Nutrition Care Process and Model: An Academic and Practice …€¦ · Nutrition and Dietetics, formerly the American Dietetic Association, adopted a Nutrition Care Process and Model

This article was written by Marian I.Hammond, MS, former part-timeassistant professor of nutrition,The Pennsylvania State University,University Park; Esther F. Myers, PhD,RD, FAND, CEO, EF Myers Consulting,Trenton, IL; and Naomi Trostler, PhD,RD, (retired), Institute of Biochemistry,Food Science and Nutrition, The RobertH. Smith Faculty of Agriculture, Food,and Environment, Hebrew Universityof Jerusalem, Rehovot, Israel.

http://dx.doi.org/10.1016/j.jand.2014.07.032Available online 11 October 2014

*Melissa MartilottaInstructor, DepartmenSciences, The Pennsylversity, University Par

ª 2014 by the Academy of Nutrition and Dietetics. JO

PRACTICE APPLICATIONS
Topics of Professional Interest
Nutrition Care Process and Model: An Academicand Practice Odyssey

IN 2003, THE ACADEMY OFNutrition and Dietetics, formerlythe American Dietetic Association,adopted a Nutrition Care Process

and Model (NCPM) that identifies theunique contribution of dietetics prac-titioners to health care outcomes andestablishes a global standard for pro-vision of nutrition care by dieteticspractitioners (Figure 1).1

This pivotal landmark enjoys a longodyssey. It honors the pre-1970s re-searchers, educators, and practitionerswho built firm foundations for futurechange.2 One of the early visions of anNCPM diagram emerged when MarianI. Hammond, MS, RD, a nutrition pro-gram faculty member in what is nowthe Department of Nutritional Sciencesat The Pennsylvania State University(PSU), created a series of visual dia-grams called the Hammond models.This series consisted of the 1970 orig-inal integrative Hammond model andthe 1977, 1984, and 1986 iterations(Figures 2 through 5). At that time,dietetics educators faced teachingemerging nutritional counseling prin-ciples without a framework to organizethe changing content of dieteticspractice.Independently, the Kellogg Con-

tinuing Professional Education Devel-opment Project Team embarked ona 5-year project (1980 to 1985) todevelop new approaches to con-tinuing education (CE) programming

for selected professions, includingclinical dietetics.3,4 As part of its work,the Kellogg Continuing ProfessionalEducation Development Project Teamreviewed the Hammond model andendorsed the 1986 iteration to repre-sent its research results and todisseminate them through the Acad-emy/Kellogg Continuing ProfessionalEducation Development Project Teamcollaboration.Developmental work with the Ham-

mond models ended in 1986 whenHammond left the teaching field andstored relevant documents. A succeed-ing PSU faculty member used the 1986iteration in a nutrition counselingcourse.*In 1998, the Academy appointed a

Health Services Research Task Forcecharged with documenting the value ofdietetics services’ contribution tohealth care outcomes to further justifyreimbursement for dietetics services/medical nutrition therapy. One of themain challenges facing the task forcewas how to identify the unique contri-bution of dietetics to overall health careoutcomes (ie, What specific activitieswere consistently accomplished onlyby dietitians? What changes in healthcare outcomes could be reasonablyattributed to those activities?).This article reviews the steady

evolution of the Hammond models andtheir impact on the current NCPM,compares key concepts of the Ham-mond models and NCPM iterations, de-scribes their uses and benefits, andincludes references used in their devel-opment. It provides an important his-torical perspective about the evolutionof the NCPM and, consequently, pre-sents information that will be helpfulfor developing future models/strategiesto achieve best practices in nutritioncare.

, MS, RD, LDN,t of Nutritionalvania State Uni-k.

