Academic journal article Health Sociology Review

The Struggle to Balance System and Lifeworld: Swedish Dietitians' Experiences of a Standardised Nutrition Care Process and Terminology

Academic journal article Health Sociology Review

The Struggle to Balance System and Lifeworld: Swedish Dietitians' Experiences of a Standardised Nutrition Care Process and Terminology

Article excerpt


In recent decades, several health care professions have developed and implemented standardised models for working processes and terminologies (Bueche et al., 2008; Stearns, Price, Spackman, & Wang, 2001; Yura, Walsh, & Garzón, 1988). Dietitians - with the professional task to identify nutritional problems as well introduce and guide changes in food choice, eating behaviour and nutritional intake -have, in line with this trend, developed the Nutrition Care Process (NCP) and standardised Nutrition Care Process Terminology (NCPT) (Academy of Nutrition and Dietetics; Hammond, Myers, & Trostler, 2014). In this study, we explored the experiences of Swedish dietitians regarding the use of a standardised model and terminology.

The NCP (see Figure 1) is presented as a systematic problem-solving method developed as a framework for critical thinking and decision-making in nutrition care (Bueche et al., 2008). A brief explanation of some NCP key concepts is found in Table 1. In this article, both the NCP (the process) and the NCPT (the terminology) are referred to when using the abbreviation NCP(T).

Among dietitians, international and national professional associations have welcomed the development and implementation of an NCP(T) (International Confederation of Dietetic Associations, 2011; Swedish Association of Clinical Dietitians, 2013a). The NCP(T) was translated from English to Swedish in 2011, after which the Swedish implementation process commenced. A survey from the Swedish Association of Clinical dietitians revealed that in 2013, around half of Swedish dietitians had begun to implement elements of the NCP(T) (Swedish Association of Clinical Dietitians, 2013b).

The use of NCP(T) becomes particularly visible in patient records. Earlier studies show that the implementation of standardised processes and languages in health care seems to improve the clinical documentation quality (Considine, Potter, & Jenkins, 2006; HakelSmith, Lewis, & Eskridge, 2005). Documentation quality, in turn, is seen as an important prerequisite for patient safety (Shojania, Duncan, McDonald, & Wachter, 2001). Today, almost all Swedish health care professionals use electronic patient record systems for clinical documentation, and many patients have the option to log in and review their own electronic record online. Thus, demands for clarity and comprehensibility in the patient record do not only concern health care professionals, but also patients (Keselman et al., 2007).

The NCP(T) has many similarities with corresponding processes in nursing and standardised nursing diagnoses developed in the late twentieth century (Herdman, 2011). In the 1980s and 1990s, critics of this standardised process and nursing diagnoses claimed that, as the system was derived from a medical scientific culture, it implied inherent reductionist values and solidified an already unequal hierarchy between nurse and patient. Furthermore, some critics argued that the diagnostic judging and labelling of patients attitudes, beliefs and behaviours could have devastating consequences for the relationship between nurses and patients (Barnum, 1987; Lützén & Tishelman, 1996; Mitchell, 1991; Powers, 2002). Proponents of nursing diagnoses, on the other hand, claimed that there is no contradiction between a systematic, consistent labelling of patients' conditions and a collaborative or intuitive nursing approach (Kritek, 1985). According to Lacey and Pritchett (2003), there is an important difference between standardised care and standardised caring processes such as NCP; standardised care infers that all patients with a certain medical condition receive the same care, while standardised caring processes refer to a consistent structure which can support individualised care.

With the overall push towards standardisation of health care processes and the earlier nursing discussions about reductionism and holism in mind, we wanted to explore clinical dietitians' experiences of the use of the NCP(T), as the implementation has now been ongoing for approximately four years in Sweden. …

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