is an undertaking for this partnership of opportunity to be extended internationally, but its potential is yet to be realized. Originating in 2003 with the American Dietetic Association (now the Academy of Nutrition and Dietetics [Academy]), the standardized model for documenting and describing nutrition care, the NCP, linked with the International Dietetics and Nutrition Terminology, has been reviewed and is now adopted as the NCP and NCPT.2 Adoption of the four stages of the NCP and standardized reporting allows comparison of outcomes to substantiate the results of nutrition intervention and care on a much broader scale than individual practitioners or centers can access. Evidence for the quantifiable benefits of nutrition care has traditionally been difficult to gather in the complex health environment of multiple interventions, but the availability of large amounts of
comparable data allows RDNs to assemble this evidence and ultimately to refine the processes and evidence. The importance of evidence-based care as a cornerstone of best practice is well documented, and is included in national health strategies.3 Evidence-based dietetic care is recommended and expected by a number of dietetic associations in addition to the Academy. Evidence-based practice is supported with libraries of material and resources, including the Academy Evidence Analysis Library4 and the Practice-Based Evidence in Nutrition Library, to which a number of dietetic associations contribute.5 Further justification of the role of evidence-based practice in health care and in nutrition care is not required here. Evidence-based care, together with the NCP, NCPT, and nutrition informatics, comprise the foundation of international best practice. The NCP and NCPT can be applied in settings using either paper records or EHRs. A small study comparing documentation over successive 6-month periods, using a manual system followed by an electronic system of reporting, indicated that less time was spent per consultation with the electronic system and a greater number of nutrition diagnoses were resolved using the EHR.6 This observation, without quantitative data, has been reported elsewhere, including in an intensive care setting.7 Inclusion in the decision-making processes, which can ensure the system chosen for the EHR is compatible with the NCPT, allows maximization of the benefits of both the EHR and the NCPT. Where nutrition and dietetic care is not integrated with information systems, potential benefits to both systems may be lost.8 Managing the data produced by the NCP and NCPT is the work of nutrition informatics. Yadrick’s definition of nutrition informatics is the “intersection of information, nutrition and technology” and is about “improving our use of knowledge.”9 An article describing the broad and exciting opportunities offered by informatics acknowledges that the term informatics is often seen as off-putting by RDNs who may not see themselves as technologically skilled.9 In describing the role of nutrition informatics, the article emphasizes that the principles of nutrition care are not challenged by the process, but that RDNs are offered the prospect of the vast new opportunities that combining systematic reporting of the nutrition information relating to patient care with technology can offer. The benefits can influence at all levels—providing fast and detailed information on patient dietary intake and care plans, developing reports to share with patients on their progress, and enabling RDNs to review their care across a patient group or for a department to demonstrate its
ª 2017 by the Academy of Nutrition and Dietetics.
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
ARTICLE INFORMATION Article history: Submitted 10 March 2017 Accepted 25 July 2017
Keywords: Nutrition Care Process Informatics Research translation 2212-2672/Copyright ª 2017 by the Academy of Nutrition and Dietetics. http://dx.doi.org/10.1016/j.jand.2017.07.022 *
APD¼Accredited Practising Dietitian (Australia). FDAA¼Fellow Dietitians Association of Australia.
‡
D
1727
RESEARCH effectiveness. A literature review originating in Australia in consultation with the Academy8 confirmed the view that nutrition informatics has the capacity to “improve efficiencies, reduce costs, support research, and ultimately enhance patient care.” The Academy Health Informatics Infrastructure10 offers RDNs in the United States access to a sophisticated technology to record care and to achieve the promised benefits for themselves, for their patients, and for their organizations. For the field of dietetics, the NCP and NCPT offers the possibility for international collaboration and sharing of practice strengths and research possibilities.8 The International Confederation of Dietetic Associations has a mission to support “national dietetics associations and their members, beyond national and regional boundaries.”11 The goals of International Confederation of Dietetic Associations for 20122106 include “increasing adoption of the international standardized language for nutrition and dietetics.” The International Working Group, part of the NCP Committee of the Academy, was established in 2012 to focus on the growing needs of the international community. The NCP has currently been translated into 11 languages and dialects and the electronic version of the NCPT into nine languages. A number of countries are using and teaching the NCP and NCPT across Europe, Asia, the Pacific region, and the Middle East as well as the Americas, with recommendations for adoption as standard dietetic practice in a number of countries.12 For the realization of best practice internationally, experiences must be shared among professionals in other settings and countries. Publications reporting on progress and activities related to dietetic best practice are able to do so sharing a common language. The article by Lövestam and colleagues in this issue13 offers insight into a Swedish experience with the implementation of the NCP from the perspective of nutrition and dietetics practitioners across a range of practice settings of differing sizes and types. The article stimulates reflection on a number of levels, including the progress of adoption of the NCP into practice and the broader issues of implementing change in a profession where work pressures are great and where the availability of time and funding for practice improvement are not always highly prioritized. A complementary audit of the quality of documentation using the NCP indicated a need for improvement if the full benefits of the NCP are to be realized.14 The article by Lövestam and colleagues13 details the progress toward use of the NCP as experienced by the RDNs involved. The case examples and quotations add life to the findings and will resonate with many practitioners. In a methodology that included semistructured focus groups followed by qualitative analysis, the areas arising as key on thematic analysis were “leadership and implementation strategy, the group and colleagues, the EHR, and evaluation.”13 The themes in the article reflect the categories of the context construct within the Promoting Action on Research Implementation in Health Services (PARIHS) framework for successful implementation.15 A number of models are available and are used within health care and by RDNs in knowledge translation, implementing organizational change, and knowledge transfer. These models include the PARIHS framework,15 Kotter’s schema for organizational change,16 and the Ottawa Model 1728
