Embed Size (px)
Citation preview
Faculty of Social and Life SciencesNursing Science
DISSERTATION
Karlstad University Studies2008:41
Mona Wentzel Persenius
Nutritional Nursing Care
Nurses’ interactions with the patient, the team and the organization
Karlstad University Studies2008:41
Mona Wentzel Persenius
Nutritional Nursing Care
Nurses’ interactions with the patient, the team and the organization
Mona Wentzel Persenius. Nutritional Nursing Care - Nurses’ interactions with the patient, the team and the organization
DISSERTATION
Karlstad University Studies 2008:41ISSN 1403-8099 ISBN 978-91-7063-201-3
© The Author
Distribution:Faculty of Social and Life SciencesNursing Science651 88 Karlstad054-700 10 00
www.kau.se
Printed at: Universitetstryckeriet, Karlstad 2008
3
Vi är varandras gåva,
vi är varandras ansvar
5
ABSTRACT
Nutritional Nursing Care. Nurses’ interactions with the patient, the team and the organization.
The overall aim of the thesis was to gain a deeper understanding of nutritional nursing care in municipal care and county council care, with specific focus on enteral nutrition (EN) in intensive care.
Quantitative and qualitative methods were used. Telephone interviews regarding assessment of the nutritional status of patients were carried out with special medical nurses (CNs) (n = 14) in municipalities in one county and first line managers (CNs) (n = 27) in one county council. Registered nurses (RNs) in municipalities (n = 74) and county councils (n = 57) answered a questionnaire about nutritional assessment and documentation (I). RNs (n = 44) at three different intensive care units answered a questionnaire about responsibility, knowledge, documentation and nursing interventions regarding EN. Observations (n = 40) on nursing care interventions for patients with EN were carried out (II). RNs (n = 8), enrolled nurses (n = 4) (III) and patients (n = 14) (IV) were interviewed and nutritional nursing care was observed (III-IV) at an intensive care unit.
The results showed that assessment of nutritional status was not performed on all patients, according to RNs/CNs. Malnourished patients were estimated to occur to a varied extent. Sixty-six percent of RNs/CNs answered that there were no guidelines for nutritional care and 13% that they did not know if there were any. RNs saw the VIPS model as a guide in nursing care, but also as an obstacle to information exchange (I). A majority of RNs answered that there were guidelines for EN. There were differences between the RNs’ opinions about their responsibility, knowledge and documentation. Deviations from recommended nursing care interventions occurred (II). The developed substantive theory of nurses (RNs and enrolled nurses) concerns and strategies of nutritional nursing care for patients with EN, includes the core category ”to have and to hold nutritional control – balancing between individual care and routine care” and the categories ”knowing the patient”, ”facilitating the patients’ involvement”, ”being a nurse in the team”, ”having professional confidence” and ”having a supportive organization”. In order for RNs and enrolled nurses to have a sense of control over the patients’ care in relation to nutrition, a balance between routine care and individual care was required (III). The developed substantive theory regarding the patients’ experiences of nutritional care includes the core category ”grasping nutrition during the recovery process”. The core category is reflected in, and dependent on, the categories ”facing nutritional changes”, ”making sense of the nutritional situation” and ”being involved with nutritional care”. The patients alternated emotionally between worry, fear and failure, and relief and hope. The patients experienced a turning point and felt an improvement in their condition when their appetite returned, when the stomach and gut were functioning and when the feeding tube was removed (IV).
The conclusion is that quality and safety in relation to nutritional nursing care is dependent on the interactions between the nurse and patient, between the nurse and the team, and the nurse and the organization.
Keywords: assessment, documentation, enteral nutrition, intensive care, intervention, malnutrition and nutrition.
6
SAMMANFATTNING
Nutritionsomvårdnad. Sjuksköterskors och undersköterskors interaktion med patient, team
och organisation.
Det övergripande syftet med avhandlingen var att erhålla en djupare förståelse av omvårdnad relaterat
till nutrition inom kommunernas och landstingets hälso- och sjukvård, med speciellt fokus på enteral
nutrition (EN) inom intensivvård.
