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Implementation strategies for nutritional guidelines in nursing homes: Effects on care staff and residents
Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för folkhälso- och vårdvetenskap, Klinisk nutrition och metabolism.ORCID-id: 0000-0002-8081-7090
2017 (engelsk)Doktoravhandling, med artikler (Annet vitenskapelig)
Abstract [en]

Introduction: The number of older adults (≥ 65 years) is increasing in Sweden. At the same time, the elderly care system is being restructured with an increased care burden in nursing homes (NHs). Several studies report a high prevalence of malnutrition among older adults. In recent years public awareness about malnutrition has increased and collective initiatives have been undertaken. However, we lack knowledge regarding how to implement these initiatives to achieve real improvements in practice.

Aims: The overall aims of the thesis are to update our knowledge of the nutritional situation in municipal elderly care and to evaluate different implementation strategies (external facilitation and educational outreach visits) for implementing nutritional guidelines in the NH setting.

Methods: Residents and staff of altogether eight NH units participated in the studies. The two implementation strategies were external facilitation (EF) and educational outreach visits (EOV). The EF strategy was a one-year, multifaceted intervention that included support, guidance, practice audits and feedback in four NH units. The EOV strategy comprised one three-hour lecture about the nutritional guidelines in four other NH units. Both strategies were targeted to selected NH teams, which consisted of a unit manager, a nurse and 5-10 care staff.

Results: In paper I, the prevalence of malnutrition in the NH setting remained high, i.e., 30% were malnourished and 63% at risk of malnutrition, and malnutrition was associated with deterioration in function and cognition and one-year mortality. However, possible improvements in nutritional status among NH residents over time (from 1996 to 2010) were observed. In paper II, the EF strategy improved mealtime ambience compared to the EOV strategy with respect to arranging the table, offering a choice of beverage and more to drink, serving the meal, increasing social interactions between staff and residents, decreasing social interactions among staff and reducing noise from the kitchen. In paper III, the EF strategy may have been related to a delay in cognitive deterioration in a sub-sample of communicative NH residents. In paper IV, the EF strategy improved, on average, the ability and willingness of the staff to implement the guidelines, i.e., the staff experienced a clearer assignment of responsibilities regarding nutritional procedures and that they had more time, tools and support from leadership. Moreover, the staff felt that they experienced less resistance from work colleagues, that their knowledge and experience were valued, that the guidelines worked in practice and that the implementation of guidelines was not labourious. 

Conclusions: Malnutrition is prevalent in Swedish nursing homes. Implementation of nutritional guidelines by an external facilitator, as compared to traditional methods, may be more effective on mealtime ambience, provide better preconditions for change among the staff, and may have positive effects on cognition among residents.

sted, utgiver, år, opplag, sider
Uppsala: Acta Universitatis Upsaliensis, 2017. , s. 85
Serie
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 1288
Emneord [en]
implementation, clinical guidelines, malnutrition, nursing home
HSV kategori
Forskningsprogram
Medicinsk vetenskap
Identifikatorer
URN: urn:nbn:se:uu:diva-312229ISBN: 978-91-554-9789-7 (tryckt)OAI: oai:DiVA.org:uu-312229DiVA, id: diva2:1062729
Disputas
2017-02-24, hörsal Auditorium Minus, Museum Gustavianum, Akademigatan 3, Uppsala, 09:15 (svensk)
Opponent
Veileder
Tilgjengelig fra: 2017-02-02 Laget: 2017-01-08 Sist oppdatert: 2017-02-02
Delarbeid
1. Does undernutrition still prevail among nursing home residents?
Åpne denne publikasjonen i ny fane eller vindu >>Does undernutrition still prevail among nursing home residents?
2013 (engelsk)Inngår i: Clinical Nutrition, ISSN 0261-5614, E-ISSN 1532-1983, Vol. 32, nr 4, s. 562-568Artikkel i tidsskrift (Fagfellevurdert) Published
Abstract [en]

BACKGROUND & AIMS

During recent years public awareness about malnutrition has increased and collective initiatives have been undertaken. Simultaneously, the number of older adults is increasing, and the elderly care has been placed under pressure. The aim was to assess the nutritional situation and one-year mortality among nursing home (NH) residents, and compare with historical data.

METHODS

Mini Nutritional Assessment-Short Form (MNA-SF), ADL Barthel Index (BI), Short Portable Mental Status Questionnaire (SPMSQ), EQ-5D, Charlson Comorbidity Index (CCI), and blood samples were collected from 172 NH residents (86.3 ± 8 years, 70% women). Mortality data was taken from NH records. Nutritional data from 166 NH residents (83.8 ± 8 years, 61% women) examined in 1996 was retrieved for historical comparison.