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
for Knowledge Transfer.17 Although the PARIHS model is used in the context of implementing the NCP and NCPT, the model may have broader use, including changes needed to implement evidence-based practice. The themes identified within the Swedish study13 are also consistent with key steps of Kotter’s approach to organizational change.16 Kotter’s schema16 is used widely and was employed in developing, implementing, and evaluating a package for introduction of the NCP in a group of Australian hospitals that considered measures of pre- and postimplementation knowledge and confidence, and employed a range of strategies, including webinars, e-mail discussion groups, and telephone support.18 The Swedish experience13 confirms the empirical experience that for change to proceed successfully, participants must be engaged and the process cognizant of the local context, including the perceived relevance of the planned change and local barriers to its success. The success of the change, and of future changes in practice, is influenced by personal experience. Among participating institutions in the study by Lövestam and colleagues,13 and at the stage of data collection, little evaluation of the process or outcomes had been undertaken. Where goals were set and evaluated, these related to the early process stage of development of the Nutrition Diagnosis, specifically the problem, etiology, signs, and symptoms statements. Not all facilities employed an EHR and there was no report of progress toward using data in an integrated way. Although recommended as best practice by the Swedish Association of Clinical Dietitians, there are indicators of varied progress toward universal implementation of the NCP in this Swedish group.12 Implementation of the NCP and NCPT in a group of institutions across an extensive geographic area in Australia employing a train the trainer model and use of local champions, reflected increased knowledge and confidence with the process among RDNs compared with preimplementation, but identified the need for ongoing training and support.19 This implementation benefited from support from senior management within the organization, whereas lack of executive support was noted as a concern in some centers in the Swedish study.13 Auditing, accompanied by feedback, is accepted as a useful tool in quality improvement. An audit instrument has been developed for use with the NCP and NCPT to review accuracy of documentation.20 The authors20 emphasize that the tool is not intended for measuring quality of care. The instrument scored highly on content validity and performed in the moderate to high range for inter- and intrarater reliability. Fidelity in recording is essential for merging and comparing information. There is opportunity for validation of the tool in other settings and for international uptake. Several trials have considered utility in specific practice settings. An Israeli group21 considered use of the NCP and NCPT in a geriatric population and determined that a single set of diagnostic codes does not address their specialist population nor their country’s health care system. In a trial in a community nutrition support setting,22 a team found the terminology and process limited for their client group where social context is a key consideration. The recognition of the NCP and NCPT as models in development of local resources is itself a step toward implementation. In contrast, in reviewing November 2017 Volume 117 Number 11
RESEARCH adoption of the NCP, a group of pediatric specialist RDNs identified that a higher proportion of certified pediatric practitioners were using the NCP (81.5%) compared with other practitioners (55.2%). In using the NCP, the challenges of using the standardized language were seen as challenging for pedatrics.23 An ambitious and exciting example of the international application of both Evidence-Based Nutrition Practice Guidelines (EBNPG) and use of the NCP is illustrated in the Diabetes in India Nutrition Guidelines Study.17 With no local evidence-based nutrition guidelines for type 2 diabetes mellitus in India the Academy EBNP guidelines for diabetes were agreed upon as the basis for an intervention project. Twenty-four RDNs were randomized into a control and intervention group of usual care and EBNPG groups. The usual care group used a generic template for data collection and EBNPG group used a purpose-designed template, including the NCP with standardized language. Patient participants underwent follow-up at 6 and 12 months. Results were significantly better on several parameters in the EBNPG group than in the usual care group, with only triglyceride level reduction significantly different between groups at 12 months. RDNs and the authors17 highlighted the complexity of this project using the Ottawa Knowledge Transfer Model, which describes an implementation tailored to local context to implement evidence-based approaches. It has been said that based on the time required for the translation of knowledge to practice, it would take 15.6 years for a new practice to arrive at a 50% use rate.24 A member survey undertaken by the Academy in 2011 to consider the application of nutrition informatics among RDNs indicated increasing adoption, along with the use of NCP and NCPT, in the context of the EHR, compared with 2008.25 The triad of delivery of evidence-based care, implementation of the NCP, and the specialized data management in nutrition informatics provides the field of dietetics with the tools to be more responsive. As data become available, we must be ready to use the lessons learned and integrate them into practice speedily and effectively.
5.
Dietitians of Canada. Practice-based evidence in nutrition. https:// www.pennutrition.com. Accessed June 15, 2017.
6.
