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The aim of this thesis was to explore dietetic notes in Swedish patient records regarding content, language and the meaning of standardization. Firstly, an audit instrument for dietetic notes in patient records, Diet-NCP-Audit, was elaborated and tested. The instrument, a 14-item scoring questionnaire based on the four steps of the Nutrition Care Process (NCP), proved to have high content validity and moderate to high inter- and intra-rater reliability. The instrument was then used in an evaluation of the content, language and structure of 147 Swedish dietetic notes. Although the nutrition intervention and some information about the evaluation were well documented, the overall result showed a need for improvement in several aspects of documentation, such as nutrition prescriptions, goals and the connection between problem-etiology-symptom. After this, 30 of the audited dietetic notes were also included in a critical linguistic study exploring how the patients and dietitians were referred to in the notes. The dietetic notes contained several linguistic devices that impersonalized and passivized both the patient and the dietitian. Thus, the grammar of the dietetic notes did not enhance or reflect the patient-centered care and the active patient-caregiver relationship that is emphasized in most health care guidelines today. Finally, a focus group study was performed. Swedish dietitians’ experiences of the standardized Nutrition Care Process (NCP) and its connected terminology (NCPT) were explored and analyzed from the perspective of Habermas’ system and lifeworld concepts. While recognizing many advantages with the NCP and NCPT, dietitians also expressed difficulties in combining the structured and standardized process and terminology with a flexible, patient-centered approach in nutrition care. In summary, I argue that strategies for the improvement of dietetic documentation are needed. I also suggest that the NCP and NCPT play an essential role in dietetic professionalization. At the same time, however, this standardization may entail the risk of a reductionist view and difficulties regarding how to balance the different ideals of health care. Thus, there is a need for discussions concerning how to use and develop the NCP and dietetic language in a way that ensures the best possible care for the patient.

Bakgrund NCP är en systematisk, problemlösande metod med ett unikt standardiserat språk som används av yrkesverksamma dietister för dokumentation. Det bidrar till att dietisten agerar utifrån ett kritiskt tänkande där besluten för att hantera patientens nutritionsproblem sker utifrån kunskap av evidensbaserad erfarenhet. Dietisternas Riksförbund (DRF) uppmanar legitimerade dietister att arbeta enligt NCP. Syfte Studiens syfte var att studera svenska dietisters arbete med att ställa nutritionsdiagnoser enligt NCP. Metod En webbaserad enkät utformades. Yrkesverksamma dietister rekryterades via det sociala mediet Facebook samt via DRF:s hemsida. Insamlad data bearbetades i SPSS Statistics 22, och analyserades med Chi-2-test och Correlate Bivariate Spearman. Signifikansnivån bestämdes till p-värde < 0.05. Resultat 119 dietister deltog i studien varav 103 (87 %) skrev nutritionsdiagnoser. I genomsnitt hade dietisterna arbetat i 2 år (1-3 år) med NCP, och över hälften arbetade inom akutsjukvård. Analysen visade att det fanns ett samband mellan antal år dietisterna arbetat med NCP och hur många nutritionsdiagnoser de skrev (r=-0.197, p=0.046). Ett samband visades även mellan tiden dietisterna arbetat med NCP och tiden det tog att skriva nutritionsdiagnoser (r=-0.226, p=0.022). Av de 103 dietisterna som använde NCP ansåg 60 % att deras kunskap och erfarenhet kunde förbättras, 89 % tyckte att nutritionsdiagnoser var användbara. Engelskan i referensbladen tyckte 48 % till viss del var svårtolkad och (n=13) angav att översättning till svenska kunde underlätta arbetet. Det framgick att mer än hälften (53 %) av dietisterna ibland utformade PES-meningar utan att ha funnit passande tecken/symtom i referensbladet. Slutsats Svenska dietister önskar mer kunskap och utbildning i NCP och översättning av referensbladen till svenska skulle sannolikt kunna öka användandet av nutritionsdiagnoser. En vidare implementering av NCP i Sverige behövs. / Background The Nutrition care process is a systematic, problem-solving approach with a standardized language used by dietitians for documentation. It stimulates dietitians to critically appraise and take evidence-based decisions on a patient's nutritional problems. The Swedish Association of Clinical Dietitians (DRF) appeals qualified dietitians to work according the NCP. Objective The aim was to study Swedish dietitians’ work with nutrition diagnosis according to the NCP. Method(s) A web-based questionnaire was developed. Dietitians was recruited through the social media Facebook and the DRF website. The collected data were processed in SPSS, analyzed by Chi-2-test and Correlate Bivariate Spearman, with significance level at p < 0.05. Results A total of 119 dietitians responded to the questionnaire and 103 (87 %) of the respondents wrote nutrition diagnosis. The respondents had on average worked with the NCP for 2 years (range 1-3 years), and over half worked in hospitals. There was a correlation between years working according to the NCP and the number of written diagnosis (r=-0.197, p=0.046). Also, the time for writing a nutritional diagnosis was reduced as the experience of working with NCP increased (r=-0.226, p=0.022). It was 60 % that thought their knowledge and experience in NCP could be improved, 89 % stated that the NCP was useful. The English in the reference sheets 48 % of the respondents said partly was difficult to understand and (n=13) wanted them to be translated into Swedish. It showed that more than half (53 %) of the dietitians sometimes composed PES-statements without finding the appropriate signs/symptoms in the reference sheet. Conclusion Swedish dietitians consider themselves to be in need of more knowledge and training in the NCP, and translations of the reference sheets would possibly increase the use of nutrition diagnosis. A further implementation of the NCP is needed in Sweden.

