A total of
n = 138 participants were involved (Table
2; Note sustainiability participants were also participants in the post implementation phase). Results suggest that several implementation changes were sustained and spread successfully leading to an overall culture change whereby the importance of nutrition care to the recovery of patients was prioritized. Successful implementation included improving processes, perceptions, and ultimately patient outcomes, as described elsewhere [
28,
29]. Based on this success observed by sites, focus shifted to strategies to sustain and spread improvements, which also provided opportunities for implementation of further best practices. One small change was unlikely to lead to a culture change, but a series of changes that were sustained and spread did result in a shift in values towards the importance of nutrition care as indicated in the framework (Fig.
1).
Table 2
Participant demographics
# of Participants | 45 | 10 | 71 | 12 |
Gender | Female | 40 (89%) | 6 (60%) | 61 (86%) | 10 (83%) |
Male | 5 (11%) | 4 (40%) | 9 (13%) | 2 (17%) |
Missing Data | 0 | 0 | 1 (1%) | 0 |
Age Group | < 30 years | 3 (7%) | 2 (20%) | 19 (27%) | 0 |
30–39 years | 10 (22%) | 2 (20%) | 21 (30%) | 1 (8%) |
40–49 years | 14 (31%) | 3 (30%) | 13 (18%) | 3 (25%) |
50–59 years | 13 (29%) | 3 (30%) | 13 (18%) | 5 (42%) |
60+ years | 3 (7%) | 0 | 4 (6%) | 0 |
Prefer not to say | 1 (2%) | 0 | 0 | 1 (8%) |
Missing | 1 (2%) | 0 | 1 (1%) | 2 (17%) |
Profession | Dietitian | 16 | 2 | 6 | 5 |
Diet Technician/Diet Assistant | 1 | 0 | 2 | 0 |
Food Service Supervisor/Manager | 7 | 1 | 0 | 1 |
Registered Nurse | 9 | 4 | 25 | 2 |
Registered Practical Nurse/Licensed Practical Nurse | 1 | 2 | 7 | 0 |
Health Care Aide/Personal Support Worker | 0 | 0 | 5 | 0 |
Attending Physician | 2 | 1 | 4 | 1 |
Physiotherapist/Occupational Therapist | 0 | 0 | 9 | 0 |
Pharmacist | 0 | 0 | 3 | 0 |
Management | 14 | 2 | 0 | 7 |
Otherb | 2 | 0 | 10 | 1 |
| Missing | 1 | 0 | 0 | 0 |
Sustain
All sites experienced a shift from implementation to sustainability. “With any initiative, the most difficult piece isn’t the processes themselves. It’s the change management and sustaining those improvements.” (IA-14:Nurse). Specific strategies to sustain a change included: maintaining the new routine, building intrinsic motivation, continuing to measure and report, and engaging new staff and management.
Maintaining the new routine
After a change had started becoming embedded into the routine, sites recognized that effort was still needed to keep it going. “We have to build it, and then we still have to maintain it and then we’ll see the effects.” (IA-11:Registered Dietitian [RD]). Sites also had to make sure the change was having the desired effect. “Making sure that what we’ve set up is actually working. ... You can’t just put something in place and hope that it’ll continue to run successfully.” (SC-1:RD + Manager).
To maintain the new routine, key unit staff needed to remain involved in keeping others engaged. “In addition to a clinical manager, we have nurse educators and clinical care leaders; those are key because they’re the ones that are going to be continuing to talk and have the discussions around nutrition care in the absence of clinical nutrition.” (SB-1:RD + Manager). Supportive unit managers and nurse educators were key to delivering education, answering questions, and providing continued support, reminders and progress updates after the implementation team moved on to other priorities for improvement: “If you see something falling by the wayside, keep subtly putting it in there again.” (ID-5:RD).
The change also had to be seen as part of the job, building accountability, such as through performance reviews, or finding ways to standardize the process (e.g., Standard Operating Procedures etc.). Maintaining the new routine was about making sure staff had what they needed and it was easy. “I think just making sure that you give them the tools. I mean, they’ll do it if it’s easy and if it’s there.” (SB-2:Manager).
Engaging new staff and management
Participants discussed the challenges of high staff turnover. “It’s that maintenance and continuing to collaborate with new staff that are coming onboard, be it frontline nurses or new managers or new volunteer coordinators or physicians. It’s a continuous need to remind and raise that awareness.” (SC-1:RD + manager). For engaging new management it was about giving them some time to understand the new environment and then setting up a brief meeting to explain that nutrition care was prioritized, what had been achieved, and future plans. “You have to give people a bit of time to kind of get acclimatized to the unit [and then bring them on board]” (SE-2:RD + Manager). One champion who experienced high turnover, indicated: “A lot of my work has just been making sure that things carry on with new leaders.” (SC-1:RD + Manager).
