Background
Methods
Setting
Sampling
Participants
Profession | Place of work (nursing home, home care, home nursing) | Number of years educated (range) | Years of working in nursing homes and/or home care/home nursing (range) | |
---|---|---|---|---|
Focus group 1 | Registered nurse (1A) Registered nurse (1B) Social and health service assistant (1C) | Home nursing Home nursing Home care | (18 months – 15 years) | (18 months – 14 years) |
Social and health service assistant (1D) | Nursing home | |||
Social and health service assistant (1E) | Home care | |||
Social and health service helper (1F) | Nursing home | |||
Social and health service helper (1G) | Home care | |||
Focus group 2 | Registered nurse (2A) Registered nurse (2B) Social and health service assistant (2C) | Home nursing Home nursing Nursing home | (18 months – 35 years) | (1 year – 31 years) |
Social and health service assistant (2D) | Nursing home | |||
Social and health service assistant (2E) | Home care | |||
Social and health service helper (2F) | Home care | |||
Social and health service helper (2G) | Home care |
Data collection
Education: - Registered nurses - Social and healthcare assistants - Social and healthcare helpers | |
Number of years of education: - Maximum variation of years since completion of education | |
Number of years in a primary health care setting: - Maximum variation of years of employment in a primary health care setting (home care, home nursing or nursing homes) | |
Employment: - Current employment and working in the municipality was a main criterion |
Assumptions | Purpose | Questions |
---|---|---|
Routines in relation to nutrition: Healthcare professionals are not well-trained or educated in identifying nutritional problems, setting up goals, identifying interventions and evaluating nursing sensitive outcomes. | To investigate how healthcare professionals’ self-perceived views on competencies within nutrition and documentation and organizational structures influence their daily work and the quality of care provided within the nursing home and home care/home nursing setting. | -How do healthcare professionals describe their specific nutritional routines in their daily work? |
Routines in relation to documentation: Healthcare professionals are not well-trained or educated in systematically developing care plans | -How do healthcare professionals describe their specific documentation practices in their daily work? | |
Knowledge in relation to nutrition: Malnutrition or nutritional issues are often overlooked in nursing homes and home care/home nursing, because the healthcare professionals lack awareness and knowledge of which variables affect and influence patients’ nutritional state, hence affecting the quality of care. | - Do the different healthcare professionals consider that their education sufficiently prepares them to provide nutritional care? | |
Knowledge in relation to documentation: Healthcare professionals are not using existing nutritional screening tools or guidelines because they are not aware of how to put them to use in a clinical setting. | - Do the different healthcare professionals consider that their education sufficiently prepares them to document and develop nutritional care plans? | |
Attitudes towards nutrition: Malnutrition or nutritional issues are often overlooked, because healthcare professionals do not prioritize nutritional care. | -Do healthcare professionals consider nutrition to be an important part of their job and daily tasks? | |
Attitudes towards documentation: Malnutrition or nutritional issues are often overlooked, because healthcare professionals do not prioritize documentation. | -Do healthcare professionals feel that documentation is an important part of their job and daily tasks? | |
Factors that affect daily work and quality of care (organizational obstacles): Nutrition and documentation routines are not specified and clear for the healthcare professionals and could therefore have a negative impact on both the daily workflow and continuity of care and treatment. Healthcare professionals are not using existing screening tools or guidelines because they do not feel obliged and are not required to do so | -Does their place of work have clear guidelines for routines regarding nutrition and documentation within and between the three groups of healthcare professionals? -How do the different healthcare professionals’ experience enabling the retrieval and use of nutritional screening tools? | |
Factors that affect daily work and quality of care (context/setting): The performance and execution of nutritional related activities could be influenced by the fact that observations and interventions are done in the patients’ home, lacking, for instance, a weighing scale. | -Do healthcare professionals consider the context of their workplace as an obstacle? -Does their workplace prioritize nutrition and documentation in their daily work? | |
