Journal of Clinical Nutrition & Dietetics

Keywords

nutrition care process; Implementation process; Registered nutritionist dietitian; Hospital dietitian; Enablers and barriers; Experiences

Introduction

As a unique contribution of dietetics practitioners to the health care outcomes, the Academy of Nutrition and Dietetics (2003) adapted the Nutrition Care Process Model (NCPM) in facilitating critical thinking and decision-making in providing medical nutrition therapy in patient care [1,2]. The NCPM describes the Nutrition Care Process (NCP) by presenting the workflow of professionals in diverse individuals and population care delivery settings [3]. The NCP consists of four distinct but interrelated and connected steps: (a) Nutrition assessment, (b) Nutrition diagnosis, (c) Nutrition intervention, and (d) Nutrition monitoring and evaluation. The NCP model and associated terminology (NCPT) are also used to improve applications of evidence-based guidelines, critical thinking, and ensure more focused documentation of dietetic care [4]. This scientific process of nutrition care intends to provide diagnosis-oriented assessment and to treat nutrition problems with intervention plans [5].

Nutrition Care Process is a framework that is effective to provide improved nutrition care. Dietitians who use this framework are producing consistent and easy-to-read documentations of clinical practices that benefit other health-related members. In using this framework, dietitians increase productivity by providing diagnosis-specific and focused documentation [5]. NCP helps to provide common nutrition diagnosis those results to positive impact of nutrition in patient care [6,7]

Moreover, on the study of Mujlli regarding on the impact of NCP documentation on obese children, they found out that there is an association between the quality of dietitian documentation in NCP and patient nutritional outcomes [8]. In addition to this, the literature supports the association between dietitian documentation in NCP and the improvement of patient outcomes in malnourished patients. This new process on nutrition care provides dietetics professionals with the best possible foundation for the highest quality patient centered care [2,9].

The development and implementation of the NCP provided means for dietitian practitioners to become more autonomous within their profession. Many countries started to implement the NCP in their respective workplace setting including hospital setting. With regard to the implementation of the NCP in the international setting, only a few surveys together with some minor implementation reports from different hospitals have addressed dietitians’ perspectives regarding this fundamental process. Since the NCP concept is quite new, very little has been conducted on implementation of the nutrition care process, e.g., factors that support or hinder the process and the dietitians’ experience [9,10].

In the Philippines, the implementation of Nutrition Care Process in the hospital setting is new. It was launched last 2019, when the Department of Health (DOH) released the Guidelines for the Implementation of Nutrition Care Process in Philippine Hospitals, through the Administrative Order 2019-0033. According to the scope and coverage, this order provides the mandate and direction for public and private hospitals to operationalize and institutionalize the Nutritional Care Process in their respective facilities. The AO-2019-0033 is a response to the Section 28 of the Republic Act 10862, also known as Nutrition and Dietetics (ND) Law. According to the scope of Practice of Nutrition and Dietetics, a Registered Nutritionist-Dietitian (RND) should offer a professional service such as providing Medical Nutrition Therapy (MNT) through the application of Nutrition Care Process for the purpose of disease prevention, treatment, and management.

To date, no earlier studies have been conducted regarding the NCP implementation particularly at specialty hospitals in Metro Manila, Philippines. In connection to this, the qualitative study aimed to explore the experiences of hospital dietitians as well as to identify the enablers and barriers on the implementation of Nutrition Care Process of selected specialty hospitals in Metro Manila, Philippines.

Materials and Methods

The study used a cross sectional method with the use of survey questionnaire. Hospital Dietitian (Registered Nutritionist Dietitian) working in selected specialty hospitals in Metro Manila Philippines were included in the study. Hospital Dietitian who is unable to complete the survey study and did not consent was excluded from the study.

Online platform was the primary medium for data collection. The researcher used Google Mail to send an invitation to the chief/head of the department for the consent to conduct a study. The present study followed the Data Privacy Act of 2012 where all data collected were strictly used for research purposes and shall never be shared to a third party, not authorized by the researcher.

The present study used Google Forms to collect data from the subject. After the confirmation from the subject, the researcher would send an email with an attachment of the Google Form link.