URNAL OF THE ACADE

MODEL DEVELOPMENTHammond Models (1970 to 1986)Modern clinical dietetics practitionersintegrate the sciences and humanitiesto promote healthy lifestyles byproviding nutrition care in diversesettings. In the pre-1970s, most thera-peutic dietitians provided direct care toinpatients in institutional settings un-der physicians’ supervision.5-7 Ensuingchanges in health care philosophies,delivery systems, and marketplace de-mands created new roles for dietitians.New audiences for nutrition care chal-lenged existing academic curricula. TheAcademy updated its accreditation andcredentialing standards and embracedthe 4-year coordinated undergraduateprogram philosophy.8-10

In response to these changes, thePSU Department of Nutritional Sci-ences faculty integrated applied mod-ules into its new undergraduatemedical dietetics curriculum.11 The diettherapy module was piloted in 1970.During course design, literature re-views and experience affirmed thattraditional diet therapy instruction wasmainly theory based. Practice di-rectives were scattered across journalarticles and nursing-specific textbooks.Diets reflected standardized protocolsand were presented primarily as tex-tual lists. Comprehensive diagramsdepicting nutritional counseling prin-ciples were not found.12-14

Hammond utilized the academicfreedom and opportunities at PSU toshift diet therapy instruction silos for-ward to integrate the behavioral sci-ence of dietetics with the biologicalscience of dietetics. The need for aconstruct that visualized nutritionalcounseling/nutrition care planningcomponents and their relationshipsbecame clear as Hammond worked tomake integrated diet therapy mean-ingful to students.

The ensuing Hammond modelsturned nutritional counseling/nutritioncare planning principles into holisticflow diagrams that portrayed the

MY OF NUTRITION AND DIETETICS 1879

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Figure 1. 2003 Academy Nutrition Care Process and Model. Reprinted from Lacey and Pritchett.1


evolution of dietetics practice throughfour separate and consecutive timeperiods and for differing users. Itera-tions were continually reviewed andrevised, but those presented here arethe major benchmarks.Numerous influences guided creation

and evolution of the Hammond models.Among them were Hammond’s philoso-phies shaped by personal background,coordinated undergraduate programdevelopment experience, PSU teachingexperience, Academy Position Papers,literature from related fields (eg, psy-chology, sociology, and anthropology),and work by the Kellogg ContinuingProfessional Education DevelopmentProject Team.3,4

Key Concepts and RationaleApplication of the Hammond modelsassumed current diet therapy theorycompetence at undergraduate studentor practitioner levels. Figure 6 presentsthe development of the four Hammondmodels (from 1970 through 1986) andkey concepts: purpose and goals, target

1880 JOURNAL OF THE ACADEMY OF NUTRI

audiences, schema, language, title, andcomponents (Entry, Core, Contact/VisitCycle steps, and Outer Frames/Rings).

Purpose and Goals. The long-termpurpose and goals of the Hammondmodels were to depict current nutri-tional counseling/nutrition care planningprinciples in one schematic and todevelop analytical, reasoning, and disci-pline foundations for learning and prac-tice updates for various target audiences.

Schema. The first schematic to repre-sent the model’s philosophy was ahand-drawn sketch that organizednutritional counseling concepts intoa wheel-like shape (Figure 2). Thisshape portrayed nutritional counselingas a continual cyclic and dynamicflow within and among discrete butintertwining components. The patient/dietitian connection formed the wheel’shub, and steps in the contact/visit cycleformed its rim. Graphic design features(arrows) formed spokes that connectedand supported the components. If/whenany part of the structure or supports

TION AND DIETETICS

was omitted or weakened, the processbecame compromised.

Ensuing iterations expanded keyconcept details and design features,but this original vision held truethroughout (Figures 2 through 5).

Language and Title. Each modelused the language of its time withwords and phrases carefully chosen todescribe concepts and produce teachingmoments. Gradually, the literaturebegan to refine confusing terminology,such as dietary, nutrition, nutritional,counseling, teaching, and nutrition edu-cation andprovided synonyms, pairings,or various forms of the terminology.In addition, dietitians were initiallycalled therapeutic dietitians, later clinicaldietitians, and most recently registereddietitian nutritionists.6,10,15-18

As practice evolved, language choicesconverted inert nouns into activeproblem-solving verbs (eg, develop,assess, and plan). Other terms (eg,formulate, interpret, impressions, andmonitor) reflected the more autono-mous roles dietitians were assuming.