Factors that affect daily work and quality of care (collaboration between different healthcare providers): Malnutrition or nutritional issues are often overlooked, because healthcare professionals are not aware of their specific role and collaboration with other caregivers in nutritional care and subsequent documentation. Variation in healthcare professionals’ nutritional routines and documentation practices could influence both the workflow and continuity of care and treatment. | -How do healthcare professionals with various educational levels describe and consider their nutritional care responsibilities? -How do healthcare professionals with various educational levels talk, describe and consider their responsibilities regarding documentation? -Do they describe or outline any ambiguities or disagreements in terms of their routines and practices? |
Domain | Examples of interview questions |
---|---|
Routines (nutrition and documentation) | - Is nutritional care a routine task in your workplace? - What are your specific daily tasks or routines in relation to nutrition? - Do you experience that your daily routines are consistent? - Do you develop nutritional care plans? - When do you think that it is necessary to develop nutrition care plans? - Can you tell me how you work with and use documentation in your daily work? - Do you consider a primary care context as an advantage or disadvantage when planning and documenting nutritional care? - How do you primarily communicate nutritional related observations with your colleagues? |
Knowledge (nutrition and documentation) | - Can you tell me which type of knowledge you base your nutritional advice upon? (evidence /expert)? - Can you mention some of the latest nutritional advice you gave a patient? - Do you feel that you know enough about nutrition? - Where do you seek guidance concerning nutritional care or documentation if needed? - How do you become aware of nutritional issues with the patient? - What do you do if a patient is malnourished or at risk of malnutrition? - Do you know of existing nutritional screening instruments? - Do you know how to develop nutritional care plans? |
Attitudes (nutrition and documentation) | - Do you consider nutrition to be part of your responsibility? - Do you all have the same degree of responsibility or are there different levels of responsibility? - Is nutritional care important? Does it “work”? - Do you think that documentation supports you in your daily work? - Is documentation a priority in your workplace? |
Data analysis
Results
Lack of uniform and systematic communication affect nutritional care practices
“:..but there is also something that is called actions plan in the patients home, where you write how and what to…for instance, if there is something about their dietary intake that you need to be aware about…or if you have talked to the dietician then you correct it in the action plan…that is definitely how I develop my action plans..” (SSH 2F)…“don’t you mean that you have made a note that you stick up on the kitchen cabinet..?” (RN 2A)…“…yes..” (SSH 2F)...“..that should not be out in the patients’ own home and that is NOT an action plan!” (RN 2A). (Focus group 2).
“:. I think that the overall intention is that we should primarily communicate through the patients’ healthcare record, but…” (SSA 2C)“…doing so, will make the little details and nuances disappear…” (RN 2B) (Focus group 2).“..primarily we are documenting in the patients’ healthcare record, so that if someone comes and say; “I have not had that service”, then you can go in and see that someone in fact has delivered this service..” (SSA 2D)“…I mean, it is to avoid those newspaper front pages..” (RN 2A)(Focus group 2).
“…I am really, really excited to hear where you document it?..” (RN 1A)“…under nutrition. I develop an action plan name it nutrition..” (RN 1B)“…we also do that in x district…” (SSA 1C) (Focus group 1).
“... But when you are out there in the citizens home, as a new employee, you think why has he not eaten anything… is he sick or what is wrong? Is it the teeth or something else? Then it turns out that it was something entirely different…but it wasn’t written anywhere…but then someone said that they had heard something about him...” (SSH 1G) (Focus group 1).
Experience-based knowledge among the primary workforce influences daily clinical decisions
“…there is always someone who has tried something, right?..” (SSA 1C)“…then you can ask them, what you should do in the particular situations..” (SSA 1D) (Focus group 1).“…but then, when you are out here, then I think that years of experience enable you to know, that you can do so and so and so..” (SSH 1F)“…I ask my colleagues what they usually do…” (SSH 1G) (Focus group 1)
“…we do not have a forum where we share knowledge or anything else. It is up to ourselves to know who may know something about particular topics..” (SSA 1E)“… yeah, its learning by doing..” (RN 1A)(Focus group 1).
Different attitudes towards nutritional care leading to differences in the quality of care
“…but I think that we all are aware of how important it is (nutrition)” (RN 2A)“…but what about the poor patient? The patients who are dependent on the healthcare professional’s interest in nutrition. As a healthcare professional you are the only one who should be able to connect problems with nutrition…” (SSA 2D)“…and then there are some healthcare professionals who do it more than others because they have a higher interest in the topic and prioritize it…” (SSA 2C) (Focus group 2).
