Implementation Science and Nutrition: From Research to Practice

Implementation of nutritional care in hospitals: A qualitative study of barriers and facilitators using implementation theory

BACKGROUND

Disease-related malnutrition is prevalent among hospitalised patients, but not all patients achieve the needed nutritional care. At a Danish University Hospital, focus has been on implementing nutritional practices based on clinical guidelines, but there is continuously variation between the wards regarding the quality of nutritional care.

AIM

The aim of this study was to identify the potential barriers and facilitators for implementation of the clinical guidelines for nutritional practices and to recommend suggestions for development of nutritional practices, using a theoretical implementation strategy.

METHOD

The design was a qualitative interview study of employees at a Danish University Hospital, using a semi-structured interview guide. The participants were nurses, nurse's assistant, nurse nutrition expert, head nurse and dieticians. We recruited 11 employees, representing eight different wards.

FINDINGS

The analysis identified six themes: (1) clear allocation of responsibilities and committed management enhances nutrition practices, (2) leadership support is essential, (3) physical settings and tools affect possibilities for action, (4) selection of equivalent staff is core, (5) teaching promotes the knowledge and skills and (6) a dietitian in the ward facilitates implementation of nutritional care. Barriers and facilitators among the themes were identified and has led to suggestions to strengthen nutritional care, based on implementation theory.

CONCLUSION

Various factors were identified as having impact on the implementation of nutrition practices and different suggestions have emerged to accommodate those factors, as well as to apply an implementation strategy to facilitate change in practice.

Particularity, Engagement, Actionable Inferences, Reflexivity, and Legitimation tool for rigor in mixed methods implementation research

BACKGROUND

Implementation science helps generate approaches to expedite the uptake of evidence in practice. Mixed methods are commonly used in implementation research because they allow researchers to integrate distinct qualitative and quantitative methods and data sets to unravel the implementation process and context and design contextual tools for optimizing the implementation. To date, there has been limited discussion on how to ensure rigor in mixed methods implementation research.

PURPOSE

To present Particularity, Engagement, Actionable Inferences, Reflexivity, and Legitimation (PEARL) as a practical tool for understanding various components of rigor in mixed methods implementation research.

DATA SOURCES

This methodological discussion is based on a nurse-led mixed methods implementation study. The PEARL tool was developed based on an interpretive, critical reflection, and purposive reading of selected literature sources drawn from the researchers' knowledge, experiences of designing and conducting mixed methods implementation research, and published methodological papers about mixed methods, implementation science, and research rigor.

CONCLUSION

An exemplar exploratory sequential mixed methods study in nursing is provided to illustrate the application of the PEARL tool. The proposed tool can be a useful and innovative tool for researchers and students intending to use mixed methods in implementation research. The tool offers a straightforward approach to learning the key rigor components of mixed methods implementation research for application in designing and conducting implementation research using mixed methods.

CLINICAL RELEVANCE

Rigorous implementation research is critical for effective uptake of innovations and evidence-based knowledge into practice and policymaking. The proposed tool can be used as the means to establish rigor in mixed methods implementation research in nursing and health sciences.

NIH-supported implementation science and nutrition research: a portfolio review of the past decade

Objective

This portfolio analysis aims to describe the scope of NIH-funded extramural research grants at the intersection of nutrition research and implementation science (IS) from 2011 to 2022 and to offer insights into future research opportunities relevant to the Strategic Plan for NIH Nutrition Research 2020-2030.

Methods

A portfolio analysis of funded grants using NIH reporting systems was conducted to identify nutrition research and IS awarded between fiscal years 2011 and 2022. The authors screened the titles and abstracts for inclusion criteria: research and career development awards involved a nutrition and/or dietary intervention and measured a stated implementation outcome or used an IS theory, model, or framework.

Results

In total, 33 NIH-funded awards met the inclusion criteria. Almost half of the awards (48.5%) were investigator-initiated research projects compared to research career awards and cooperative agreements. While studies were predominantly conducted in the United States, 15.2% were conducted in low- and middle-income countries in Africa, Latin America, and Asia. Adults aged 19-64 years and children aged 2-11 years represented most of the study populations (45.5 and 15.2%, respectively). Studies provided nutrition/dietary guidelines and created culturally tailored interventions, which were then adapted in collaboration with community partners in schools, hospitals, and religious settings. The most cited IS outcomes were feasibility, costs, adoption, and acceptability. Sixteen awards (48.5%) used an IS theory, model, or framework to guide their work.

Discussion

The findings show the breadth of NIH-funded nutrition and implementation research and highlight potential research opportunities.

Uptake of Innovations in Nursing: The Necessity for Implementation Science

Innovations are critical for improving clinical practice and nursing education, and for enhancing learning and practice change for frontline nurses and nursing students. Continuous innovation for delivering safe care and improving patient outcomes is needed. Merely demonstrating the effectiveness of research innovations is not enough to promote their uptake and use in practice. A 2021 study in cancer research reported that moving research into practice takes about 15 years. Implementation science, a systemic process of identifying the most relevant approaches to move research into practice, has emerged as an effective way to bridge the research-practice gap. The purpose of this article is to discuss why and how Implementation Science is necessary to promote the uptake of innovations in clinical and educational practice.