Kvantitativa och kvalitativa metoder har använts. Telefonintervjuer om bedömning av patienters
nutritionstillstånd genomfördes med medicinskt ansvariga sjuksköterskor (n=14) i fjorton kommuner
inom ett län och första-linjenchefer (n=28) i ett landsting. Sjuksköterskor i kommuner (n=74) och
landsting (n=57) besvarade en enkät om nutritionsbedömning och dokumentation (I). Sjuksköterskor
(n=44) vid tre intensivvårdavdelningar besvarade en enkät om ansvar, kunskaper, dokumentation och
omvårdnadsåtgärder för patienter med EN. Observationer (n=40) av omvårdnadsåtgärder till patienter
med pågående EN genomfördes (II). Sjuksköterskor (n=8), undersköterskor (n=4) (III) och patienter
(n=14) (IV) intervjuades (III) och omvårdnad relaterat till nutrition observerades (III-IV) vid en
intensivvårdsavdelning.
Resultatet visar att bedömning av nutritionstillståndet inte genomfördes på alla patienter enligt
sjuksköterskor/chefer. Undernärda patienter bedömdes förekomma i varierande grad. Sextiosex
procent av sjuksköterskorna/cheferna svarade att det inte fanns riktlinjer för nutritionsvård och 13 %
att de inte kände till om det fanns riktlinjer. Sjuksköterskor uppfattade VIPS-modellen som en
vägledning i omvårdnadsarbetet men också som ett hinder vid informationsutbyte (I). Flertalet
sjuksköterskor svarade att det fanns riktlinjer för EN. Det var skillnader mellan sjuksköterskornas
uppfattningar om deras ansvar, kunskaper och dokumentation. Avvikelser från rekommenderade
omvårdnadsåtgärder förekom (II). En substantiv teori utvecklades över sjuksköterskors och
undersköterskors omsorg och strategier avseende deras omvårdnad relaterat till nutrition för patienter
med EN. Teorin inkluderar kärnkategorin ”att få och behålla kontroll over nutritionen – en balans
mellan individuell vård och rutinstyrd vård” och kategorierna ”känna patienten”, ”underlätta patientens
medverkan”, ”vara en i teamet”, ”vara trygg i yrkesrollen” och ”ha en stödjande organisation”. För att
sjuksköterskor och undersköterskor skulle uppleva kontroll över patientens omvårdnad i relation till
nutritionen krävdes en balans mellan rutinstyrd och individuell vård (III). En substantiv teori
utvecklades avseende patienternas erfarenheter av nutritionsvård. Teorin omfattar kärnkategorin ”att få
grepp om nutritionen under tillfrisknandet”, vilken reflekteras i och är beroende av kategorierna ”möta
nutritionsförändringar”, ”förstå nutritionssituationen” och ”delta i nutritionsvården”. Patienterna
skiftade känslomässigt mellan oro, rädsla och misslyckande, samt lättnad och hopp. När patienternas
aptit återvände, sonden avlägsnades och magen och tarmarna kom igång upplevdes det som
vändpunkter och att de var på bättringsväg (IV).
Konklusionen är att kvalitet och säkerhet i relation till omvårdnad vid nutrition omfattas av
interaktion mellan sjuksköterska/undersköterska och patient, mellan sjuksköterska/ undersköterska och
teamet, samt mellan sjuksköterska/undersköterska och organisationen.
Nyckelord: bedömning, dokumentation, enteral nutrition, intensivvård, nutrition, omvårdnadsåtgärder
och undernäring.
