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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.