RESULTS

The prevalence of malnutrition was 30%, as compared to 71% in the historical data set, corresponding to a present average body mass index of 23.7 ± 5.1 compared with 22.3 ± 4.2 kg/m(2) (p < 0.01). Reduced nutritional status was associated with decline in function (p < 0.001) and cognition (p < 0.01). One-year mortality was 24%. Regression analyses indicated high age (OR = 1.09, 95% CI (1.03-1.16)), high scores in CCI (OR = 1.54, (1.19-1.99)), low BMI (OR = 2.47, (1.14-5.38)) and malnutrition (OR = 2.37, (1.07-5.26)) to be independently associated with one-year mortality.

CONCLUSIONS

Malnutrition still prevails and is associated with deteriorated cognition, function and increased mortality. A possible improvement in nutritional status in NH residents over time was observed.

HSV kategori
Identifikatorer
urn:nbn:se:uu:diva-187331 (URN)10.1016/j.clnu.2012.10.007 (DOI)000321726300011 ()23137706 (PubMedID)
Tilgjengelig fra: 2012-12-05 Laget: 2012-12-05 Sist oppdatert: 2018-02-22bibliografisk kontrollert
2. The effects of nutritional guideline implementation on nursing home staff performance: a controlled trial
Åpne denne publikasjonen i ny fane eller vindu >>The effects of nutritional guideline implementation on nursing home staff performance: a controlled trial
2018 (engelsk)Inngår i: Scandinavian Journal of Caring Sciences, ISSN 0283-9318, E-ISSN 1471-6712, Vol. 32, nr 2, s. 622-633Artikkel i tidsskrift (Fagfellevurdert) Published
Abstract [en]

Rationale: Suboptimal nutritional practices in elderly caresettings may be resolved by an efficient introduction ofnutritional guidelines.Aims: To compare two different implementation strate-gies, external facilitation (EF) and educational outreachvisits (EOVs), when introducing nutritional guidelines innursing homes (NHs), and study the impact on staffperformance.Methodological design: A quasi-experimental study withbaseline and follow-up measurements.Outcome measures: The primary outcome was staff perfor-mance as a function of mealtime ambience and food ser-vice routines.Interventions/research methods: The EF strategy was a 1-year,multifaceted intervention that included support, guidance,practice audit and feedback in two NH units. The EOVstrategy comprised one-three-hour lecture about nutri-tional guidelines in two other NH units. Both strategieswere targeted to selected NH teams, which consisted of aunit manager, a nurse and 5–10 care staff. Mealtime ambi-ence was evaluated by 47 observations using a structuredmealtime instrument. Food service routines were evalu-ated by 109 food records performed by the staff.Results: Mealtime ambience was more strongly improvedin the EF group than in the EOV group after the imple-mentation. Factors improved were laying a table(p = 0.03), offering a choice of beverage (p = 0.02), theserving of the meal (p = 0.02), interactions between staffand residents (p = 0.02) and less noise from the kitchen(p = 0.01). Food service routines remained unchanged inboth groups.Conclusions: An EF strategy that included guidance, auditand feedback improved mealtime ambience when nutri-tional guidelines were introduced in a nursing home set-ting, whereas food service routines were unchanged bythe EF strategy.

HSV kategori
Identifikatorer
urn:nbn:se:uu:diva-312221 (URN)10.1111/scs.12487 (DOI)000436254800018 ()
Tilgjengelig fra: 2017-01-08 Laget: 2017-01-08 Sist oppdatert: 2022-01-29bibliografisk kontrollert
3. Strategies to implement community guidelines on nutrition and their long-term clinical effects in nursing home residents
Åpne denne publikasjonen i ny fane eller vindu >>Strategies to implement community guidelines on nutrition and their long-term clinical effects in nursing home residents
2015 (engelsk)Inngår i: The Journal of Nutrition, Health & Aging, ISSN 1279-7707, E-ISSN 1760-4788, Vol. 19, nr 1, s. 70-76Artikkel i tidsskrift (Fagfellevurdert) Published
Abstract [en]