7
CONTENTS
ABSTRACT....................................................................................................................................... 5
SAMMANFATTNING ..................................................................................................................... 6
INTRODUCTION........................................................................................................................... 10
THE PATIENTS’ NEED OF FOOD AND NUTRITIONAL CARE............................................................... 11 History..................................................................................................................................... 11 Malnourished patients ............................................................................................................. 12
NUTRITIONAL CARE ...................................................................................................................... 14 Ethical and legal aspects and responsibility ........................................................................... 14 Recommendations and guidelines ........................................................................................... 16 Nursing documentation ........................................................................................................... 18 Screening and assessment ....................................................................................................... 18 Nutritional support .................................................................................................................. 20 Nutritional care in the ICU ..................................................................................................... 23
Who does what (nutritionally) in an ICU? ......................................................................................... 25 The patients’ nutritional experience ................................................................................................... 26
RATIONALE FOR THE THESIS......................................................................................................... 27 GENERAL AND SPECIFIC AIMS....................................................................................................... 28
METHODS...................................................................................................................................... 29
STUDY DESIGNS (I-IV) .................................................................................................................. 29 SETTING AND PARTICIPANTS (I AND II) ......................................................................................... 30
Telephone interviews............................................................................................................... 31 Questionnaires......................................................................................................................... 31
DATA COLLECTION (I AND II)........................................................................................................ 33 Interview guide, questionnaires and protocol ......................................................................... 33
PROCEDURE (I AND II) .................................................................................................................. 33 STATISTICAL ANALYSIS (I AND II)................................................................................................. 34 QUALITATIVE CONTENT ANALYSIS (I)........................................................................................... 35 RELIABILITY AND VALIDITY (I AND II).......................................................................................... 35 TRUSTWORTHINESS (I).................................................................................................................. 36 GROUNDED THEORY (III AND IV) ................................................................................................. 36
Setting, participants and data collection................................................................................. 36 Analysis ................................................................................................................................... 38 Trustworthiness ....................................................................................................................... 40
ETHICAL CONSIDERATIONS........................................................................................................... 40
MAIN FINDINGS........................................................................................................................... 43
STUDY I ........................................................................................................................................ 43 Occurrence of malnutrition and awareness of guidelines ....................................................... 43 Assessment of nutritional status .............................................................................................. 43 Nursing documentation ........................................................................................................... 44
STUDY II ....................................................................................................................................... 46 Responsibility, knowledge and documentation........................................................................ 46 Prescription of enteral nutrition.............................................................................................. 48 Enteral nutritional nursing care.............................................................................................. 49
STUDY III...................................................................................................................................... 51 STUDY IV...................................................................................................................................... 54 COMPREHENSIVE UNDERSTANDING.............................................................................................. 56
DISCUSSION .................................................................................................................................. 57
GENERAL DISCUSSION................................................................................................................... 57 Nutritional nursing care and the nurse-patient interaction..................................................... 57
The patients’ nutritional condition ..................................................................................................... 57 Thinking and reasoning ...................................................................................................................... 59 Involvement........................................................................................................................................ 61
8
Nutritional nursing care and the nurse- team interaction....................................................... 62 Seeking dialogue and cooperation...................................................................................................... 62 Challenged by attitudes and values .................................................................................................... 63 Ruled by responsibilities .................................................................................................................... 63
Nutritional nursing care and the nurse-organization interaction ........................................... 64 Guidelines .......................................................................................................................................... 64 Documentation and assessment/screening tools ................................................................................. 66 Nutritional team ................................................................................................................................. 67 The nutritional care environment ....................................................................................................... 68 Continuity........................................................................................................................................... 68 Leadership.......................................................................................................................................... 68
METHODOLOGICAL CONSIDERATIONS........................................................................................... 70
CONCLUSIONS AND IMPLICATIONS FOR PRACTICE .......... ........................................... 76
FUTURE RESEARCH................................................................................................................... 78
SUMMARY IN SWEDISH ............................................................................................................ 79
ACKNOWLEDGEMENT.............................................................................................................. 86
REFERENCES................................................................................................................................ 88
9
Original papers
This thesis is based on the following papers, which will be referred to by their
Roman numerals:
I. Wentzel Persenius, M., Hall-Lord, ML., Bååth, C., & Wilde-Larsson, B.
(2008). Assessment and documentation of patients’ nutritional status:
Perceptions of registered nurses and their chief nurses. Journal of Clinical Nursing,
17(16), 2125-2136.
