LETTER TO THE EDITOR
Practicalities of Using the Nutrition Care Process in Research E THANK MS. McCarthy for her comments1 in response to our recently published article2 and would like to express strong agreement that adherence to the standardized language and systematic processes of the Nutrition Care Process and Terminology (NCPT) is a vital for the comparability of research findings and advancement of nutrition outcomes research. We disagree that the inclusion of screening in our algorithmic process constitutes the addition of a step to the NCP. The eNCPT Nutrition Terminology Reference Manual (eNCPT) states that ‘‘patients/clients enter nutrition assessment, the first step of the NCP, through screening, surveillance systems data, and/or referral, all of which are outside of the NCP.’’3 We noted that the screening portion of the algorithm was not a part of the NCP in the final row of our flowchart description of the algorithm (Figure 1 in the original article2), yet the patients in the study must have a point of entry into the NCP. In practice, screening may or may not be conducted by a nutrition professional, but in research study staff must verify eligibility and gain informed consent, and this often necessitates the use of registered dietitian nutritionists (RDNs) for the screening in addition to the nutrition care. We also disagree that highlighting the components of a Nutrition Diagnosis constitutes the addition of a step to the NCP. As described by the eNCPT, ‘‘The nutrition diagnosis or nutrition problem is summarized into a structured sentence called the nutrition diagnosis statement or PES statement, and is composed of three distinct components: the problem (P), the etiology (E), and the signs and symptoms (S).’’4 This complex construction of clinical judgment simply cannot be represented algorithmically by a single clinician input. Our algorithm separated the selection of the problem statement from the identification of the etiology to collect structured data about both components, and we further divided the etiology, which is defined in eNCPT as ‘‘those factors contributing to the existence or maintenance of. problems,’’4 to prompt RDNs to consider
W
Financial Disclosure: Mr. Murphy, Dr. Steiber, and Ms. Hand are employees of the Academy of Nutrition and Dietetics, an organization that may have a commercial interests in the ANDHII and eNCPT technologies discussed in this letter. Address correspondence to W.J. Murphy, MS, RDN, LDN, Department of Research, International, and Scientific Affairs, Academy of Nutrition and Dietetics, 120 South Riverside Plaza, Suite 2000, Chicago, IL 60606.
E-mail: [email protected] Ó 2015 by the National Kidney Foundation, Inc. All rights reserved. 1051-2276/$36.00 http://dx.doi.org/10.1053/j.jrn.2014.12.009
Journal of Renal Nutrition, Vol -, No - (-), 2015: pp 1-2
factors related to both existence (etiologies) and maintenance (barriers) of problems while collecting structured data about each. When constructing NCP chains, we maintained the separation of the Nutrition Diagnosis step into two components according to the precedent set by Hakel-Smith et al.5 This separation is necessary to support appropriate targeting of Nutrition Interventions as described in the eNCPT: ‘‘Whenever possible, food and nutrition professionals direct the nutrition intervention at the etiology of the problem.’’6 We regret that opportunities were missed to use standardized language in some instances in our algorithm. The Nutrition Diagnosis Terminology, the oldest and most widely adopted of the eNCPT terminology categories, was used faithfully in the algorithm, but the options for Assessment and Monitoring and Evaluation were not created with standardized terms despite the fact that it would have been possible. It is important to note that the documentation of etiology is described in the eNCPT as, ‘‘Usually free text,’’4 meaning that descriptions outside of the standardized language are permitted. The options used for intervention were also not in-line with the standardized language. This was due, in part, to the need for data more granular than what was available in the NCPTat the time, but, in retrospect, there was potential for closer alignment with and organization according to the standardized terminology. One important note, made in our manuscript and in Ms. McCarthy’s response, is that the Nutrition Care Process and its terminology is evolving. This year the NCP has transitioned