December 2014 Volume 114 Number 12

Figure 2. 1970OriginalHammondModel.This isascanof theoriginalhand-drawnpencil sketch.Readerscannotetheerasures in thepatientedietitiancore. Hammond initially placed the dietitian first in the relationship, then, after realizing that the patient came first, changed the order.

†A formal “exit” was not di-agrammed into the Hammond model.


Components and Flow. The Ham-mond models depicted nutrition carethat flowed systematically throughmultiple components and cycles. TheEntry component illustrated the pathof initial patient/clienteregistered die-titian contact. Patients traditionallyentered care from a hospital setting,but later came from various screeningand referral sources. The Core compo-nent (PatienteDietitian leading to TheHelping Relationship leading to Part-nership) cemented the patient/cli-enteregistered dietitian partnership asthe nucleus for effective outcomes innutrition care.19-22 It depicted thepartnership moving forward togetherto incorporate diet principles andbehavior change into the patient’slifestyle.The Contact/Visit Cycle component

encompassed six steps that translateduniversal problem-solving languageinto dietetics language (Figure 6). A


systematized process evolved overtime comprising the following steps:

1. diet history leading to developdatabase;

2. prescription leading to assess/interpret;

3. recommendations leading toplan/formulate goals andstrategies;

4. teaching leading to implement;5. follow-up leading to monitor/

evaluate; and6. referral leading to communi-

cate/document.

These steps were ordered in logicalsequence andweightedequally. In ordertomaximize accuracyandefficiency, thepartnership needed to complete eachstep before moving to the next.The Outer Frames/Rings component

recognized overarching opportunitiesand constraints that affected nutri-tional counseling/nutrition care

JOURNAL OF THE ACADE

planning outcomes, practice decisions,and long-term professional goals:medical care team leading to healthcare team, counseling/helping rela-tionship leading to counseling/style,and time.4-6,15,17,18,20,21,23

Nutritional counseling/nutrition careplanning continued until either desiredgoals had been achieved or one or bothpartners ended contact.†

Hammond Model Iterations andRationaleThis section highlights the mostimportant features and rationale ofeach Hammond model as the seriesevolved (Figures 2 through 6). Thefirst three Hammond models (1970,1977, and 1984) demonstrated themost significant evolution. The lastmodel (1986) included refinements


Figure 3. 1977 Hammond Model.


(eg, graphic design presentation andselected language) but retained thebasic model structure and components.

Nutrition Counseling Cycle (1970to 1972). The initial Hammond modeldistilled the 1970s practice baselinesand emerging trends into a “NutritionCounseling Cycle” that depicted a die-titian practicing by fulfilling orders/prescriptions written by physicians but


beginning to transition into newerroles24 (Figure 2). Inpatients enterednutrition care via written physician re-ferrals.5,20,25 Dietitians establishedbasic patientedietitian communication,but typically disseminated informationinstead of counseling. The nutritioncounseling literature acknowledgedthe importance and need for effectiveinterviewing and behavior change froma conceptual standpoint; however,

TION AND DIETETICS

strategies for teaching these skills todietetics students and practitionershad not yet developed.15,19,20,22,26-31

Dietitians used traditional dietary/nutrition history interviewing methodsto gather, organize, and assess infor-mation from patient interviews, foodrecords, significant others, and medicalrecords. They translated physicians’prescriptions (eg, diet for weight loss)into dietary prescriptions (eg,




1,800-kcal diet) and used the dietaryhistory to plan dietary guidelines/rec-ommendations (eg, 1,800-kcal mealplan using exchange lists or basicfood-group servings). The literatureencouraged dietitians to actively teach/translate guidelines (eg, teach patientsto use a plan to make food choices).However, teaching opportunities, usu-ally “discharge diets,” were singularevents. Follow-up consisted of recom-mending available agencies, healthprofessionals, or other communityresources.15,20,21,25,27,28,32


Dietitians routinely kept patientprogress notes in dietary departmentfiles. The Academy and the AmericanHospital Association recommendedmedical record documentation, butcharting strategies were just forming.33

Nutrition/Dietary Counseling Cycle(1972-1977). The 1977 iteration(Figure 3) evolved in a clinic settingand generally reflected a dietitian whoevaluated and counseled the self-referred patient/client as well as ful-filled the prescription ordered by a


referring physician.34 This iterationformalized component headings andadded the first outer frame. From the1977 iteration forward, componentheadings included subheadings forteaching purposes and guided studentslearning to conduct hands-on coun-seling sessions.