For engaging new staff, integrating key messages into the orientation was a key strategy. “We also mention it [nutrition] at new hire orientation.” (SC-2:Nurse Educator). In this way, nutrition care was not seen as “new,” and could be treated as a valued and expected practice on the unit. Nurse educators also supported new staff. “Our educator, who was part of our team, is doing another round of education and awareness-building because of the [staff] turnover.” (SC-1:RD + Manager).
Building intrinsic motivation
Intrinsic motivation, as noted in the baseline analysis theme of “building a reason to change” [
16], is needed to undertake and sustain a change in practice. Those who work in healthcare typically have the intrinsic motivation to help their patients; recognizing that improving nutrition care enhances patient recovery supports this intrinsic motivation.
“99% of the people, or higher, who work here want to help people and want to help the patients. So, I think we need to start with making sure that the managers buy in and see that this is really worthwhile doing, and getting some key front line champions onboard that say, ‘Yeah, I think this is important. … I’d like to do it, but I don’t want to be the only one doing it, so I’ll encourage my colleagues to do it.’” (IB-4:Manager).
Recognizing that everyone has a role to play in improving nutrition care for patient benefit was also demonstrated as a way to build intrinsic motivation. Staff were able to see their specific role, and the impact they could have. “We also developed a tool called “Find, Feed, Follow,” and it’s for every discipline. Our Malnutrition Steering Committee discussed each in an interdisciplinary group, and they each kind of discussed what their role is to find people with malnutrition, to feed them, and to follow. There was a lot of “a-ha” moments with the team, realizing that, “Oh, a piece connects to my world.” So, that was valuable.” (SE-1:Manager).
Intrinsic motivation was also built by engaging staff throughout the change, including involving them in decisions. “I think really asking nursing and staff feedback was a good way to start and a good way to continue on through. I think it kept them engaged.” (ID-1:RD). Encouragement when staff were doing well also facilitated continued motivation. “Recognizing staff for the work that they’re doing. When they hear, “This is really good work. Keep it up,” … It starts to become more of an intrinsic motivation to do it, versus, “We’re doing this because we have to.”” (IA-12:Nurse). However, with busy hospital staff, intrinsic motivation on its own may not be not enough: “We still have resistance from nursing. I say that, being one. Can’t get them to prioritize patient setup or even bedside table setup for us. We’ve struggled with that. They have multiple competing priorities and will tell you that’s not their first priority. …We don’t feel that that’s as important as it is.” (IB-9:Manager). Although intrinsic motivation is important, it may not be sufficient to sustain a change.
Continue to measure and report
Data was seen as essential for implementation and sustainability. “It [data] needs to be local, it needs to be timely and it needs to be in a format where you can see your trend and your results. The reinforcement is extremely important.” (IA-15:Manager). A strong implementation plan should include collection of data from baseline, throughout implementation, and continue longer term to show if the changes were being sustained. Monthly INPAC audit reports based on chart review completed twice per month served this purpose in More-2-Eat. “We have to keep auditing. Audits are a huge thing. If you keep auditing and you see that it’s fallen to the wayside then you can talk about it more and keep trying to sustain everything that we’ve started.” (ID-4:RD + Manager). Audits may not need to be collected as regularly as during implementation, however they are still important. “There needs to be dedicated audits. We need to see where the gaps are. … I don’t think it needs to be at the same frequency, but I think that it’s important that we maintain that for momentum.” (IC-4:Nurse+Manager).
Reporting results were also key for sustainability, engagement, and contributed to building intrinsic motivation. “They can take pride in it [audit results], and then, therefore, I think it’s just intrinsically rewarding themselves. And they go, “Well, I’m going to keep doing this because, look at that, I get this…” they get the feedback about it.” (IA-10:Manager). Specific strategies for relaying audit results included huddles, quick chats with individual staff, e-mails, posters etc. “The audits were the most important thing. Then when they were noticing a dip down in practice, then we would talk about it at huddles. I would send out emails and let them know what the compliance was and that they needed to improve that.” (IC-4:Nurse+Manager). Audit results were also useful for management. “I always want to see results. I want to see, ok, we’re doing this study, we’re doing it, but I want to see results, and that it’s working. … What it improved… How?... Show me the numbers…” (ID-FG1).
