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Nutrition and Health Sciences -- Faculty Nutrition and Health Sciences, Department of
Publications
6-2010
VValidation alidation of Nutrition of Nutrition StandarStandardizdized Language—Next ed Language—Next Steps Steps
Paula Ritter-Gooder
University of Nebraska-Lincoln
Nancy M. Lewis
University of Nebraska--Lincoln, nlewis2@unl.edu
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Ritter-Gooder, Paula and Lewis, Nancy M., "Validation of Nutrition Standardized Language—Next Steps"
(2010). Nutrition and Health Sciences -- Faculty Publications. 7.
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Published in Journal of the American Dietetic Association, Volume 110, Issue 6 (June 2010), pp. 832, 834–835; doi: 10.1016/j.jada.2010.04.016
Copyright © 2010 American Dietetic Association; published by Elsevier Inc. Used by permission.
Published online May 22, 2010.
Validation of Nutrition Standardized Language—Next Steps
Paula Ritter-Gooder, PhD, RD, LMNT
Nancy M. Lewis, PhD, RD, FADA
Paula Ritter-Gooder is a research assistant, and Nancy M. Lewis is a professor in the Department of Nutrition and Health Sciences, University of
Nebraska–Lincoln.
To provide a model for quality care and ognized leaders and award winners the task the terms are accurate for labeling nutri-
outcomes management, the Nutrition Care of identifying nutrition problems. Later, a tion problems.
Process (NCP) and standardized language 12-member NCP/Standardized Language A validated standardized language pro-
were introduced in 2003 by the American Committee gathered input on the initial vides the benefit of allowing RDs to differ-
Dietetic Association (ADA). set of diagnostic terms from community, entiate one diagnostic term from another
The standardized language, published in ambulatory, acute care, and long-term care (13, 14). RDs identify a nutrition diagnosis
the International Dietetics & Nutrition Termi- practitioners and researchers. The results by observing the signs and symptoms that
nology (IDNT) Reference Manual: Standardized of this work, the labeling of nutrition di- demonstrate its presence in a patient along
Language for the Nutrition Care Process (1), agnostic terms, was published (6), and an- with the underlying cause, the etiology.
is designed to facilitate communication, nual updates (7, 8) were made as terminol- Signs/symptoms of a diagnostic term must
improve care, and close the gap in health ogy was identified for the remaining steps occur in a cluster in a sufficient number of
care quality (2). When registered dietitians in the NCP—assessment, intervention, cases to be included in the diagnostic term
(RDs) are oriented to a nutrition care pro- and monitoring and evaluation. and these sets of highly reliable clues pro-
cess, improvement in their documentation vide accuracy in diagnosing. For exam-
of nutrition care occurs (3). Since the in- Validation Refines the Standardized ple, the diagnostic terms involuntary weight
troduction of the NCP and standardized Language loss and inadequate energy intake require val-
language, RDs and dietetic technicians, idated clusters of signs and symptoms
registered (DTRs), have begun to adopt After the diagnostic terms are labeled, within each diagnosis to allow the RD to
the process and language into their prac- the next logical step in language develop- distinguish between the diagnoses. Is each
tice (4, 5). This article explains why valida- ment is to validate the language (9). Con- diagnostic term a separate and distinct
tion of the standardized language is needed tent validation is the process of testing the concept? The ability of RDs and DTRs to
to make the language accurate and mean- language to learn whether the diagnostic discern between diagnostic terms provides
ingful for practice and describes how vali- terms fulfill the intended purpose of iden- for accuracy and consistency in use of the
dation is conducted using RDs. tifying and labeling separate and distinct standardized language. Accuracy in diag-
nutrition problems (10). In essence, valida- nosing is required for determining what
Origins of the Standardized tion of the content of nutrition diagnostic evidence-based interventions are needed
Language terms confirms or verifies the definition, and what outcomes can be expected. The
related etiologies, and the signs/symptoms validation of the diagnostic terms may pos-
The standardized language consists of required to define the term and ensure the sibly disclose overlap of some terms.
terms describing all NCP steps; assess- language is clear, explicit, and succinct for Another benefit of validating the stan-
ment, diagnosis, intervention, and moni- each term. Currently, one published study dardized language is explicating or defin-
toring and evaluation. Nutrition diagnostic has been conducted to test the validity of ing the meanings of the signs/symptoms
terms were the first language identified us- the content of the diagnostic terms by us- for proper measurement and use by RDs.
ing concept analysis, a critical first step in ing a convenience sample of RDs to test Definitions of signs/symptoms and re-
language development (Figure). Concept all IDNT diagnostic terms (11). Another lated etiologies of the term are instruc-
analysis is a method of examining attri- study measured the reliability of use of tions for what will be observed and how
butes or characteristics of nutrition prob- the terms among RDs with different years it will be observed. Operational defini-
lems for the purpose of defining the do- of practice (12). Clearly, more validation tions are needed to provide the bridge be-
main and boundary of each term. In this studies are needed using nutrition experts tween incidental observation and scien-
process, the definition, etiologies, and with experience in providing patient care tific validation (15) and make it possible to
signs/symptoms of the term are proposed. for each of the 60 diagnostic terms in the replicate studies and relate findings across
ADA initiated this step by appointing rec- IDNT reference manual (1) to assure that studies. For example, the signs/symptoms
832
Validation of nutrition Standardized language—next StepS 834
Figure 1. Development and refinement of the American Dietetic Association’s standardized language diagnostic terms. aFehring RJ. The Fehring model.