The 1977 title “Nutrition/DietaryCounseling Cycle” straddled terminol-ogy confusion but gave preference tonutrition vs dietary terms. It was thefirst iteration to summarize steps re-quired to develop nutrition care plans




and SOAP (subjective, objective,assessment, and plan) medical recordnotes.The physician’s problem statement

identified patients that required careand the patient/client entered directlyinto the core relationship. The coreexpanded into a more functionalpatient/client-registered dietitian con-nection through Danish’s pioneeringresearch at PSU entitled “The HelpingRelationship,” which provided earlysystematic teaching/training for ap-plying effective relationship-buildingand goal-setting skills.30,35,36


The 1977 iteration condensed step 1 togathering and organizing dietary historyinformation. The former assessmentcomponent moved to a new step 2,labeled “Assessment (Definition ofNutritional/Dietary Problem(s)).”A 1971 Academy Position Paper

stated that clinical nutrition specialistsshould “accept responsibility for thediet prescription.”10 PSU clinic practi-tioners and students began developingdietary diagnoses and prescriptions forselected nutrition problems in the early1970s.34 However, the emergingconcept of the nutrition prescription

TION AND DIETETICS

and its partner, nutritional diagnosis,was generating so much controversythat these overt labels were omittedfrom the model.

The patient/clienteregistered dieti-tian formed the assessment into aproblem statement(s) and then intocomprehensive and individuallytailored nutrition, exercise, andbehavior modification programs withshort- and long-term goal strategies(step 3).

Placing students in outpatientnutrition clinics that provided long-term patient follow-up made teaching


Figure 6. Comparison of Hammond models and Academy of Nutrition and Dietetics models reflecting dietetics practice. Eachmodel (from 1970 through 2008) is shown and key concepts described: purpose/goal of model, target audience, schema, language,title, entry into the model, the core of the model, the steps involved in patient contact, the outer frames or rings reflecting theenvironment in which dietitians practice, and the supporting systems of the model. (continued on next page)


more efficient (steps 4 and 5). Inaddition, new tools were develop-ing, including behavior-modificationtechniques, three-dimensional foodmodels, and educational materialsdesigned for PSU dining and exercisesituations.17,29,37-39


Step 6 developed into a formalizedcommunication step that mandatedcommunication to and from other medi-cal care team/health care team membersand specified where communicationwasrecorded (ie,medical, dietary, and referralagency records).33,40 Organizing and


writing patient/client contact summariesforced students and practitioners to thinklogically, systematically, and efficiently.Documenting each patient/client con-tact was becoming vital for qualityassurance, cost-containment policies,third-party reimbursement, legal


igure 6. (continued) Comparison of Hammond models and Academy of Nutrition and Dietetics models reflecting dieteticsractice. Each model (from 1970 through 2008) is shown and key concepts described: purpose/goal of model, target audiencechema, language, title, entry into the model, the core of the model, the steps involved in patient contact, the outer frames or ringsflecting the environment in which dietitians practice, and the supporting systems of the model. (continued on next page)


Fpsre

1886 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS December 2014 Volume 114 Number 1

,

2

Figure 6. (continued) Comparison of Hammond models and Academy of Nutrition and Dietetics models reflecting dietetics practice.Each model (from 1970 through 2008) is shown and key concepts described: purpose/goal of model, target audience, schema,language, title, entry into the model, the core of the model, the steps involved in patient contact, the outer frames or rings reflectingthe environment in which dietitians practice, and the supporting systems of the model.