The present study explored the RND`s experiences of selected specialty hospitals in Metro Manila on NCP implementation regarding strategies, leadership, NCP documentation formats, and enablers and barriers in the implementation using an open ended question modified from the study of Lovestam, Orrevall, Koochek and Andersson [4,10]. The data being collected in this qualitative study was analyze using thematic analysis in accordance to methods of Braun and Clarke. A qualitative thematic analysis was performed, condensing the text to meaning units and classifying them into different codes and categories/themes [12].

The present study was executed in accordance with the principles of Declaration of Helsinki and abides to the Data Privacy Act of 2012.

Results and Discussion

A total of 52 Registered Nutritionist-Dietitians (RND) from selected specialty hospitals in Metro Manila, Philippines, completed the survey. Respondent characteristics are shown in Table 1. Most of the respondents are female with a total of 37 (71.2%). Most of the respondent’s age was <30 years of age (69.2%). In terms of educational attainment, bachelor degree as the highest educational level and in terms of experience as RND most of respondents are 5 years with less than 10 years (30.8%).

Table 1: Characteristics of the Respondents.

Implementation strategy and leadership: Nutrition care process implementation requires a multidisciplinary approach with the help of other health care workers. As stated in the AO-2019-033 health care workers specifically the physician, nurses, pharmacist, and social worker have their specific roles and responsibilities in implementing NCP. As we compare the result of the present study to other related study the implementation strategy specifically in Sweden hospital, at first dietitians attended national dietetic congress for NCP [11]. Same with the Philippines, (NDAP) conducted a seminar series in NCP and also the Department of Health conducted training and seminar regarding NCP documentation (DOH, 2019).

“Nutrition Committee which consists of physicians, dietitians, nurses, pharmacists, medical social workers and Integrated Hospital Operations and Management Program (IHOMP) was formed on the last quarter of 2019”.

“We conducted a series of seminars for doctors, nurses, and other members of the healthcare team”.

“The nutritionally at risk patients are automatically referred for MNT and so NCP is used for proper management”.

“The doctor will refer the patient for nutrition care process, and then we will assess the patient, make the intervention and give it to the doctor”.

“We practice NCP by doing patient assessment and counseling as well providing special diets requested by the doctors. In addition, the doctors usually communicating with the dietitian regarding the changes and progress of the patient's diet”.

According to the study of Lovestam in large hospitals, the manager initiated implementation and one person has an assigned facilitator role, leading a group of NCP champions. Not the same with small hospital were dietitians initiated implementation in dialogue with management (Table 2)[10,12].

Table 2: The implementation of Nutrition Care Process in the hospital is mandatory and as much as possible follow the AO 2019-0033.

NCP documentation formats: Based on the responses on this section, dietitians need to modify the form or add something on the form in order to fit in their needs for complete NCP documentation. While other dietitian still using other forms.

In the international setting, based on the literature most of problems of the dietitian in NCP documentation is the unfit features of their electronic health record. In large hospitals several key words fit with the NCP or in some cases key words were restructured due to the NCP, which consumed a lot of resources while on small hospitals, key words not adapted to the NCP or in some cases key words were adapted to the NCP, which forced dietitians into NCP use (Tables 3 and 4) [10,13].

Table 3: The use of NCP forms attached in the AO with modification.

Table 4: The use of other NCP forms.

Enabler and Barrier in NCP implementation: The present study identifies existing enablers and barrier in the implementation of the NCP [14-16]. Enablers in the implementation are reasons which increase the likelihood of efficacious implementation while barriers are the challenges in the implementation process. The result of the analysis of the present study was consistent with the other study (Tables 5-7) [17-22].

Table 5: The RND`s identified different factors that help them and their department in initiating or implementing NCP such as management support, peer support, proper education, allocated time to practice, professional integrity, regular training session, availability of electronic health record and required by the hospital.

Table 6: The RND`s identified different obstacles in initiating or implementing NCP such as lack of manpower, lack of support, lack of time, lack of sufficient data, lack of education and proper training, lack of financial resources, and the effect of pandemic.