II. Wentzel Persenius, M., Wilde-Larsson, B., & Hall-Lord, ML. (2006). Enteral
Nutrition in intensive care. Nurses’ perceptions and bedside observations.
Intensive and Critical Care Nursing, 22(2), 82-94.
III. Wentzel Persenius, M., Wilde-Larsson, B., & Hall- Lord, ML. To have and
to hold nutritional control: Balancing between individual and routine care. A
grounded theory study. (Submitted).
IV. Wentzel Persenius, M., Hall-Lord, ML., & Wilde-Larsson, B. Grasping the
nutritional situation: A grounded theory study of patients’ experiences in
intensive care. (Submitted).
Reprints were made with permission from the publishers.
10
INTRODUCTION
Having access to a safe and healthy variety of nutrition is a fundamental human
right for all patients (Council of Europe, 2003) irrespective of caregiver. A high-
quality nutritional care is needed where patient safety is an important
foundation (SFS 1982:763; SOSFS 2005:12; Ödegård, 2006).
Nutrition is essential for health promotion and disease prevention (Mowe et al.,
2008). Already when admitted to hospital (Kyle et al., 2003; McWhirter &
Pennington, 1994) and municipal care (Christensson et al., 2002), some patients
are malnourished. Treatable malnutrition often goes under-recognized and
under-treated (Elia et al., 2005). The nutritional status may further deteriorate
during admission (Bruun et al., 1999; McWhirter & Pennington, 1994; Saletti et
al., 2005; Ulander et al., 1998), with negative consequences for the patients
quality of life (Brantervik et al., 2005) and wellness (Dudek, 2006). Medical
treatment and nutritional nursing care are important for patients’ nutritional
condition and may prevent malnutrition (Kondrup et al., 2003).
Most patients in the intensive care unit (ICU) are unable to fulfil their own
nutritional needs. Therefore, they are at high risk to develop energy deficit.
Early enteral nutrition (EN) is today considered standard care in most intensive
care units (ICUs), but when insufficient, the deficit should be supplemented
parenterally (Kreymann et al., 2006).
Registered nurses’ (RNs’) skills and knowledge are crucial when creating secure
care for the patient (SSF, 2007). This places RNs in a unique position to secure
good nutritional nursing care.
In this thesis, nutritional nursing care is in focus, with one study within
municipal care and county council care (hospital wards), and three studies in
intensive care.
11
BACKGROUND
The patients’ need of food and nutritional care
History
According to the third and fifth book of Moses in The Bible, the Israeli people
were pioneers regarding diet in public health. In ancient times the Egyptians
introduced medical specialization and outpatient medicine. Dietary treatment
was prescibed for patients under the direction of a nurse (Bullough & Bullough,
1979). In Egypt they also used nutrient enemas of wine, milk, whey and broths
of spelt three days a month in order to preserve health according to Bliss (1882)
quoting Herodotus Euterpe (about 480-420 BC). Hippocrates (about 460-370
BC) prescribed a healthy diet to either prevent illness or to aid recovery from
illness, because; ”a slender and restricted diet is always dangerous in chronic
diseases, and also in acute diseases, where it is not requisite” (Clendening, 1942
p 15).
From a nursing perspective, Florence Nightingale highlighted the patients’
needs of nutritional care. She urged the importance of adequate food intake in
recovery from illness and encouraged the nurse to ”have a rule of thought
about your patient’s diet; consider, remember how much he has had, and how
much he ought to have to-day” (Nightingale, 1969 p 68).
Virginia Henderson (1991) described basic nursing as helping the patient with
activities or providing conditions under which the patient can perform them
unaided. The 14 nursing activities described contribute to health or its recovery
and include such things as: breathe normally, eat and drink adequately, eliminate
body wastes, and sleep and rest. These activities could also be viewed as
fundamental human needs and basic needs of the patient, e.g. the needs of food
and fluid. Keeping a patient well nourished during a long comatose period is
one of the most difficult arts within nursing.