issues, and marketing of clinical di-etitians’ contributions to healthcare.7,17

An outer frame, “Framework of theMedical Care Team,” anchored thepatient/clienteregistered dietitianinto the health care team setting andwas the first attempt to depictthe connection to the external envi-ronment in which dietitians practiced.Resources were urging practitionersto define, claim, and communicatetheir rightful contributions tocomprehensive health care and com-monalities with other health careteam members. Most descriptionsidentified the clinical dietitian as ateam consultant rather than a teammember.5-7,18,23


Nutritional Care Planning Cycle(1977-1984). During the next 7-yearperiod, experience, the literature, andother resources developed signifi-cantly. Mason and colleagues publisheda benchmark systems- and process-oriented four-step guide to nutritionalcare.18 Hammond experimented withMason’s Systems Model and observedthat although the textdiscussedbroaderpractice issues, the model depicted onepractice dimension: Process. In addi-tion, the schematic’s 90-degree angles,straight lines, and boxes imparted a lessdesirable flat and structured flow tonutrition care planning.In 1982, the Academy published a

Position Paper that labeled and delin-eated the clinical dietetics specialty role


and conceptually outlined the clinicaldietitian’s responsibilities.6 These ad-vances reinforced the 1984 iterationthat described the case-oriented profes-sional.24 This iteration’s title broadenedto “The Nutritional Care Planning Cycle”to represent comprehensive nutritionalcare programs. The subtitle character-ized nutritional counseling/nutritioncare planning as “AGeneric Philosophy”because of the model’s potential as auniversal tool. This and later iterationsremoved “Entry” to make the modelmore widely applicable.

By 1984, patients had become full-fledged members of the health careenterprise and core language became“Partnership,” indicating that eachpatient/clienteregistered dietitian was


Figure 7. 2001 Academy Model of Nutrition Care Process. Reprinted from Splett and Myers.48


1888 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS December 2014 Volume 114 Number 12

Figure 8. 2008 Academy Nutrition Care Process and Model. Reprinted from International Dietetics and Nutrition TerminologyReference Manual: Standardized Language for the Nutrition Care Process.45


both a sender and a receiver. In addi-tion, each member’s individualityaffected the partnership dynamics,process, and, most likely, quality ofoutcomes.17,19,30,37-39

Through experience, core skillsseparated into two discrete but rein-forcing groups. Basic helping skills,such as active listening and open-ended questioning, helped establishthe partnership and were teachable inthe PSU undergraduate curriculum.Advanced counseling skills moved to anew outer frame.


From 1984 onward, the first stepin the contact/visit cycle became“Develop Data Base,” a stronger direc-tive and a nod to growing computertechnology (Figure 4). The partnershipwas tasked with gathering data fromsix newly defined categories: medical/clinical, medication, biochemical, an-thropometric, dietary, and psycho-socio-economic. Data sources expanded toinclude medical records and otherhealth care team resources.6,17,18,41

“Assessment” (step 2) organizeddata into three newly defined


categories: subjective (clarify andinterpret patient interviews),objective (interpret data againstreliable standards), and impressions(develop artfully from education,experience, and instincts). The im-pressions category was an earlyarticulation of nutrition diagnosis.Step 5 changed to “Monitor/Eval-uate,” focused on outcomes, andbegan to incorporate practitionereffectiveness evaluations.17,18,38

A new outer frame, “Counseling/Helping Relationship,” reflected


Defined key concepts and systematized Nutrition Counseling/Nutrition Care Planning� Integrated practice components (counseling, procedural, and environmental influences) into one focus� Provided a consistent framework that enabled comprehensive and individualized solutions to case studies and practice

issues� Made teaching and learning more efficient because components were easy to picture, internalize, and recall� Promoted quick cross-checks and targets for study and practice updates through a visual image� Allowed patient-specific data to vary across patients/clients, health issues, and settings� Encouraged flexibility and creativity by adapting to different student/practitioner skill levels, learning/practice styles, and

practice environments� Demonstrated commonalities among clinical dietitians and other health care professionals� Showed potential for providing a common base for introductory applied nutrition courses with minor changes in

languagea

� Showed potential for standardizing dietetics instruction across academia and practice across the dietetics profession� Portrayed dietetics care as a stimulating integration of biological and behavioral science

aThe Department of Nutritional Sciences, The Pennsylvania State University, introduced such a course (Nutrition Assessment)into its curriculum.