“…no, I would not spend more time documenting!..” (RN 1A)“..I mean, it is exactly it… we spend, I mean, a lot of time documenting. We have had this new horrible system for 1 ½ year and it just takes so much time… I don’t think anyone is interested in spending more time documenting…” (RN 1B)“…but it is a huge issue in the media, how much time us nurses spend on documenting, so we are not unique in that sense…” (RN 1A)(Focus group 1).
“…I actually think I would like to spend more time documenting..” (SSA 2C)“…because there is a lot to document..” (SSH 2F)“…it is really important to document about those things to benefit both the patient and myself. Your colleagues need to know what is going on..” (SSA 2C)“..and it is not always that we have time to even write anything..” (SSH 2F).(Focus group 2).
Differences in organizational culture affects quality of care
“…I also feel that you accept a NO to quickly…or what should you say. If you come in to the patients home and should serve the food, and they say “no, I don’t want it, I am not hungry” – then you just accept it, right. Instead of trying to in some way to say something that can encourage the patient to eat their food…” (SSA 1D)“…and it is probably because that you are told that you should accept, erm, the patients’ own wishes or whatever..” (SSA 1C)“…it must also be super annoying that someone comes and say that you should eat your food..” (SSA 1E) (Focus group 1).
“…but there you definitely face some challenges..” (SSA 1C) “..when facing the patient and their family, then you are just…set aside. Then all of our training is just thrown to the ground..” (SSH 1G)“…because, it is actually what we basically have been taught in our educational training..” (RN 1A)“…so right now, we are actually heading away from what we have learned..” (SSA 1C)“..and do the opposite of what we think should be done..” (RN 1A)(Focus group 1).
Blood sugar schemes: “…when I started working in this municipality I started out in a nursing home. And there I was taught to use these blood sugar schemes. Then I was transferred to home care and was told that I under no circumstances should use these schemes. These were really odd to me, as I actually thought that they were really useful..” (SSA 1E)“.. I don’t understand that. What are the difference between being in a nursing home and home care?” (RN 1B)“…I don’t know – but it should be the same…especially in the same municipality” (SSA 1E) (focus group 1).
Nutritional screening instruments: “.. No, we don’t use nutritional screening instruments in the patient’s home. In nursing homes I definitely think they do..” (SSH 2G) “..and in the hospitals. That’s where you screen for nutritional issues, right?..” (SSA 2D)“.. but we have some..” (SSA 2C)“..yeah, they exist..” (SSA 2D)“…sure..” (SSH 2G) (Focus group 2).
Lack of clear nutritional care responsibilities affect how daily care is performed
“..I mean, that’s where the challenge is. It’s not that there aren’t any food service suppliers or something like that.. that’s not the problem. The problem is who you should get a hold of if an issue arises..” (SSA)(Focus group 2).
“..No, we do not have specific or different levels of responsibilities. We all should do the same..” (SSA)“…I mean, in our district, if we see that someone might have a nutritional problem, we usually visit them and them…er…we contact the nurse or dietician if it is really bad..” (SSA)“..I’m thinking that it primarily is the ones who are with the specific patient, who are responsible, regardless of their education…(RN)” (Focus group 1).
Lack of clinical leadership and priorities makes nutritional care invisible
Time: “..well, we are not supposed to say it. But lack of time is an important factor that prevents us from doing our job…” (SSH) (Focus groups 1)
Agenda: “..no, I don’t think that nutrition is on the agenda here…” (SSA) (Focus group 2).
“…it is nothing but a decoding of my colleagues practices..” (SSA)“…I mean, I think that within nursing, whenever a new colleague arrives, then an employee gets the job to train and teach this new colleague. But one employee teaches routines and practices in one way, another in a different way. So there are no rules. No structured training. So two new colleagues can be trained totally differently, because there are not structure for our practices and training…” (RN)(Focus group 1).
“…it’s impossible to be aware of which tools to use, when the training we got from our workplace was so deficient and incorrect..”(SSH)“…plus, there are all other kinds of tools that I talked to our leader about. Then there is this and that tool, which actually are the same as this one. However, we should not use any of them, because they only exist on paper, so it takes extra time to apply it to the documentation system. So that’s a NO-GO…” (RN)(Focus group 1).