Nutrition is ever-changing during the life cycle and along the wellness-illness
continuum (Dudek, 2006). Aside from a physiologically point of view, it is also
important psychologically, socially and culturally. Food brings family and
friends together, since food symbolizes love, care, concern, security, friendship
and life itself (Kayser-Jones, 2002).
12
Malnourished patients
Malnourished patients are common across different health care settings around
the world (Meier & Stratton, 2004). Aside from complications and suffering for
the patient, malnutrition also affects the work load for the health care
professionals, as well as costs for the society.
Malnutrition is a broad term including protein-energy malnutrition (both over-
and under-nutrition) and malnutrition of other nutrients. There is no consensus
of the definition and recognition of malnutrition (Meier & Stratton, 2004). It is
suggested that malnutrition can be defined as: ”A state of nutrition in which a
deficiency or excess (or imbalance) of energy, protein and other nutrients
causes measurable adverse effects on tissue/body form, function and clinical
outcome” (Elia, 2000 p 52). Just recently another definition has been proposed:
“A subacute or chronic state of nutrition in which a combination of varying
degrees of over-or undernutrition and inflammatory activity have led to a
change in body composition and diminished function” (Soeters et al., 2008 p 3).
In this thesis, the concepts malnutrition and undernutrition are used
interchangeably.
The average frequency of malnutrition in 24 Swedish studies covering 3914
patients in municipal care and hospital care during the 1980-90ths was 36%
(Elmståhl, 2000). Despite this high prevalence, a total of 168 patients within
adult hospital care in Sweden were diagnosed as being undernourished in 1997.
In 2007 the equivalent number was 134 patients (Socialstyrelsen, 2008).
However, comparisons between different countries and different health care
settings are hindered by lack of a universally agreed way to detect risk for
malnutrition (Meier & Stratton, 2004). There are several reasons for this:
information about the patient’s specific condition is missing and there is a lack
of comprehensive comparison of malnutrition prevalence in different diseases
and conditions using common criteria. The staff also uses different criteria
when defining the prevalence of malnutrition (Stratton et al., 2003).
The effects of malnutrition include considerable changes in mental function,
cardiovascular and renal function, respiratory function, function of the
gastrointestinal tract, thermo-regulation, immunological function and wound
healing (Barendregt et al., 2004). Concurrent stress situations like trauma,
sepsis, inflammations and burns accelerate the loss of tissue mass and function
and may result in death. The interaction of nutrition and disease is known;
13
disease may cause secondary malnutrition and malnutrition may influence the
underlying disease (Jeejeebhoy, 2000). If special attention is paid to patients’
nutritional care and if guidelines for nutritional screening is followed,
malnutrition can be prevented and treated (Kondrup et al., 2003; Mowe et al.,
2008).
The consequences for the patient being malnourished is associated with
impaired quality of life (Brantervik et al., 2005; Larsson et al., 1994), increased
mortality (Correia & Waitzberg, 2003) complications, mainly infections (Correia
& Waitzberg, 2003; Villet et al., 2005), slower convalescence (Allison & Stanga,
2004; Lumbers et al., 1996) and prolonged length of stay in hospital (Correia &
Waitzberg, 2003; Giner et al., 1996). A high prevalence of malnourished
patients may lead to increased work load for the personnel (Elia et al., 2005). It
can also influence health care costs (Correia & Waitzberg, 2003; Eckerlund &
Stig, 2000).
It is obvious that malnutrition is found to be a significant problem. Therefore it
is of utmost importance that a condition such as malnutrition is identified and
treated (Elia et al., 2005).
14
Nutritional care
Nutritional care is a concept including different aspects that need to be handled
in a seamless way. The patient is entitled to the right kind of individual
nutritional support at the right time and in the right place. Successful nutritional
care is dependent on careful management supported by an effective
infrastructure (Howard et al., 2006).
In the Swedish State of the Art Report (Socialstyrelsen, 2000) it is concluded
that nutritional care forms part of successful medical treatment and nursing
care. Nutrition is a strong and integral part of nursing care (Dudek, 2006),
which can be named nutritional nursing care. Furthermore, nutritional care
must be taken into consideration during the entire care process (Akner et al.,
2000) and should perhaps be considered as necessary for a successful medical
intervention (Mossberg, 2006). In this thesis, the concepts nutritional care and
nutritional nursing care are used interchangeable.
