Co-design of nutrition intervention strategies (CONS-F)
Research type
Research Study
Full title
Perceptions of nutritional management by multidisciplinary health professionals and patients and the co-design of intervention strategies for nutritionally vulnerable older people utilising falls prevention services
IRAS ID
260613
Contact name
Elizabeth Weekes
Contact email
Sponsor organisation
Guy's & St Thomas' Foundation NHS Trust
Duration of Study in the UK
2 years, 5 months, 30 days
Research summary
Research Summary
Malnutrition (defined as underweight) among the older population is complex, with an interplay of different risk factors affecting its cause as well as its treatment. Evidence from the literature suggests that the bulk of malnutrition originates in the community, and malnutrition is often unrecognised and untreated with significant challenges its identification and management highlighted across healthcare settings. Improved opportunities for recognition of nutritionally vulnerable individuals, and the implementation of management pathways are needed. Malnutrition can arise at any time and at any stage in a patient’s disease pathway requiring timely and effective identification and treatment. Thus, the question arises surrounding the responsibility of nutritional care for the prevention of malnutrition and with whom does it lie? In theory, given the multifaceted healthcare needs among older adults, this may be a responsibility of all key healthcare professionals (HCPs) older adult patients encounter. Currently, HCPs are mainly involved in nutritional screening and first line assessment within the nutritional care process. Understanding the perceptions and barriers of HCPs towards nutritional management, is a preliminary step towards improvement of care and identification of responsibility. Additionally, a gap exists surrounding community dwelling older adult patients’ own perceptions of nutritional management, which may result in improved and tailored nutritional interventions.
HCPs in key contact with nutritionally vulnerable older adults include multidisciplinary teams working to decrease risk of falls and fall related injuries, but nutrition appears to have a limited role within these services. This presents an ideal opportunity to explore the feasibility of service development to incorporate nutritional interventions. Experience Based Co-design (EBCD) provides an opportunity to (1) capture and understand the experiences of patients and health care workers in a service and to (2) collaborate for re-design of patient cantered services (Robert et al., 2015; The King's Fund, 2011). The use of this method aims to understand the perceptions of nutritional care from both staff, patients and their carers using the service and to enable the co- design of nutritional strategies appropriate for a multidisciplinary falls management service, ultimately aiming for the timely identification and prevention of malnutrition.Summary of Results
The aims of this study were to identify and understand non-dietetic healthcare professionals (HCPs), older peoples and their carers’ perceptions and experiences of nutritional care services within outpatient falls clinic and associated community falls services and to identify the potential points or ‘touch points’ for intervention in the first line nutritional management of nutritionally vulnerable older people and explore strategies for improving nutritional care from these touchpoints. Key findings from observations and interviews with staff and service users (and one carer) identified three shared themes among the HCPs and service users within an outpatient and community falls services which refer to: (1) ‘the patient is a complex story, but is nutrition part of it’, (2) ‘everyone’s job, but no one’s responsibility’, and (3) ‘is the dietitian invisible?’
These findings highlighted the limited and non-standardized nutritional service provision within the multidisciplinary falls services, the lack of understanding and responsibility of nutritional care practices among the HCPs, the challenges reported around provision of nutritional care, which included a lack of knowledge, confidence, experience and time which may be contributing towards the ad hoc nutritional activities and lack of prioritising nutritional care within a multidisciplinary service. Limited accessibility to dietetic services and limited awareness of the role of the dietitian were also reported among HCPs. These barriers among HCPs translated into gaps and touchpoints identified within patient nutritional care as reported by the service user and carer interviews across their healthcare journey. Service users’ highlighted varied perceptions and experiences of what nutrition encompasses. The changes affecting their eating habits through the course of their life, and their perceptions for changing their habits ranged along a spectrum. Some service users define and perceive ‘nutrition’ as important for their wellbeing, while in contrast other users viewed nutrition or eating as solely a means for survival. Similarly, on one end of the spectrum, some service users described their age, underlying health conditions or the need to take medications as impacting their nutritional habits. While on the other end, others described no impact of age, lifestyle or health on nutrition. Findings also highlighted service user experiences seeking nutritional information on their own resulting in the need for motivation and support, and the lack of understanding of the role of the dietitian. Two key gaps were highlighted between HCPs and service users. HCPs were more aware of the links between nutrition and health than service users. There was also a gap on the responsibility for discussing nutrition, where majority of service users expected HCPs to discuss this topic. On the other hand, HCPs felt that service users were not forthcoming or did not link nutrition and health.Key improvement priorities highlighted from the ‘touch points’ or crucial moments in service user’s healthcare journeys were identified (1) increasing nutritional knowledge, (2) improving communication within consultations (3) improving motivation and support and (4) increasing the visibility of the dietitian and dietetic services. Nutritional intervention strategies proposed by HCPs and service users to target these improvement priorities included: training of HCPs in the identification of nutritionally at-risk individuals and appropriate referral procedures, merging and awareness of dietetic services, inclusion of nutritional care within group exercise and strength and balance classes.
Overall findings highlight the gaps and opportunities for improved detection and frontline management of malnutrition within two falls services and provide groundwork for the integration of nutritional care within these services. Findings propose nutritional intervention strategies by HCPs and the older population accessing falls services which help guide the development of complex interventions for the prevention and management of malnutrition in nutritionally vulnerable older people in the community. Strategies included improved referral systems, in service trainings, and integrated nutrition within exercise groups. Explorations of the behavioural factors which influence HCP and service users’ engagement with nutritional interventions is needed for individualised, tailored interventions. Future research is needed to feedback strategies and explore the feasibility of the suggested interventions in both multidisciplinary healthcare teams and older adults within falls prevention services.REC name
North West - Haydock Research Ethics Committee
REC reference
19/NW/0288
Date of REC Opinion
5 Jul 2019
REC opinion
Further Information Favourable Opinion