from a reference manual printed bi-annually7 to a completely web-based platform for the language.8 In addition, the name of this language has changed from the International Dietetics and Nutrition Terminology to Nutrition Care Process Terminology (eNCPT) as used in this response. The platform change allows for more rapid updates, as well as international translations of the eNCPT. Another important way that the terminology evolves is by practitioners and researchers identifying gaps in the language or process, and suggesting them as revisions, as we did in our algorithm. Despite the inclusion of the NCP in the Standards of Practice for Renal Dietitians,9 we frequently encounter renal RDNs who are unaware of the language or feel it does not fit their practice. To create a language which is standardized for research and useful for all practice areas, those who identify gaps must submit those to the Academy’s Nutrition Care Process Committee for consideration of whether the term can be incorporated in eNCPT updates.10 1
2
MURPHY, HAND, AND STEIBER
The lessons learned from this study, including the missed opportunities for standardized language, have been applied in the development of a new outcomes management system for users of the NCPT, the Academy of Nutrition and Dietetics Health Informatics Infrastructure (ANDHII).11 ANDHII provides outcomes collection and management tools for practitioners in any setting and is based on a faithful implementation of the four steps of the NCP and its standardized terminologies. We encourage future researchers to consider how ANDHII can assist in their use of the eNCPT in projects and encourage RDNs in practice to enter patient visits in ANDHII, so nutrition care outcomes can be tracked around the United States. More information about gaining access to ANDHII is available at www.andhii. org/info. William J. Murphy, MS, RDN, LDN Department of Research International, and Scientific Affairs Academy of Nutrition and Dietetics Chicago, Illinois Rosa K. Hand, MS, RDN, LD Department of Research International, and Scientific Affairs Academy of Nutrition and Dietetics Chicago, Illinois Alison L. Steiber, PhD, RDN Department of Research International, and Scientific Affairs Academy of Nutrition and Dietetics Chicago, Illinois
References 1. McCarthy MP. Words of caution regarding research design when using the nutrition care process model. J Ren Nutr. 2015;25:75-76. 2. Steiber AL, Leon JB, Hand RK, et al. Using a web-based nutrition algorithm in hemodialysis patients. J Ren Nutr. 2015;25:6-16. 3. Academy of Nutrition and Dietetics. Nutrition assessment introduction. eNCPT: Nutrition Terminology Reference Manual Web site. http://ncpt. webauthor.com/pubs/idnt-en/page-001. Updated 2014. Accessed December 19, 2014. 4. Academy of Nutrition and Dietetics. The ND statement: PES. eNCPT: Nutrition Terminology Reference Manual Web site. http://ncpt.webauthor. com/pubs/idnt-en/page-032. Updated 2014. Accessed December 19, 2014. 5. Hakel-Smith N, Lewis NM, Eskridge KM. Orientation to nutrition care process standards improves nutrition care documentation by nutrition practitioners. J Am Diet Assoc. 2005;105:1582-1589. 6. Academy of Nutrition and Dietetics. NI components. eNCPT Nutrition Terminology Reference Manual Web site. http://ncpt.webauthor.com/pubs/ idnt-en/page-050. Published No Date. Updated 2014. Accessed December 19, 2014. 7. Academy of Nutrition and Dietetics Standardized Language Committee. International Dietetics and Nutrition Terminology (IDNT) Reference Manual. 4th ed Chicago: Academy of Nutrition and Dietetics; 2012. 8. Academy of Nutrition and Dietetics. eNCPT: Nutrition Terminology Reference Manual Web site. http://ncpt.webauthor.com. Updated 2014. Accessed December 19, 2014. 9. Kent PS, McCarthy MP, Burrowes JD, et al. Academy of nutrition and dietetics and national kidney foundation: revised 2014 standards of practice and standards of professional performance for registered dietitian nutritionists (competent, proficient, and expert) in nephrology nutrition. J Acad Nutr Diet. 2014;114:1448-1457.e45. 10. Academy of Nutrition and Dietetics Standardized Language Committee. Nutrition controlled Vocabulary/Terminology Maintenance/Review. http://aincp.webauthor.com/pub/file.cfm?item_type5xm_file&id521551. Updated 2012. Accessed December 19, 2014. 11. Murphy WJ, Steiber AL. A New Breed of Evidence and the Tools to Generate It: Introducing ANDHII. J Acad Nutr Diet. 2015;115:19-22.
