Department of Food Studies, Nutrition and Dietetics, Uppsala University, Uppsala, Sweden.
Department of Neurobiology, Care Science and Society, Division of Nursing, Karolinska Institutet, Huddinge, Sweden.
Scand J Caring Sci. 2023 Jun;37(2):472-485. doi: 10.1111/scs.13131. Epub 2022 Nov 3.
The documentation of goals and outcomes of nutrition care in Electronic Health Records is insufficient making further exploration of this of particular interest. Identifying common features in documentation practice among Scandinavian dietitians might provide information that can support improvement in this area.
To explore the associations between clinical dietitians' self-reported documentation of patients' goals and outcomes and demographic factors, self-reported implementation of the systematic framework the Nutrition Care Process 4th step (NCP) and its associated terminology, and factors associated with the workplace.
Data from a cross-sectional study based on a previously tested web-based survey (INIS) disseminated in 2017 to dietitians in Scandinavia (n = 494) was used. Respondents were recruited through e-mail lists, e-newsletters and social media groups for dietitians. Associations between countries regarding the reported documentation of goals and outcomes, implementation levels of the NCP 4th step, demographic information and factors associated with the workplace were measured through Chi-square test. Associations between dependent- and independent variables were measured through logistic regression analysis.
Clinically practicing dietitians (n = 347) working in Scandinavia, Sweden (n = 249), Norway (n = 60), Denmark (n = 38), who had completed dietetic education participated. The reported documentation of goals and outcomes from nutrition intervention was highly associated with the reported implementation of NCP 4th step terminology (OR = 5.26; p = 0.009, OR = 3.56; p = 0.003), support from the workplace (OR = 4.0, p < 0.001, OR = 8.89, p < 0.001) and area of practice (OR = 2.02, p = 0.017). Years since completed dietetic training and educational level did not have any significant associations with documentation practice regarding goals and outcomes.
Findings highlight strong associations between the implementation of the NCP 4th step terminology and the documentation of goals and outcomes. Strategies to support dietitians in using standardized terminology and the development of tools for comprehensive documentation of evaluation of goals and outcome are required.
电子健康记录中对营养护理目标和结果的记录不足，因此特别需要进一步探索这一问题。确定斯堪的纳维亚营养师在记录实践中的共同特征可能会提供支持这一领域改进的信息。
探讨临床营养师自我报告的患者目标和结果记录与人口统计学因素、自我报告的营养护理过程第 4 步（NCP）实施情况及其相关术语以及与工作场所相关因素之间的关系。
使用 2017 年基于先前经过测试的网络调查（INIS）向斯堪的纳维亚营养师（n=494）分发的横断面研究数据。通过电子邮件列表、电子新闻通讯和营养师社交媒体群组招募受访者。通过卡方检验测量与目标和结果记录、NCP 第 4 步实施水平、人口统计学信息和与工作场所相关因素有关的国家之间的关联。通过逻辑回归分析测量因变量和自变量之间的关联。
在斯堪的纳维亚地区从事临床实践的营养师（n=347）中，有 249 人来自瑞典，60 人来自挪威，38 人来自丹麦，他们都完成了营养师教育。营养干预目标和结果的报告与 NCP 第 4 步术语的报告实施高度相关（OR=5.26；p=0.009，OR=3.56；p=0.003）、工作场所的支持（OR=4.0，p<0.001，OR=8.89，p<0.001）和实践领域（OR=2.02，p=0.017）。完成营养师培训后的年限和教育水平与目标和结果的记录实践没有任何显著关联。
研究结果强调了 NCP 第 4 步术语的实施与目标和结果记录之间的紧密联系。需要采取策略支持营养师使用标准化术语并开发全面记录目标和结果评估的工具。