Spread
When a change was seen as having a positive impact, it led to the desire for other units and hospitals to consider that improvement. “I’ve been happy with how it’s starting to seep out to other areas within the organization.” (IB-8:RD + Manager). A year after project completion, nutrition screening and use of a standardized assessment to diagnose malnutrition (i.e., subjective global assessment; SGA) were used hospital-wide in all sites and had also spread to other local hospitals. Strategies for spreading successful changes included: being responsive to opportunities, considering local context and readiness, and making it easy to spread.
Being responsive to opportunities
Other units and hospitals were interested in implementing the successful changes from the pilot units. “We are still hearing from other units… They’re asking us, ‘When are you going to roll out that form on our unit,’ or, ‘When are you going to roll out that initiative on our unit?’ So, there still is interest out there.” (SE-2:RD + Manager). Recognizing that interest, responding, and providing support helped spread and maintain the momentum. “If the interest or the desire is there, I think what we have to do is kind of capitalize on when that interest is being expressed.” (IB-8:RD + Manager).
These opportunities could arise from the micro (individuals, unit etc.), meso (hospital etc.) or macro (regional etc.) levels, and each could be utilized in their own way. At the micro level, individual interest could spur change: “If there’s an interest, they volunteer, than they’ve already met half of the battle by demonstrating their interest.” (SB-1:RD + Manager). An example of a meso-level opportunity was leadership demonstrating their support for food and nutrition initiatives. “This idea of having the executive team deliver meal trays when they’re doing rounding with patients would be, I think, a good way to get staff to buy in that, you know, it’s not just your responsibility, but we’re all kind of doing our part.” (SE-2:RD + Manager). At the macro level, aligning the regional initiatives provided many opportunities such as materials, resources, and benefits of having similar goals. “Our healthcare region has probably been the strongest impetus moving things forward.” (IE-2:RD + Manager). Examples of opportunities being seized included when admission forms were being changed anyways, “they wouldn’t change the forms for us unless they were already being changed” (IB-4:RD); when a new electronic medical record systems was being set up; or when nutrition could connect to another priority, such as patient safety.
Considering local context and readiness
Each unit was unique so local context and readiness needed to be determined before starting full implementation. “How others should do it has to be driven by what makes the most sense on those units.” (IB-8:RD + Manager). An individualized approach to spread was encouraged. “I would view it as a unit-by-unit implementation. … healthcare has its own culture, and change is difficult… you need to sort of make sure that everybody buys in. I’ve seen far too many projects where we try to do this wholesale implementation, and they fail. So, I think it’s much better to do it smaller scale and slow steps, and then, before you know it, it’s replicated across the patch and you don’t have to worry about selling people because it sells itself.” (IA-6:Manager).
Checking for unit readiness was about understanding what was happening to see if it was the right time to encourage implementation in specific units. “To take a look at if there’s readiness. I’d like to be able to promote some of the results that will come forth in the upcoming months and years to really start understanding with units as to who’s ready, who might like to look at an implementation, and who might like to take a look at making some changes.” (ID-6:Manager).
Units that have expressed interest and had a strong team seemed to be the ones who were ready for implementation. “We find that if singular units have readiness and they have a cohesive team and want to work together and do more, these would be some of the ways that we could approach it and take a look at trying to implement some of the same things and using the tools that were already created to help.” (ID-6:Manager).
Making it easy to spread
After learning from initial implementation, several meso and macro level changes were used to make it easier for the change to spread. One aspect was understanding the barriers that were faced in initial implementation, and being upfront and working to overcome these earlier in the new setting: “Just being open and honest and telling them that these are the obstacles that we’re going to come across.” (SE-1:Manager).
Having systems already set up also made it easier for new units. For example, when the screening and referral process was already in the computer system, the focus was on changing behavior so the system was used, rather than setting-up the system. Examples included having screening questions embedded in forms or the malnutrition assessment components “we actually embedded it [subjective global assessment] into our initial nutrition assessment documentation form. That definitely… oh, yeah, that makes a difference.” (SE-1:Manager); setting up medication pass (oral nutritional supplementation delivered with medication) with an already available product; or including the best practices in standard operating procedures.
Learning from each other also made it easier. “I wouldn’t mind just being part of helping other units start all of this – like, a little bit of hand-holding because sometimes I find that people need that.” (IB-I1:RD). Another manager indicated the benefits of learning from past experience: “Whenever I’m looking to roll something new out, I don’t want to reinvent the wheel. I want to go to somebody that’s tried and true, and steal shamelessly from them and use what I can.” (IA-6:Manager).