Practicalities of Using the Nutrition Care Process in Research E THANK MS. McCarthy for her comments1 in response to our recently published article2 and would like to express strong agreement that adherence to the standardized language and systematic processes of the Nutrition Care Process and Terminology (NCPT) is a vital for the comparability of research findings and advancement of nutrition outcomes research. We disagree that the inclusion of screening in our algorithmic process constitutes the addition of a step to the NCP. The eNCPT Nutrition Terminology Reference Manual (eNCPT) states that ‘‘patients/clients enter nutrition assessment, the first step of the NCP, through screening, surveillance systems data, and/or referral, all of which are outside of the NCP.’’3 We noted that the screening portion of the algorithm was not a part of the NCP in the final row of our flowchart description of the algorithm (Figure 1 in the original article2), yet the patients in the study must have a point of entry into the NCP. In practice, screening may or may not be conducted by a nutrition professional, but in research study staff must verify eligibility and gain informed consent, and this often necessitates the use of registered dietitian nutritionists (RDNs) for the screening in addition to the nutrition care. We also disagree that highlighting the components of a Nutrition Diagnosis constitutes the addition of a step to the NCP. As described by the eNCPT, ‘‘The nutrition diagnosis or nutrition problem is summarized into a structured sentence called the nutrition diagnosis statement or PES statement, and is composed of three distinct components: the problem (P), the etiology (E), and the signs and symptoms (S).’’4 This complex construction of clinical judgment simply cannot be represented algorithmically by a single clinician input. Our algorithm separated the selection of the problem statement from the identification of the etiology to collect structured data about both components, and we further divided the etiology, which is defined in eNCPT as ‘‘those factors contributing to the existence or maintenance of. problems,’’4 to prompt RDNs to consider
W
Financial Disclosure: Mr. Murphy, Dr. Steiber, and Ms. Hand are employees of the Academy of Nutrition and Dietetics, an organization that may have a commercial interests in the ANDHII and eNCPT technologies discussed in this letter. Address correspondence to W.J. Murphy, MS, RDN, LDN, Department of Research, International, and Scientific Affairs, Academy of Nutrition and Dietetics, 120 South Riverside Plaza, Suite 2000, Chicago, IL 60606.
E-mail: [email protected] Ó 2015 by the National Kidney Foundation, Inc. All rights reserved. 1051-2276/$36.00 http://dx.doi.org/10.1053/j.jrn.2014.12.009
Journal of Renal Nutrition, Vol -, No - (-), 2015: pp 1-2
factors related to both existence (etiologies) and maintenance (barriers) of problems while collecting structured data about each. When constructing NCP chains, we maintained the separation of the Nutrition Diagnosis step into two components according to the precedent set by Hakel-Smith et al.5 This separation is necessary to support appropriate targeting of Nutrition Interventions as described in the eNCPT: ‘‘Whenever possible, food and nutrition professionals direct the nutrition intervention at the etiology of the problem.’’6 We regret that opportunities were missed to use standardized language in some instances in our algorithm. The Nutrition Diagnosis Terminology, the oldest and most widely adopted of the eNCPT terminology categories, was used faithfully in the algorithm, but the options for Assessment and Monitoring and Evaluation were not created with standardized terms despite the fact that it would have been possible. It is important to note that the documentation of etiology is described in the eNCPT as, ‘‘Usually free text,’’4 meaning that descriptions outside of the standardized language are permitted. The options used for intervention were also not in-line with the standardized language. This was due, in part, to the need for data more granular than what was available in the NCPTat the time, but, in retrospect, there was potential for closer alignment with and organization according to the standardized terminology. One important note, made in our manuscript and in Ms. McCarthy’s response, is that the Nutrition Care Process and its terminology is evolving. This year the NCP has transitioned from a