In Carroll-Johnson RM, ed. Classification of Nursing Diagnoses: Proceedings of the Tenth Conference. Philadelphia, PA: Lippincott; 1994:55-62 (19).
of early satiety and poor intake listed in the RDs in different practice settings or pa- toms are more easily remembered than a
standardized language may have different tient populations. Validation uses expert longer list of less-specific parameters. The
meanings among RDs and DTRs. If these and clinical testing in two separate phases possible reduction in the number of defin-
are described as “stops eating within five (Figure 1, Step 2a and 2b). In the expert ing signs/symptoms and related etiologies
minutes” and “eats less than 50% offered” validation phase (Figure 1, Step 2a), nu- would make the diagnostic terms easier to
they have clearer meaning. The evidence or trition experts analyze the content of the use by RDs and DTRs.
results of the validation are strengthened term. Experts use fewer cues or signs/ Content validation by expert RDs pro-
when meanings are explicit; therefore, val- symptoms when compared with novices to vides evidence that the group thinks a cer-
idating the standardized language requires derive a correct diagnosis (18). To validate tain way. However, there are no assurances
operational definitions of all items. content of the term, the relevance, speci- that their judgment represents real-world
ficity, representatives, and clarity of the di- phenomena. In the second phase of con-
Validation Models for Diagnostic agnosis is rated among the experts using a tent validation (Figure 1, Step 2b), the di-
Terms quantitative Likert-type scale in the Diag- agnoses are studied using the Clinical Diag-
nostic Content Validation Model (19). A nostic Validation Model (19) in the clinical
In the early 1980s, methodologies for weighted response for each item is calcu- setting to provide a total picture of content
validating nursing diagnoses appeared in lated to arrive at a mean score. Using the validity. Independent clinicians observe
the literature, with these methods still mean score, items are classified into major, and rate the etiologies and signs/symp-
used in their research today (16, 17). Vali- minor, or irrelevant characteristics. The ir- toms in patients who are prediagnosed by
dation of nutrition diagnostic terms should relevant etiologies and signs/symptoms a clinical expert other than the observers.
replicate the scientific rigor and models are removed. A reduction in the number of The same scoring method of the Diagnos-
used in nursing validation studies to re- signs/symptoms needed to identify a diag- tic Content Validation Model is used to ob-
fine the language (Figure 1). The models nosis has been an outcome of nursing di- tain major, minor, and nonrelevant char-
allow comparisons between studies of the agnosis language validation studies (20, acteristics. The validated language is then
same language when one term is rated by 21). Conceptual and succinct signs/symp- available for IDNT revisions and future re-
835 ritter-gooder & lewiS in Journal of the american Dietetic association 110 (2010)
search studies that collect and measure nu- cess/Standardized Language Commit- ference, Lippincott, Philadelphia, PA (1994),
trition care outcomes captured from elec- tee, Nutrition care process and model part pp. 55–62.
tronic health care records. This research I: The 2008 update, J Am Diet Assoc 108 20. N. Oliveira, T. Chianca, and G. H. Rassool,
is vital to inform evidence-based practice (2008), pp. 1113–1117. A validation study of the nursing diagnosis
(22), to improve quality of care, and to fa- 5. Writing Group of the Nutrition Care Pro- anxiety in Brazil, In J Nurs Terminol Classif 19
cilitate reimbursement of nutrition ser- cess/Standardized Language Committee, (2008), pp. 102–110.
vices (23, 24). Nutrition care process part II: Using the In- 21. E. V. Carmona and M.H.B.M. Lopes, Con-
ternational Dietetics and Nutrition Ter- tent validation of parental role conflict in
minology to document the nutrition care the neonatal intensive care unit, In J Nurs
Future Direction process, J Am Diet Assoc 108 (2008), pp. Terminol Classif 17 (2006), pp. 3–9.
1287–1293. 22. American Dietetic Association House of
Diagnostic terms may be validated us- 6. American Dietetic Association. Nutrition Di- Delegate, Fall 2009 mega issues: Evidence-
ing nutrition experts who are members of agnosis: A Critical Step in the Nutrition Care based practice and health reform. American
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fied specialists who commonly see the nu- sociation; 2006. eatright.org/HODMegaIssues ; accessed
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ies, the exposure to and adoption of the American Dietetic Association; 2007. guage are essential components of a concep-
standardized language may increase, as a 8. American Dietetic Association. International tual model to guide and document nutrition
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Acknowledgments — This manuscript is a 13. L. O. Walker and K. C. Avant, Strategies for eatright.org/HealthProfessionals/
contribution of the University of Nebraska Ag- Theory Construction in Nursing (3rd ed.), Ap- content.aspx?id=7077
ricultural Research Division. This manuscript pleton and Lange, Norwalk, CT (1995). • Nutrition Care Process SNAPshots out-
was supported in part through the American 14. B. L. Rodgers, Concept analysis: An evo- lining the standardized language in
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