Figure 9. Benefits attributed to the Hammond models.

‡“Caring for Individuals, Not Dis-eases: A Comprehensive Approach tothe Nutrition Care of Persons withDiabetes,” March 6-7, 1985 and June10-11, 1986.

§“Caring for Individuals, Not Dis-eases: A Comprehensive Approach toNutritional Care Planning,” co-presented by Marian I. Hammond,MS, RD, assistant professor, and PennyM. Kris-Etherton, PhD, RD, assistantprofessor, Nutrition Program, Collegeof Human Development, The Pennsyl-vania State University, University Park.


advanced counseling consistent withthe literature and retained Danish’s“Helping Relationship” identity.30,42

The former “Medical Care Team”

frame was renamed “Health Care TeamSetting” to acknowledge the growth ofoutpatient practices and ancillaryhealth professions. It moved outwardbecause the health care team encircledother concepts.18

By 1984, the Kellogg ContinuingProfessional Education DevelopmentProject Team assembled a forward-looking practice description for clin-ical dietetics that closely aligned withthe 1984 Hammond model iteration.After study, it provisionally adoptedthe 1984 iteration to represent itsresearch results.

The Nutrition Care Process: AGeneric Philosophy (1986). The1986 iteration portrayed state-of-the-art clinical dietetics practice anddescribed the case-oriented clinicalnutrition specialist24 (Figure 5). Its aimwas to introduce practitioners to newnutrition care protocols, applications,and CE opportunities.This iteration incorporated re-

finements recommended by the Kel-logg Continuing Professional EducationDevelopment Project Team. It becamea professionally drawn graphic design.Components originally pictured asfour-sided frames became circularrings to synchronize and emphasizepractice dynamics. The Kellogg


Continuing Professional EducationDevelopment Project Team recom-mended changing the title to “NutritionCare Process: A Generic Philosophy” tobetter represent the literature. Ham-mond saw nutrition care planning in alarger context in which process repre-sented only one of the model compo-nents, but yielded to the group on thefinal diagram title. This iteration alsorefined selected component headingssuch as core, contact/visit cycle steps 3and 4, and outer ring 2.A new third outer ring, “Time,” encir-

cled all other components to addressthe challenges and opportunities oftime on nutrition care planning, practi-tioners, and patients/clients. Fromthe practitioner’s perspective, time is-sues affected the nature and quality ofmost relationships, practice decisions,and professional development de-cisions. In addition, patients/clientslived and worked within health, cul-tural, motivational, and other personalcircumstances that determined thetime they could devote to makingnutrition care planning visits andlearning and implementing newbehaviors.4,5,15,28,31,37

After testing,‡ a 1986 iterationworkshop was presented at the 1986

TION AND DIETETICS

Academy 69th Annual Meeting§

through the collaboration of the Acad-emy and the Kellogg Continuing Pro-fessional Education DevelopmentProject Team. The model’s schema wasconverted into a handout format enti-tled “The Clinical Dietitian’s PocketGuide to Individualized, Comprehen-sive Nutrition Care.”

Academy NCPM (2001, 2003, and2008)The development process and specificsof the Academy NCPM are detailedelsewhere.1,43-47 Splett and Myers syn-thesized input from regional telephonefocus groups into a diagram to describethe specific aspects of nutrition carethat could logically lead to positivehealth outcomes48 (Figure 7).

In 2002, the Academy appointed twocommittees that worked in parallel toexplore development of a commonnutrition care process for the dieteticsprofession and to elucidate conceptsand terminology for nutrition di-agnoses. The development processspanned almost 3 years, involved >150


Application area Nutrition Care Process and Model uses and benefits

United States

Accreditation Serves as the framework for developing undergraduate accreditation standards, conductingregistration examination, asking questions that guide evidence analysis projects, and organizingthe Evidence-Based Nutrition Practice Guidelines.