Ethical and legal aspects and responsibility
Nutritional care is based on ethical principles, scientific knowledge and proven
experience (Beauchamp & Childress, 2001; Unosson, 2000a). Access to a safe
and healthy variety of food is a fundamental human right (Council of Europe,
2003). Nutritional nursing care is therefore guided by four ethical principles
(Beauchamp & Childress, 2001; SSF, 2007), with the intention to do what is
good and what is right for the patient with respect for the patients integrity and
autonomy. Complex nutritional situations needing special measures may arise
and ethical aspects will need special attention (Unosson, 2000a).
In Sweden, the assignment of nutritional responsibility to different
professionals is described in the State of the Art Report: the physician has an
overall nutritional responsibility, whereas responsibility for evaluation of the
patient’s nutritional status, documentation and passing nutritional information
to next caregiver is jointly shared by physicians, RNs and dieticians. The
physician prescribes nutritional treatment in consultation with other personnel.
Furthermore, nutritional teams consisting of RNs, physicians, dieticians and
other co-workers are recommended (Cederholm & Rothenberg, 2000). The
RNs have an autonomous responsibility for the patients’ nursing care in line
with the nursing process care through assessments, nursing prescription,
planning, accomplishing, evaluation and documentation of the patients’ care.
15
RNs competence also includes ability to communicate and interact, with
patients, next of kin, personnel and others with respect, sensitivity and
empathy. Furthermore, to reflect on, motivate and participate in developing a
good care environment (Socialstyrelsen, 2005).
Usually RNs and enrolled nurses collaborate regarding the patients’ nutritional
care, with the RN acting as a supervisor for the enrolled nurse. Hereby, they
have unique opportunities to influence the efficiency and safety of the patients’
nutritional care. Each nurse, RNs as well as enrolled nurses, is responsible for
his or her own activities (SFS 1998:531). However, even with a collective
responsibility, studies show that only few professionals are actively engaged in
nutritional care (Lindorff-Larsen et al., 2007; Mowe et al., 2006).
The special medical nurse and the first-line nurse manager have a general
responsibility to provide safe and appropriate nursing care of good quality in
accordance with science and reliable experience (SFS 1998:531; SFS 2008:355;
SOSFS 1997:10; SOSFS 2005:12).
There have been some changes regarding the responsibilities in Swedish social
services and health care since the beginning of the 1990s, which in turn have
had influence on the nutritional care. In 1992, the Community Care Reform
came into force, shifting the responsibility for care of the elderly population
from the county councils to the municipalities. During the 1990s, the county
councils restricted their hospital care substantially, with a reduction of hospital
beds leading to increasingly shortened mean lengths of stay, more admissions
and a greater turnover of patients (Socialstyrelsen, 2007a). This made it difficult
for the municipalities to meet up with the resources, competence and
organization needed, and nutritional competence was not transferred
(Socialstyrelsen, 2003). This was in turn jeopardizing the medical security
(Lundman et al., 2001) and shortcomings in nutritional nursing were reported,
for example lack of assistance with eating and lack of evaluation of intake
(Socialstyrelsen, 2002). The amount of work, responsibilities for and demands
on first-line managers increased, which has been discussed as a problem, since
they are supposed to be the ones responsible for the nursing care including
nutritional care (Furåker & Berntsson, 2003).
