Individual and contextual factors in the Swedish Nutrition Care Process Terminology implementation

Abstract

Background Standardised terminologies and classification systems play an increasingly important role in the continuous work towards high quality patient care. Currently, a standardised terminology for nutrition care, the Nutrition Care Process (NCP) Terminology (NCPT), is being implemented across the world, with terms for four steps: Nutrition Assessment (NA), Nutrition Diagnosis (ND), Nutrition Intervention (NI) and Nutrition Monitoring and Evaluation (NME). Objective To explore associations between individual and contextual factors and implementation of a standardised NCPT among Swedish dietitians. Method A survey was completed by 226 dietitians, focussing on: (a) NCPT implementation level; (b) individual factors; and (c) contextual factors. Associations between these factors were explored through a two-block logistic regression analysis. Results Contextual factors such as intention from management to implement the NCPT (OR (odds ratio) ND 15.0, 95% Confidence Interval (CI) 3.9–57.4, NME 3.7, 95% CI 1.1–13.0) and electronic health record (EHR) headings from the NCPT (OR NI 3.6, 95% CI 1.4–10.7, NME 3.8, 95% CI 1.1–11.5) were associated with higher implementation. A positive attitude towards the NCPT (model 1 OR ND 3.8, 95% CI 1.5–9.8, model 2 OR ND 5.0, 95% CI 1.4–17.8) was also associated with higher implementation, while other individual factors showed less association. Conclusion Contextual factors such as intention from management, EHR structure, and pre-defined terms and headings are key to implementation of a standardised terminology for nutrition and dietetic care. Implications for practice Clinical leadership and technological solutions should be considered key areas in future NCPT implementation strategies.

Clinical documentation integrity: Its role in health data integrity, patient safety and quality outcomes and its impact on clinical coding and health information management

“…Payton et al (2023) reported the need for balance between structured and narrative forms of documentation and that highly structured formats (a feature of EHRs) can limit usability. Several authors highlighted multifactor influences on CDI, including personal, systemic and environmental (Jebraeily et al, 2023; Lövestam et al, 2022; Rowlands et al, 2022).…”