Public policy Aids in advocating for public policy stances in reimbursement, coverage, and informatics.51

Health records Serves as the framework for development of the Electronic Nutrition Care Process Record System,which, if adopted, will be the standard for future development of electronic health recordssystems that support work completed by registered dietitian nutritionists.

Standardized languageand terminology

Aids in developing standardized language to reflect the activities that occur in each of theNutrition Care Planning steps50; the IDNT has been promoted as a data element for research andfor use in practice, particularly as the foundation for recording nutrition care in electronic healthrecords.

Global

Global input on NCPM Aids in facilitating and incorporating global input. The Academy hosted several international inputsessions in 2005 and 2010 and currently has formally incorporated international members in theNCP Standardized Language Committee to provide ongoing input to refinement of both theNCPM and terminology supporting the NCPM. The International Confederation of DieteticsAssociation and European Federation of Associations of Dietitians embraced the concept ofhaving a common nutrition care process for the global dietetics community and appointed acommittee to evaluate whether the NCPM requires modification to be a truly global model.

Global and multiculturaloutreach

Assesses global dietetic practices. Beginning in 2007, presentations and workshops were providedto multinational and multicultural audiences representing a variety of forms and complexity levelsof dietetic practices in Sweden, Israel, Italy, Portugal, South Korea, Mexico, Norway, Japan,Malaysia, Australia, Brazil, and Canada.

Commitment to NCPMand IDNT

Facilitates commitment to NCPM and IDNT. For example, several associations (Canada, Australia,Japan, and Sweden) have formally adopted the NCPM and IDNT. South Korea, Mexico, Italy,Norway, France, Denmark, Taiwan, and the United Kingdom have signed translation licensurecontracts with the Academy, strongly suggesting commitment to adopt NCPM and IDNT in theirpractice.

Figure 10. National and global applications of the Nutrition Care Process and Model (NCPM). The NCPM and the InternationalDietetics and Nutrition Terminology (IDNT) are used in various ways in the United States and other ways globally. The applicationareas in the first column indicate the broad areas of practice where the NCPM is used and the second column identifies the specificuse and benefit attributed to using the model.


Academy members,1 and includedreviewing published literature, theHammond model materials, seminalwork completed by Mary Ann Kight,PhD, RD, and summarizing textbookapproaches to describing dieteticspractitoners’ nutrition care in inpa-tient, outpatient, long-term care, andcommunity settings. After significantcommittee deliberation, severaldifferent diagrams were provided tothe Academy’s House of Delegates fordialogue. After integrating the input,the resulting NCPM was strikinglysimilar to the Hammond model.In addition, during the 2008 NCPM

update, Hammondwas invited to reviewthe NCPM and provide input to the


Nutrition Care Process-StandardizedLanguage Committee. After minor re-finements were made, the NCPM wasrepublished49 (Figure 8).

MODEL USESEducational Use of HammondModelsFrom 1970 to 1986, the Hammondmodel holistic flow diagrams evolvedwith the growth of dietetics practice.They fulfilled their intended purposesand goals and yielded the additionalbenefits shown in Figure 9.The mind and skill sets required to

implement the practice componentswere complex and diverse. Students


were introduced to the model’s orga-nization and meanings of selectedcomponents and asked to apply themodel to beginning case studies.Kellogg Continuing Professional Edu-cation Development Project Teamworkshops invited practitioners to self-assess their practices against themodel’s components and to plan theirCE accordingly.

US and Global Applications of theAcademy ModelsThe NCPM provides the Academywith tools to guide US education,standardized practice, and Academystrategic planning initiatives. It



advocates public policy stances and isframing an Electronic Nutrition CareProcess Record System. Multinationaland multicultural associations, groups,and local meetings spanning morethan 12 countries and 3 continentsprovide ongoing input into NCPMrefinement, dissemination, and adop-tion for their individual health caresystems (Figure 10).50,51

RESEARCH OPPORTUNITIESMany of the research opportunitiesidentified in the Hammond modelyears remain, such as formal evaluationof model efficacy, core relationshipdevelopment, exploration of practi-tioner individuality and its effects onnutrition care planning outcomes,techniques for teaching model con-cepts, CE program development, andthe impact of time. The NCPM providesan essential framework for exploringthese issues.The Academy’s annual meeting has

frequently included a specific categoryof research for abstracts and originalcontributions dedicated to researchabout the use and implementation ofthe NCPM and the International Di-etetics and Nutrition Terminology.Authors who publish in the Journal ofthe Academy of Nutrition and Dieteticsare encouraged to use the NCPM as aframework for articles describingnutrition care provided by dieteticspractitioners.