Rossi M, Campbell KL, Ferguson M. Implementation of the Nutrition Care Process and International Dietetics Nutrition Terminology in a single-center hemodialysis unit comparing paper vs electronic records. J Acad Nutr Diet. 2014;114(1):124-130.
7.
Simon C, Faut C, Wooley J. Lessons learned in applying the nutrition care process to critically ill patients. Support Line. 2009;31(2):9-13.
8.
Maunder K, Walton K, Williams P, et al. Uptake of nutrition informatics in Australia compared with the USA. Nutr Diet. 2015;72(3): 291-298.
9.
Aase S. You, improved: Understanding the promises and challenges nutrition informatics poses for dietetic careers. J Am Diet Assoc. 2010;110(12):1794-1798.
10.
Academy of Nutrition and Dietetics. Health informatics infrastructure. https://www.andhii.org. Accessed June 12, 2017.
11.
International Confederation of Dietetic Associations. http://www. internationaldietetics.org/About-ICDA/Mission-and-Goals.aspx. Mission and goals. Accessed June 16, 2017.
12.
Academy of Nutrition and Dietetics. About eNCPT. https://ncpt. webauthor.com/. Accessed June 15, 2017.
13.
Lövestam E, Boström A-M, Orrevall Y. Nutrition Care Process implementation: Experiences in various dietetics environments in Sweden. J Acad Nutr Diet. 2017;117(11):1738-1748.
14.
Lövestam E, Orrevall Y, Koochek A, Karlstrom B, Andersson A. Evaluation of a Nutrition Care Process in electronic patient records: Need of improvement. Nutr Diet. 2015;72(1):74-80.
15.
Harvey G, Kitson A. PARIHS revisited: From heuristic to integrated framework for the successful implementation of knowledge into practice. Implement Sci. 2016;11:33-44.
16.
Kotter JP. Leading Change. Boston, MA: Harvard Business Press; 1996.
17.
Myers E, Trostler N, Varsha V, Voet H. Insights from the Diabetes in India Nutrition Guidelines Study: Adopting innovations using a knowledge transfer model. Top Clin Nutr. 2017;32(1):69-86.
18.
Porter JM, Devine A, O’Sullivan TA. Evaluation of a Nutrition Care Process implementation package in hospital dietetic departments. Nutr Diet. 2015;72(3):213-221.
19.
Vivanti A, Ferguson M, Porter J, O’Sullivan T, Hulcombe J. Increased familiarity, knowledge and confidence with Nutrition Care Process Terminology following implementation across a statewide healthcare system. Nutr Diet. 2015;72(3):222-231.
20.
Lövestam E, Orrevall Y, Koochek A, Karlstrom B, Andersson A. Evaluation of a Nutrition Care Process-based audit instrument, the DietNCP-Audit, for documentation of dietetic care in medical records. Scand J Caring Sci. 2014;28(2):390-397.
21.
Rachman-Elbaum S, Porat-Katz B, Kachal J, Stark A. Documentation of the dietetic care process: Developing a sectoral, tailored system. Eur J Clin Nutr. 2016;70(6):753-757.
22.
Charney P. The nutrition care process and the nutrition support dietitian. Support Line. 2007;29(4):18-22.
23.
Auslander M, Enrione E. Assessing practices and perceptions of board certified specialists in pediatric nutrition about the Nutrition Care Process/International Dietetics and Nutrition Terminology. J Acad Nutr Diet. 2013;113(9):A13.
24.
Balas E, Boren S. Managing clinical knowledge for healthcare improvement. Yearb Med Inform. 2000;1:65-70.
25.
Ayres E, Hoggle L. Nutrition Informatics member survey. J Acad Nutr Diet. 2012;112(3):360-367.
References 1.
Bueche J, Charney P, Pavlinac J, Skipper A, Thompson E. Nutrition care process and model part 1: The 2008 update. J Am Diet Assoc. 2008;108(7):1113-1117.
2.
Academy of Nutrition and Dietetics. The Nutrition Care Process. www.eatrightpro.org/resources/practice/nutrition-care-process/. Accessed June 15, 2017.
3.
Thomson K, Davidson P, Swan W, et al. Nutrition care process chains; The “Missing link” between research and evidence-based practice. J Acad Nutr Diet. 2015;115(9):1491-1498.
4.
Academy of Nutrition and Dietetics. Evidence analysis library. https://www.andeal.org. Accessed June 15, 2017.
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RESEARCH AUTHOR INFORMATION K. Gibbons is an honorary research associate, University of Melbourne, Melbourne, Australia; a professor, Food, Nutrition, and Dietetics, Victoria University, Melbourne, Australia; an honorary research manager, Murdoch Children’s Research Institute Melbourne, Melbourne, Australia; and an adjunct clinical professor, Australian Catholic University, Melbourne, Australia. Address correspondence to: Kay Gibbons, APD, FDAA, College of Health and Biomedicine, Victoria University, McKechnie St, St Albans, Victoria, Australia 3021. E-mail: [email protected]
STATEMENT OF POTENTIAL CONFLICT OF INTEREST No potential conflict of interest was reported by the author.
FUNDING/SUPPORT There is no funding to disclose.
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