16
Recommendations and guidelines
There are both international and national recommendations and guidelines
regarding clinical nutrition, providing a path for nutritional care in different
health care settings. In 1999, the Council of Europe’s Committee of Ministers
established a European network describing five common European factors
which seem to be the major barriers for proper nutritional care in hospitals: 1)
lack of clearly defined responsibilities in planning and managing nutritional
care, 2) lack of sufficient education with regard to nutrition among all staff
groups, 3) lack of influence and knowledge of the patients, 4) lack of co-
operation between different staff groups, 5) lack of involvement from the
hospital managers (Beck et al., 2001). In November 2003, the Council of
Europe’s Committee of Ministers adopted a resolution on nutritional care in
hospitals (Council of Europe, 2003). Specific nutritional guidelines were
developed by The European Society of Clinical Nutrition and Metabolism
(ESPEN) regarding nutritional screening (Kondrup et al., 2003). Furthermore,
in 2006 enteral nutritional guidelines were published for different conditions
and contexts, for example within intensive care, regarding indications,
application, route and type of formula (Kreymann et al., 2006). According to
the ESPEN guidelines, the essence of the nurse’s key role regarding nutrition is
the care of the patient relating to the intended administration of nutritional
support (Howard et al., 2006), but it is also emphasized that team work is
equally important throughout the admission.
Practical aspects of nutrition and an evaluation of available literature on the
treatment of malnutrition in connection with various medical conditions are
presented by the State of the Art Report (Socialstyrelsen, 2000). There are also
national nutritional guidelines within health care and municipal care (Larsson et
al., 2004; Livsmedelsverket, 2003; Sjukvårdsrådgivningen, 2005). In addition,
there are several local guidelines.
The use of algorithms, clinical practical guidelines and quality indicators could
reduce variations and facilitate best practice, as well as improve the quality of
care at reasonable costs (Adam, 2000; Christensson et al., 2007; Natsch & van
der Meer, 2003). Thus, the gap between scientific evidence and clinical practice
could be minimized (Woolf et al., 1999).
The majority (75%) of ICUs across Europe uses a clinical protocol or guideline
for enteral feeding, but many of them do not conform to international
17
guidelines, and there are limitations in nutritional practices and procedures
across European ICUs (Fulbrook et al., 2007). After implementing nutritional
guidelines in ICU, studies have shown enhanced early initiation of EN (Rice et
al., 2005), increases in the amount of EN delivery (Spain et al., 1999; Wøien &
Bjørk, 2006), greater consistency in nursing practice regarding aspiration of
gastric contents and rate of increment in EN (Wøien & Bjørk, 2006), shorter
mean stay in hospital, and a trend towards reduced mortality (Martin et al.,
2004). But there are also reports of no improvements in clinical outcomes (Jain
et al., 2006), that the number and duration of interruptions in EN is unchanged
(Rice et al., 2005) and that guidelines are used in varying degree within the
health care team (Hansson & Wenström, 2005). Lack of evidence-based nursing
practice (Williams & Leslie, 2004; Williams & Leslie, 2005), nutritional
knowledge among nurses (Hansson & Wenström, 2005; Lindorff-Larsen et al.,
2007; Mowe et al., 2008), and unclear responsibility regarding nutritional issues
(Hansson & Wenström, 2005) seems to be hampering nutritional nursing
practice.
In Sweden, health care professionals do not always follow the guidelines from
the Council of Europe regarding how disease-related malnutrition should be
assessed and treated (Johansson et al., 2006). In a recent review of current
nutritional guidelines, it was found that the area of nutrition is complex and that
the target group is heterogenic. There is already an extensive amount of
regulations and standardizations, but there is a lack of application in practice
(Socialstyrelsen, 2007b).
18
Nursing documentation
In accordance with the Swedish Patient Act (SFS 1985:562) and the Patient
Data Act (SFS 2008:355) there are demands on documentation within all health
care settings. Documentation should hold information that ensures good
quality and safe care of patients. However, a more detailed description of what
exactly should be documented regarding the patient’s nutrition is not given
(Socialstyrelsen, 2003). A nursing documentation model called VIPS (an
acronym for wellbeing, integrity, prevention and security) follows the structure
of the nursing process and is widely used in Sweden (Ehnfors et al., 1991;
Ehrenberg et al., 1996).