SUMMARYModels begin simply and continuallyevolve to reflect the current state of theart in a profession. When ideas ormodels are built on firm foundations,they stand the test of time. The Acad-emy established a strong foundationfor therapeutic practice beginning inthe 1950s. The seminal work on theHammond models, completed by thePSU faculty led by Hammond and incollaboration with the Kellogg Con-tinuing Professional Education Devel-opment Project Team, was built onthese foundations. Although the NCPMbegins with the 1998 Health ServicesResearch Task Force, it is clear from thisarticle that the Academy’s recent workwas built on the foundation and con-cepts of previous work. The develop-ment process described here was alsocarefully synthesized from the seminalwork of other dietitians (eg, Mary Ann


Kight, PhD, RD) and leaders from otherdisciplines (eg, Rogers, Mead, Maslow,and Danish).19,20,26,30 The Hammondmodel iterations show the importanceof research, experimentation, and dia-logue to inform the evolution of themodels over time.The richness of the content of the

Hammond models reflects the bestavailable research and published liter-ature at the time and clearly setsthe stage for the work accomplishedby the Academy in the 2000s. Manyof the same challenges identified inthe Hammond model years remain,including use of a common language todescribe care, development of the corepartnership between the dietitian andpatient/client, effective teaching andpractice strategies, and the impact oftime. This article illustrates the impor-tance of gaining buy-in and input asmodels are developed. The Hammondmodels were developed and guidedby one person. However, when theAcademy began the work in the late1990s, broad input was received frommembers throughout the professionthrough surveys, dialogue sessions inthe House of Delegates, and input fromother organizational units (ie, Accredi-tation Council for Education in Nutri-tion and Dietetics, the Commission onDietetics Registration, and other com-mittees). This led to broader under-standing, support, and adoption ofthe NCPM, which is remarkably similarto the previous Hammond models.Although the original work on theHammondmodels arose primarily froman educator’s need to teach dieteticsstudents more effectively, the currentAcademy model was developed toguide practice and policy as well. TheNCPM continues to represent thehighest standards and will guide di-etetics educators and practitionersstriving to continually improve theirlevels of teaching and practice. Theodyssey described in this article illus-trates the importance of understandinghistory and the present to inform futuremodels and strategies.

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STATEMENT OF POTENTIAL CONFLICT OF INTERESTNo potential conflict of interest was reported by the authors.

FUNDING/SUPPORTThere is no funding to disclose.

ACKNOWLEDGEMENTSThe authors would like to thank the individuals who reviewed the manuscript: Nutrition Care Process and Terminology Committee Chair, PaulaRitter-Gooder, PhD, RDN, CSG, LMNT, FAND; Penny Kris Etherton, PhD, RD, FAHA, FNLA, CLS, distinguished professor of nutrition, Department ofNutritional Sciences, The Pennsylvania State University; Ida LaQuatra, PhD, RD, LDN, assistant professor, Indiana University of Pennsylvania; KayHowarter, MS, RDN, director, EAL/NCP Business Development, Academy of Nutrition and Dietetics; Karen Lacey, MS, RD, CD, senior lectureremerita and former UW-Green Bay dietetics’ director, Ellen Pritchett, RDN, LDN, CPHQ, registered dietitian nutritionist, ManorCare HealthServices-Venice, FL; Christina West, editorial services; Teri McCann-Michalski, graphic design services.












































































































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Nutrition Care Process and Model: An Academic and Practice …€¦ · Nutrition and Dietetics, formerly the American Dietetic Association, adopted a Nutrition Care Process and Model