An equitable, community-engaged translational framework for science in human lactation and infant feeding-a report from "Breastmilk Ecology: Genesis of Infant Nutrition (BEGIN)" Working Group 5

Human milk is the ideal source of nutrition for most infants, but significant gaps remain in our understanding of human milk biology. As part of addressing these gaps, the Breastmilk Ecology: Genesis of Infant Nutrition (BEGIN) Project Working Groups 1-4 interrogated the state of knowledge regarding the infant-human milk-lactating parent triad. However, to optimize the impact of newly generated knowledge across all stages of human milk research, the need remained for a translational research framework specific to the field. Thus, with inspiration from the simplified environmental sciences framework of Kaufman and Curl, Working Group 5 of the BEGIN Project developed a translational framework for science in human lactation and infant feeding, which includes 5 nonlinear, interconnected translational stages, T1: Discovery; T2: Human health implications; T3: Clinical and public health implications; T4: Implementation; and T5: Impact. The framework is accompanied by 6 overarching principles: 1) Research spans the translational continuum in a nonlinear, nonhierarchical manner; 2) Projects engage interdisciplinary teams in continuous collaboration and cross talk; 3) Priorities and study designs incorporate a diverse range of contextual factors; 4) Research teams include community stakeholders from the outset through purposeful, ethical, and equitable engagement; 5) Research designs and conceptual models incorporate respectful care for the birthing parent and address implications for the lactating parent; 6) Research implications for real-world settings account for contextual factors surrounding the feeding of human milk, including exclusivity and mode of feeding. To demonstrate application of the presented translational research framework and its overarching principles, 6 case studies are included, each illustrating research gaps across all stages of the framework. Applying a translational framework approach to addressing gaps in the science of human milk feeding is an important step toward the aligned goals of optimizing infant feeding across diverse contexts as well as optimizing health for all.

Implementation of a best-practice guideline: Early enteral nutrition in a neuroscience intensive care unit

Current evidence suggests that early enteral nutrition is a best practice and leads to improved clinical outcomes. An evidence-based practice project was implemented in a busy neurointensive care unit in a midwestern tertiary care facility that was designed to improve care by implementing the early nutrition portion of Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine and the American Society for Enteral and Parenteral Nutrition. The Registered Nurses' Association of Ontario's (RNAO) Toolkit: Implementation of Best Practice Guidelines (BPGs) was selected and followed to guide implementation and achieve optimal results. During a 90-day implementation period, this project resulted in a 100% improvement in early nutrition. Interventions included the use of a series of cards that reminded the team to order enteral nutrition and prepacked bundles of nasogastric tube supplies. The RNAO toolkit served as a structured and effective step-by-step methodology for the implementation of a BPG.

Optimizing the Nutrition Support Care Model: Analysis of Survey Data

BACKGROUND

Malnutrition is under-recognized and under-diagnosed, despite high prevalence rates and associated poor clinical outcomes. The involvement of clinical nutrition experts, especially physicians, in the care of high-risk patients with malnutrition remains low, despite evidence demonstrating lower complication rates with nutrition support team (NST) management. To facilitate solutions, a survey was designed to elucidate the nature of NSTs and physician involvement and identify needs for novel nutrition support care models.

METHODS

This survey assessed demographics of NSTs, factors contributing to the success of NSTs, elements of nutrition education, and other barriers to professional growth.

RESULTS

Of 255 respondents, 235 complete surveys were analyzed. The geographic distribution of respondents correlated with population concentrations of the United States (r = 90.8%, p-value <0.0001). Most responding physicians (80.7%) reported being a member of NSTs, compared with 56.5% of dietitians. Of those not practicing in NSTs (N = 81, 34.4%), 12.3% reported an NST was previously present at their institution but had been disbanded. Regarding NSTs, financial concerns were common (48.9%), followed by leadership (30.6%), and healthcare professional (HCP) interest (23.4%). A majority (73.6%) of all respondents wanted additional training in nutrition, but reported insufficient protected time, ability to travel, or support from administrators or other HCPs.

CONCLUSION

Core actions resulting from this survey focused on formalizing physician roles, increasing inter-disciplinary nutrition support expertise, utilizing cost-effective screening for malnutrition, and implementing intervention protocols. Additional actions included increasing funding for clinical practice, education, and research, all within an expanded portfolio of pragmatic nutrition support care models.

CLINICAL RELEVANCY STATEMENT

Physician engagement in nutrition support continues to remain low despite the increasing prevalence of malnutrition. This problem, and the working solution, is in the context of decreased engagement of other healthcare professionals in nutrition support, as well as declining Nutrition Support Team utilization. To address these issues, the ASPEN Physician Engagement Committee (PEC) conducted a survey of healthcare professionals (HCPs) involved in nutrition support. Key findings include: (1) lack of financial support and physician champions with financial knowledge; (2) inadequate valuation of physicians and other nutrition support HCPs and NSTs, and their impact on clinical outcomes; and (3) significant barriers to primary and supplementary training for physicians in nutrition. Accordingly, the PEC recommends: (1) development of cost-effective screening and intervention for malnutrition; (2) expansion of nutrition support care models appropriately scaled to the available resources and expertise; and (3) development of a knowledge translation platform to foster transmission of novel breakthroughs while addressing research, knowledge, and practice gaps. This article is protected by copyright. All rights reserved.