reference manual printed bi-annually7 to a completely web-based platform for the language.8 In addition, the name of this language has changed from the International Dietetics and Nutrition Terminology to Nutrition Care Process Terminology (eNCPT) as used in this response. The platform change allows for more rapid updates, as well as international translations of the eNCPT. Another important way that the terminology evolves is by practitioners and researchers identifying gaps in the language or process, and suggesting them as revisions, as we did in our algorithm. Despite the inclusion of the NCP in the Standards of Practice for Renal Dietitians,9 we frequently encounter renal RDNs who are unaware of the language or feel it does not fit their practice. To create a language which is standardized for research and useful for all practice areas, those who identify gaps must submit those to the Academy’s Nutrition Care Process Committee for consideration of whether the term can be incorporated in eNCPT updates.10 1
2
MURPHY, HAND, AND STEIBER
The lessons learned from this study, including the missed opportunities for standardized language, have been applied in the development of a new outcomes management system for users of the NCPT, the Academy of Nutrition and Dietetics Health Informatics Infrastructure (ANDHII).11 ANDHII provides outcomes collection and management tools for practitioners in any setting and is based on a faithful implementation of the four steps of the NCP and its standardized terminologies. We encourage future researchers to consider how ANDHII can assist in their use of the eNCPT in projects and encourage RDNs in practice to enter patient visits in ANDHII, so nutrition care outcomes can be tracked around the United States. More information about gaining access to ANDHII is available at www.andhii. org/info. William J. Murphy, MS, RDN, LDN Department of Research International, and Scientific Affairs Academy of Nutrition and Dietetics Chicago, Illinois Rosa K. Hand, MS, RDN, LD Department of Research International, and Scientific Affairs Academy of Nutrition and Dietetics Chicago, Illinois Alison L. Steiber, PhD, RDN Department of Research International, and Scientific Affairs Academy of Nutrition and Dietetics Chicago, Illinois
References 1. McCarthy MP. Words of caution regarding research design when using the nutrition care process model. J Ren Nutr. 2015;25:75-76. 2. Steiber AL, Leon JB, Hand RK, et al. Using a web-based nutrition algorithm in hemodialysis patients. J Ren Nutr. 2015;25:6-16. 3. Academy of Nutrition and Dietetics. Nutrition assessment introduction. eNCPT: Nutrition Terminology Reference Manual Web site. http://ncpt. webauthor.com/pubs/idnt-en/page-001. Updated 2014. Accessed December 19, 2014. 4. Academy of Nutrition and Dietetics. The ND statement: PES. eNCPT: Nutrition Terminology Reference Manual Web site. http://ncpt.webauthor. com/pubs/idnt-en/page-032. Updated 2014. Accessed December 19, 2014. 5. Hakel-Smith N, Lewis NM, Eskridge KM. Orientation to nutrition care process standards improves nutrition care documentation by nutrition practitioners. J Am Diet Assoc. 2005;105:1582-1589. 6. Academy of Nutrition and Dietetics. NI components. eNCPT Nutrition Terminology Reference Manual Web site. http://ncpt.webauthor.com/pubs/ idnt-en/page-050. Published No Date. Updated 2014. Accessed December 19, 2014. 7. Academy of Nutrition and Dietetics Standardized Language Committee. International Dietetics and Nutrition Terminology (IDNT) Reference Manual. 4th ed Chicago: Academy of Nutrition and Dietetics; 2012. 8. Academy of Nutrition and Dietetics. eNCPT: Nutrition Terminology Reference Manual Web site. http://ncpt.webauthor.com. Updated 2014. Accessed December 19, 2014. 9. Kent PS, McCarthy MP, Burrowes JD, et al. Academy of nutrition and dietetics and national kidney foundation: revised 2014 standards of practice and standards of professional performance for registered dietitian nutritionists (competent, proficient, and expert) in nephrology nutrition. J Acad Nutr Diet. 2014;114:1448-1457.e45. 10. Academy of Nutrition and Dietetics Standardized Language Committee. Nutrition controlled Vocabulary/Terminology Maintenance/Review. http://aincp.webauthor.com/pub/file.cfm?item_type5xm_file&id521551. Updated 2012. Accessed December 19, 2014. 11. Murphy WJ, Steiber AL. A New Breed of Evidence and the Tools to Generate It: Introducing ANDHII. J Acad Nutr Diet. 2015;115:19-22.
