NIHR CLAHRC for South YorkshireNational Institute for

Health Research

Enhancing the quality of oral nutrition support to hospitalised patients using the Knowledge to Action cycleKate Gerrish PhD MSc B.Nurs RN Professor of Nursing, CLAHRC Implementation Lead, Sara Laker PhD BA(Hons) RN CLAHRC Project Manager

Sheffield Teaching Hospitals NHS Foundation Trust & Sheffield Hallam University, United Kingdom

BackgroundRisk of malnutrition among hospitalised patients with long-term conditions is a widespread problem leading to adverse health outcomes (Ferreira et al 2009). There is evidence to suggest that under-nutrition delays recovery and lowers resistance to medical complications, with links observed between under-nutrition and lengthened hospital stay, morbidity and mortality (NICE 2006). Despite efforts targeted at improving the nutritional status of patients and the quality of nutrition support in hospitals, under-nutrition remains widespread among in-patients in the UK.

AimTo enhance the quality of oral nutrition support provided by the multi-disciplinary team to adult patients with long-term conditions through the implementation of a malnutrition screening tool (MUST+) and associated care guidelines (MUST - Malnutrition Universal Screening Tool)

ObjectivesTo trial and evaluate two interventions designed to facilitate the uptake of MUST+ and care guidelines

• Ward-based nutrition champions• Facilitation of the multi-disciplinary team by a dietitian

To evaluate the implementation of MUST+ and care guidelines in terms of the impact on patients and on staffTo develop the capacity of the multi-disciplinary team to provide effective nutritional support to patients with / at risk of developing malnutrition

SettingMedical wards in two hospitals within an English Teaching Hospitals NHS Trust3 evaluation wards for each intervention

ApproachAction research strategy embedded within Knowledge to Action cycle (Graham et al 2006)Multi-disciplinary project team involving KT team and lead clinicians who design and oversee

the projectParticipatory approach in which clinical staff and patient representatives become active

collaborators with the KT teamFront-line nurses and dietitians seconded to work as KT facilitatorsProject management group involving KT team, front-line staff, senior clinicians, middle

managers and patient representatives who provide advice and help shape the project

Knowledge to Action cycleProvides direction to process of implementationEasily understood by all collaboratorsIterative rather than cyclical processEach step requires elaboration – other frameworks can be useful•PARHIS framework (Rycroft Malone et al 2004)•Consolidated Framework for Implementation Research (Damschroeder et al 2009)Knowledge creation stage required for selecting implementation strategiesDoes not explicitly address roll-out and transfer of learning

Knowledge Inquiry

Knowledge synthesis

Knowledge products

Tailoring knowledge

Systematic reviews oral nutrition support

NICE guidanceJoanna Briggs best practiceNutrition screening toolsCare guidelinesProfessional expertise

Action research approach

Multi-level problem identification by•Health service commissioners•Trust Board and Executive managers•Trust Multi-disciplinary Nutrition Steering Group (NSG)•Front-line staff

Appraise MUST Develop MUST+ to include additional questionsConfirm face validity with NSG & front-line staffReview guidelines using AGREE framework

Baseline data collected by means of observation of practice, audit of nutrition support and patient records

Survey of knowledge, attitudes and barriers to oral nutrition support among the multi-disciplinary team

Understand macro, meso and micro contextSecure ownership of need for change at all levels of the organisation

Develop intervention strategies by drawing upon reviews of effective interventions. Tailor interventions to local context.Actively facilitate implementation of interventions in collaboration with front-line staff

Feedback baseline data & survey results to ward teams

Modify interventions in response to changes in local context

Repeat audit of oral nutrition support and patient recordsFeedback from facilitators ,clinical staff and patient representatives via Project Advisory Group

Measure patient and staff outcomes for oral nutrition supportEvaluate intervention strategies

Phased withdrawal of facilitation

Ongoing audit to monitor sustainabilityRoll out of interventions and disseminate learning

ReferencesAGREE Collaboration (2001) The Appraisal Guidelines for Research and Evaluation (AGREE) Instrument . London, The AGREE TrustDamschroeder et al (2009) Fostering implementation of health services research findings in practice: a consolidated framework for advancing implementation science. Implementation Science 4:50Ferreira Iet al (2009) Nutritional supplementation for stable chronic obstructive pulmonary disease. The Cochrane Collaboration. Oxford, WileyGraham I et al(2006) Lost in knowledge translation: Time for a map. Journal of Continuing Education in the Health Professions 26:1 13–24NICE (2006) Nutrition support for adults: oral nutrition support, enteral tube feeding and parenteral nutrition. London, NICE Rycroft-Malone J (2004) The PARIHS framework: a framework for guiding the implementation of evidence-based practice. Journal of Nursing Care and Quality 19: 297-304

This project forms part of the NIHR CLAHRC for South Yorkshire: to find out more please contact kate.gerrish@sth.nhs.uk or sara.laker@sth.nhs.uk or go to www.clahrc-sy.nihr.ac.uk