The purpose of this study was to survey registered dietitians in Northeast Tennessee to determine attitudes toward implementation of the nutrition care process prior to and following education about the nutrition care process and/or implementation of the nutrition care process in their respective healthcare facilities. Approximately 100 registered dietitians were involved in the study. Data were collected through electronic submission and written inquiries. The findings of the study identified that there was a need for further research regarding implementation of the nutrition care process and that negative attitudes, opinions, and barriers were broken down by education, implementation, and exposure to the nutrition care process.

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Problématique : Au Québec, le Processus de soins en nutrition (PSN) est peu utilisé, les organisations appréhendent que l’implantation sera ardue mais sont motivées à procéder. Objectif : Accompagner deux services de nutrition clinique d’établissements de santé de la grande région de Montréal dans le déploiement du PSN et documenter les barrières et facteurs facilitants. Méthodologie : L’Hôpital du Sacré-Cœur de Montréal et le CSSS Champlain–Charles-Le Moyne ont été recrutés. La collecte de données fut réalisée via des séances d’accompagnement tout au long du déploiement du PSN. Une rencontre de bilan fut effectuée dans chaque milieu, avec les nutritionnistes et les chefs de service. Les données colligées sont qualitatives. Les échanges furent enregistrés et un cahier de bord complété. La synthèse a été rédigée selon un modèle de gestion de changement. Résultats : Au total, 18 séances d’accompagnement eurent lieu et cinq rencontres de bilan. Les principaux obstacles à la mise en œuvre du PSN sont en grande partie liés à l'engagement des nutritionnistes, à la formation et aux contraintes de temps. Les principaux facteurs facilitants sont les présentations d’histoires de cas accompagnées de discussion et le manuel de la Terminologie internationale de diététique et de nutrition (TIDN). Discussion : Notre système de santé est de plus en plus sujet à des changements et les dirigeants devront optimiser les ressources. L’International Confederation of Dietetic Associations a suggéré d’adopter, à l’échelle internationale, le PSN en tant que cadre pour la profession. Les stratégies d’implantation portant sur des principes de gestion du changement organisationnel faciliteront l’intégration de ces changements importants. L’expérience des deux milieux documentés sera éclairante pour les autres organisations désirant implanter le PSN. / Problem: In Quebec, the use of the Nutrition Care Process (NCP) is limited, organizations apprehend its implantation will be arduous but are motivated to proceed. Objective: To accompany two clinical nutrition services of health facilities in the greater Montreal area in the deployment of the NCP and document the barriers and facilitating factors. Methodology: The Hôpital du Sacré-Cœur de Montréal and the CSSS Champlain–Charles-Le Moyne were recruited. Data collection was accomplished through accompanying sessions throughout the deployment of the NCP. An end of project meeting was held in each area, with nutritionists and heads of departments. The data collected is qualitative. The exchanges were recorded and a logbook was completed. The synthesis was written using a change management model. Results: A total of 18 accompanying sessions were held and five end of project meetings were held. The main obstacles to the implementation of the NCP are largely related to the commitment of nutritionists, training and time constraints. The main facilitating factors are the presentations of case studies with discussion and the manual of the International Dietetics and Nutrition Terminology (IDNT). Discussion: Our health system is increasingly subject to change and leaders will need to optimize resources. The International Confederation of Dietetic Associations suggested adopting the NCP as an international framework for the profession. Implementation strategies for organizational change management principles will facilitate the integration of these important changes. The experience of the two documented environments will be enlightening for other organizations wishing to implement the NCP.