Sustain and spread
Both sustaining and spreading a nutrition activity required two further strategies, being and staying visible and maintaining roles and supporting new champions.
Being and staying visible
Being able to see the change and the people driving it were important for both sustaining and spreading changes. “I’m just wondering if that presence and visibility [of the project and dietitian] has helped to kind of sustain the changes more so than something more specific, like an education session or an auditing process.” (SB-1:RD). The change had to stay visible so people would keep talking about it, thus encouraging it to become embedded. “I think part of it is just through osmosis, right? Like, we talk about it so much, and we do things so much. And sometimes some of the front line staff won’t put two and two together that the osmosis is from us talking about it. But I think that’s when the real benefit is, is that people start just naturally putting things into their day-to-day practice.” (IB-7:Manager). For a nutrition focused project, visibility included having dietitians on the unit regularly, available for questions, and continuing to talk about success. “We’re in their faces all the time. We’re on the units all the time.” (IC-2:RD).
Maintaining roles and supporting new champions
A champion was needed throughout implementation and to sustain and spread changes with the support of an implementation team: “Somebody has to own it. Because if nobody owns it, then it goes by the wayside.” (IA-11:RD). This champion also supported others to champion specific changes or areas to spread. “We have a lot of people here who are very good at driving change and driving initiatives that are specific to this unit. I think that it will be important to take those people as champions.” (IC-4:Nurse+Manager). Involving existing leaders, including those who are seen as leaders by other staff, helped with buy-in and to drive a change. “You need to get that buy in and you need to scout out who are your leaders or who has more input with the staff or who are the staff who’s kind of their champion... Then make sure that those people are involved as well.” (SC-2:Nurse Educator).
After initial changes were in place, the implementation team either stayed in place, shrank, or merged into existing teams, such as those focused on changing practice or quality improvement. “I think our Quality Council is the place to be and the place to bring up what changes you think need to happen and then work on a plan.” (SD-1:RD). Regardless, developing and maintaining champions was a required strategy to spread or sustain improved nutrition practices.
Creating culture change
While sustaining and spreading successful improvements, a culture change was discussed by participants. “People are thinking about it, know about it, feel it. There’s a presence there, and so that’s maybe a start to a change in nutrition culture.” (IB-8:RD + Manager). People were paying attention to the changes and their impact, particularly for their benefit to the patients. “I think it’s made a big difference. I think hopefully we’re preventing people from being readmitted. I think we’re seeing the people that we really need to see… I think it’s really, really helped improve our patient care.” (IC-2:RD). This reported culture change was visible in a variety of ways such as: “people are paying more attention to what people [patients] are eating.” (IE-FG1); “we are more aware of it as a group, particularly the physicians.” (IA-FG2:Physician); “myself and my staff have become more aware of malnutrition as an issue. Conversation comes up more frequently during our discharge rounds and just day-to-day time on the unit. We discuss food much more.” (IB-7:Manager).
Culture change within administrators was also demonstrated through change in allocation of resources. In one site, it was originally mentioned that “budgets being so tight, there’s no appetite for any investment at all” (IA-6:Manager). After the More-2-Eat project ended, a request to continue specific nutrition care processes was approved. Dedicated resources to facilitate champion time was also seen as beneficial. “The real key, honestly, is being able to have some dedicated resources to continue to follow up and observe and audit and review and look for continuous ideas as to how to improve and engage improvement specialists for you to support that message. The challenge is, however, that resource isn’t readily available.” (ID-2:Manager). In the More-2-Eat project, a year after the small influx of resources to support data collection and champion time had ended, 2018 interviews indicated most changes had been sustained and spread. “[Nutrition care] continues to be a culture within our study unit.” (SB-1:RD + Manager). Changes had become “embedded into our routines and our relationships” (SA-3:Manager). It was clear that even though these changes had started as part of a research project, the end of the project did not indicate the end of nutrition care improvements. “I don’t think this thing is ever going to end to be honest... I think this is just a start, and then after the study’s over, we need to continue. That is something that speaks to me loud and clear, that this isn’t something that just stops after the study’s over. We’ve got to keep going and figuring out how we can continue making it important, that nutrition is important, and that food is medicine.” (IC-1:RD). It is apparent that successful implementation, sustaining and spread could lead to what was described as a culture change.