Objectives: Studies on implementation techniques that focus on nutrition in the setting of elderly care are scarce. The aims of this study were to compare two implementation strategies i.e., external facilitation ( EF) and educational outreach visits ( EOVs), in order to introduce nutritional guidelines ( e.g. screening, food quality and mealtime ambience), into a nursing home ( NH) setting and to evaluate the clinical outcomes. Design: A controlled study with baseline and follow-up measurements. Setting: Four NHs. Participants: A total of 101 NH residents. Intervention: The EF was a one-year, multifaceted intervention that included support, guidance, practice audits, and feedback that were provided to two NHs. The EOVs performed at the other NHs consisted of one session of three hours of lectures about the guidelines. Both interventions targeted a team of the unit manager, the head nurse, and 5-10 of the care staff. Measurements: The outcomes were nutritional status ( Mini Nutritional Assessment-Short Form, MNA-SF), body mass index ( BMI), functional ability ( Barthel Index, BI), cognitive function ( Short Portable Mental Status Questionnaire, SPMSQ, performed in a subgroup of communicative NH residents), health-related quality of life ( EQ-5D), and the levels of certain biochemical markers like for example vitamin D, albumin and insulin-like growth factor 1. Results: After a median of 18 months, nutritional parameters ( MNA-SF and BMI) remained unchanged in both groups. While there were no differences in most outcomes between the two groups, the cognitive ability of those in the EOV group deteriorated more than in individuals in the EF group ( p=0.008). Multiple linear regression analyses indicated that the intervention group assignment ( EF) was independently from other potentially related factors associated with less cognitive decline. Conclusion: An extended model of implementation of nutritional guidelines, including guidance and feedback to NH staff, did not affect nutritional status but may be associated with a delayed cognitive decline in communicative NH residents.

Emneord
Implementation, nutrition, clinical guidelines, nursing home, cognition
HSV kategori
Identifikatorer
urn:nbn:se:uu:diva-245203 (URN)10.1007/s12603-014-0522-4 (DOI)000348024800010 ()25560819 (PubMedID)
Tilgjengelig fra: 2015-02-25 Laget: 2015-02-25 Sist oppdatert: 2018-02-22bibliografisk kontrollert
4. Is it possible to influence ability, willingness and understanding among nursing home care staff to implement nutritional guidelines?: A comparison of a facilitated and an educational strategy
Åpne denne publikasjonen i ny fane eller vindu >>Is it possible to influence ability, willingness and understanding among nursing home care staff to implement nutritional guidelines?: A comparison of a facilitated and an educational strategy
Vise andre…
2021 (engelsk)Inngår i: International Journal of Older People Nursing, ISSN 1748-3735, E-ISSN 1748-3743, Vol. 16, nr 3, artikkel-id e12367Artikkel i tidsskrift (Fagfellevurdert) Published
Abstract [en]

Background: Translating nutrition knowledge into care practice is challenging since multiple factors can affect the implementation process. This study examined the impact of two implementation strategies, that is external facilitation (EF) and educational outreach visits (EOVs), on the organisational context and individual factors when implementing nutritional guidelines in a nursing home (NH) setting.

Methods: The EF strategy was a one-year, multifaceted (including support, guidance, a practice audit and feedback) intervention given to four NH units. The EOV strategy was a three-hour lecture about the nutritional guidelines given to four other NH units. Both strategies were directed at selected NH teams, consisting of a unit manager, a nurse and 5-10 care staff. A questionnaire was distributed, before and after the interventions, to evaluate the prerequisites for the staff to use the guidelines. Three conditions were used to examine the organisational context and the individual factors: the staff's ability and willingness to implement the nutritional guidelines and their understanding of them. Confirmatory factor analysis and structural equation models were used for the data analysis.

Results: The results indicated that on average, there was a significant increase in the staff's ability to implement the nutritional guidelines in the EF group. The staff exposed to the EF strategy experienced better resources to implement the guidelines in terms of time, tools and support from leadership and a clearer assignment of responsibility regarding nutrition procedures. There was no change in staff's willingness and understanding of the guidelines in the EF group. On average, no significant changes were observed for the staff's ability, willingness or understanding in the EOV group.

Conclusions: A long-term, active and flexible implementation strategy (i.e. EF) affected the care staff's ability to implement the nutritional guidelines in an NH setting. No such impact was observed for the more passive, educational approach (i.e. EOV).

sted, utgiver, år, opplag, sider
John Wiley & Sons, 2021
HSV kategori
Identifikatorer
urn:nbn:se:uu:diva-312227 (URN)10.1111/opn.12367 (DOI)000620913100001 ()33624452 (PubMedID)
Tilgjengelig fra: 2017-01-08 Laget: 2017-01-08 Sist oppdatert: 2022-08-30bibliografisk kontrollert

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