Implementing new nutrition care practices in healthcare: learning from the experience of health professionals in hospitals and Family Health Teams.

Abstract

Background: When converting evidence into practice to improve patient care, application of implementation, behaviour change and change management theory can help make the changes more effective and sustained. With a third of patients malnourished at admission to hospital and 34% of older adults at nutrition risk in the community, nutrition risk identification is a key care activity. Implementation techniques are needed to integrate screening into hospital and community settings. The overall aim of this dissertation was to understand healthcare professionals’ perspectives on implementing several new nutrition care activities in hospitals and nutrition screening in the community.

Methods: Part 1 and 2 of this dissertation are components of the More-2-Eat (M2E) study, which aimed to improve nutrition care by implementing the Integrated Nutrition Pathway for Acute Care (INPAC) in five hospital units across Canada. In Part 1, a knowledge, attitudes and practices (KAP) questionnaire was developed and tested for reliability (test-retest) and then used in the baseline period of M2E. This questionnaire was an implementation technique used to demonstrate barriers to the use of INPAC prior to tailoring to the specific hospital context. Correlation (Intra class correlation; ICC), descriptive, and association analyses were conducted. The questionnaire was then administered to hospital staff on the M2E units before INPAC implementation and again a year later. Paired and unpaired statistical analyses were used to demonstrate changes in staff KAP with implementation of INPAC and associations determined between key staff characteristics and KAP change. For Part 2, key informant interviews and focus groups were conducted with staff and management at the M2E units at baseline, after a year of implementation and a year after project completion. Verbatim transcription was completed for interviews, and focus groups were summarized. Line by line coding was completed followed by thematic analysis. Results collected 1 and 2 years after implementation were analyzed together. Part 3 is focused on stakeholder perceptions of building a program for falls and nutrition risk screening in primary care. Interviews were conducted with staff, management, and clients from six Family Health Teams in the North East Local Health Integration Network; regional representatives were also interviewed as this was a regional initiative. Family Health Team staff, management and regional representative interviews were transcribed verbatim and client interviews summarized. Line by line coding was conducted on all interviews followed by thematic analysis.

Results: Results from Part 1 indicate the KAP questionnaire is reliable (knowledge/attitude subscale ICC = 0.69 [95% CI 0.45–0.84]; practice subscale ICC = 0.845 [0.68−0.92]) and several barriers with respect to knowledge and attitudes of team members were noted in the baseline use of this questionnaire in the M2E hospitals. Comparing baseline results (n = 189) with scores after a year of implementing INPAC, (n = 147 unpaired and n = 57 paired with baseline) there was a significant increase in total score in unpaired results (from mean 93.6/128 [range, 51–124] to 99.5/128 [range, 54–119]; t = 5.97, P < .0001). There was also an increase in knowledge/attitudes (t = 2.4, P = .016) and practice (t = 3.57, P < .0001) components. There were no statistically significant changes in paired responses. After the year of INPAC implementation, 59% (n = 86) of staff felt involved in the change process, and these staff had higher knowledge/attitudes and KAP scores than those who did not feel involved. Results from Part 2 provided an understanding of what hospital staff and management considered necessary to make nutrition care improvements. Five main themes were identified from baseline data: building a reason to change; involving relevant people in the change process; embedding change into current practice; accounting for climate; and building strong relationships within the hospital team. Building on these results, 1 and 2 years later, sites described the beginning of a culture change where nutrition care activities were valued and viewed as the expected norm. Results provided an understanding of what was necessary to sustain changes: maintaining the new routine; building intrinsic motivation; continuing to collect and report data; and engaging new staff and management. Strategies to spread successful nutrition care improvements to other units in the study hospital and other nearby hospitals included: being responsive to opportunities; considering local context and readiness; and making it easy to spread. Strategies that supported both sustaining and spreading included: being and staying visible, and maintaining roles and supporting new champions.

For Part 3, a new context was considered, exploring how Family Health Teams developed falls and nutrition risk screening programs for older adults. Four themes were identified, including: setting up for successful screening; making it work; following up with risk; and an overarching theme that the implementation of this care improvement was about building relationships. Discussion: This dissertation provides guidance for healthcare providers on how to implement nutrition care improvements in hospitals and steps for building a falls and nutrition risk screening program in a Family Health Team. This dissertation research has significant impact on understanding the process of change which can impact patient care in both settings. Impact is also visible through its contribution to the M2E project overall, as M2E did improve nutrition care in all five hospital units. Comparisons can be made between how changes were initiated in each setting, specifically regarding their use of implementation, behaviour change and change management theories to support sustainable change. These theories are guides that can ensure the processes and changes are viewed from a variety of perspectives and key steps considered. In the M2E hospitals, the teams making the changes were trained on these theories and applied them throughout their implementation of INPAC, including through considering capability, opportunity and motivation, collecting audit data, involving relevant people in the change process, and more. Family Health Teams had not received such training and although they were thinking through the process and recommended use of change management strategies, they may benefit from applying implementation theories to support their progress.

Conclusion: This dissertation has significant impact in terms of understanding the process of change in hospitals and Family Health Teams. Results from the hospital work are already been applied to practice and research in other hospitals in Canada, Australia and the United Kingdom. Understanding the steps used by Family Health Teams to set up their falls and nutrition risk screening will be beneficial for others that are developing their own programs. Learning from and sharing the experiences of health professionals implementing screening and other nutrition care activities in hospitals and Family Health Teams will help to improve patient care and support continued implementation of nutrition care practices in healthcare.