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Implementation strategies for nutritional guidelines in nursing homes: Effects on care staff and residents
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Clinical Nutrition and Metabolism.ORCID iD: 0000-0002-8081-7090
2017 (English)Doctoral thesis, comprehensive summary (Other academic)
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.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2017. , p. 85
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 1288
Keywords [en]
implementation, clinical guidelines, malnutrition, nursing home
National Category
Nutrition and Dietetics
Research subject
Medical Science
Identifiers
URN: urn:nbn:se:uu:diva-312229ISBN: 978-91-554-9789-7 (print)OAI: oai:DiVA.org:uu-312229DiVA, id: diva2:1062729
Public defence
2017-02-24, hörsal Auditorium Minus, Museum Gustavianum, Akademigatan 3, Uppsala, 09:15 (Swedish)
Opponent
Supervisors
Available from: 2017-02-02 Created: 2017-01-08 Last updated: 2017-02-02
List of papers
1. Does undernutrition still prevail among nursing home residents?
Open this publication in new window or tab >>Does undernutrition still prevail among nursing home residents?
2013 (English)In: Clinical Nutrition, ISSN 0261-5614, E-ISSN 1532-1983, Vol. 32, no 4, p. 562-568Article in journal (Refereed) 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.

National Category
Geriatrics
Identifiers
urn:nbn:se:uu:diva-187331 (URN)10.1016/j.clnu.2012.10.007 (DOI)000321726300011 ()23137706 (PubMedID)
Available from: 2012-12-05 Created: 2012-12-05 Last updated: 2018-02-22Bibliographically approved
2. The effects of nutritional guideline implementation on nursing home staff performance: a controlled trial
Open this publication in new window or tab >>The effects of nutritional guideline implementation on nursing home staff performance: a controlled trial
2017 (English)In: Scandinavian Journal of Caring Sciences, ISSN 0283-9318, E-ISSN 1471-6712Article in journal (Refereed) Published
National Category
Nutrition and Dietetics
Identifiers
urn:nbn:se:uu:diva-312221 (URN)10.1111/scs.12487 (DOI)
Available from: 2017-01-08 Created: 2017-01-08 Last updated: 2018-04-12
3. Strategies to implement community guidelines on nutrition and their long-term clinical effects in nursing home residents
Open this publication in new window or tab >>Strategies to implement community guidelines on nutrition and their long-term clinical effects in nursing home residents
2015 (English)In: The Journal of Nutrition, Health & Aging, ISSN 1279-7707, E-ISSN 1760-4788, Vol. 19, no 1, p. 70-76Article in journal (Refereed) 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.

Keywords
Implementation, nutrition, clinical guidelines, nursing home, cognition
National Category
Geriatrics Nutrition and Dietetics
Identifiers
urn:nbn:se:uu:diva-245203 (URN)10.1007/s12603-014-0522-4 (DOI)000348024800010 ()25560819 (PubMedID)
Available from: 2015-02-25 Created: 2015-02-25 Last updated: 2018-02-22Bibliographically approved
4. Is it possible to influence ability, willingness and understanding among nursing home care staff to implement nutritional guidelines?
Open this publication in new window or tab >>Is it possible to influence ability, willingness and understanding among nursing home care staff to implement nutritional guidelines?
Show others...
(English)Manuscript (preprint) (Other academic)
National Category
Nutrition and Dietetics
Identifiers
urn:nbn:se:uu:diva-312227 (URN)
Available from: 2017-01-08 Created: 2017-01-08 Last updated: 2017-01-08

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