Despite the demands on documentation and the use of the VIPS model,
nutritional issues are still sparsely documented. Important nutritional notes
have been found missing in Swedish studies (Ehrenberg & Birgersson, 2003;
Söderhamn et al., 2007). Notes on nutrition were made in 87% of acute medical
care records, while this was quite rare in municipalities (Emanuelsson &
Lindencrona, 2000). Reasons for the low frequency of documentation might be
that the patients’ nutritional problems remain unidentified by the RNs (Florin
et al., 2005) and that nutritional care is considered unimportant (Lennard-Jones
et al., 1995). There might also be a lack of nutritional knowledge among the
RNs (Hansson & Wenström, 2005; Kowanko et al., 1999; Lindorff-Larsen et
al., 2007; Mowe et al., 2008).
Screening and assessment
In order to prevent and treat malnutrition it is important to identify patients in
need of nutritional care. Nursing responsibility includes identification of the
patients’ nutritional problems and needs, including risk factors (Socialstyrelsen,
2005; Unosson, 2000a).
There is no consensus on the optimal method for performing nutritional
screening and assessing nutritional status (Soeters et al., 2008), and the use of
terms like nutritional status, nutritional screening, malnutrition and nutritional
assessment are used differently in the nursing literature (Lyne & Prowse, 1999).
The lack of clarity in definitions of terms and the assumption of a simple
relationship between the level of risk of nutritional compromise and actual
nutritional status is troublesome. According to Lyne and Prowse (1999),
screening for risk factors means to estimate the degree of exposure to risk of
19
nutritional compromise. The desired result is to categorize patients in
accordance with their need for further nutritional assessment and support.
Assessment of nutritional status is made with the purpose to plan, provide and
supervise the supply of nutritional support.
According to the ESPEN guidelines the purpose of nutritional screening is to
predict the patient’s probability of a better or worse outcome due to nutritional
factors, and to find out whether or not nutritional care influences this. The
outcome of screening may lead to that the patient is found to be a) not at risk
for malnutrition, but may need to be re-screened, b) that the patient is at risk,
needing a nutrition plan to be worked out, c) that the patient is at risk with
metabolic or functional problems preventing a standard plan to be carried out,
or d) that there is a doubt that the patient is at risk. A nutritional screening of
all patients is the first step in the nutritional assessment process. It can be
conducted by admitting staff at the hospital or in municipal care. If the patient
is found to be at risk to develop malnutrition, nutritional assessment is
advocated as the next step, and should include a detailed examination of the
patient’s nutritional history, clinical examination and laboratory tests by a
nutrition nurse, an expert clinician or dietician (Kondrup et al., 2003).
There are many available nutritional assessment/screening tools to screen or
assess the nutritional status of a patient (Green & Watson, 2005). However, an
analysis of 44 assessment/screening tools showed that they were published with
insufficient information regarding their intended use and method of derivation,
and with an inadequate assessment of their effectiveness (Jones, 2002).
Examples of tools are the Subjective Global Assessment (SGA) (Detsky et al.,
1987), the Mini Nutritional Assessment (MNA) (Guigoz et al., 1994) and its
short form (SF-MNA) (Rubenstein et al., 1999), the Malnutrition Universal
Screening Tool (MUST) (Elia, 2000) the Nutritional Risk Screening 2002 (NRS-
2002) (Kondrup et al., 2003) and the Nutritional Form for Elderly (NUFFE)
(Söderhamn & Söderhamn, 2001; Söderhamn & Söderhamn, 2002).
A minimum level of screening has been recommended, including BMI, weight
loss, and mouth and eating problems (Unosson & Rothenberg, 2000).
However, a Swedish expert group in nutrition recommends a further
simplification which is a combination of BMI, weight loss and eating difficulties
(Larsson et al., 2004) without scoring and specific documents (Cederholm,
2006). According to the Swedish national guidelines for health care
20
(Sjukvårdsrådgivningen, 2005) the patient’s nutritional status can be
assessed/measured through weight and length and by calculating body mass
index (BMI). Screening/assessment tools, body composition and biochemical
markers may be helpful.
The VIPS model is not a guideline in itself, but it includes suggestions of what
should be documented regarding nutrition. The heading status is used to capture
a description of the current situation for the patient, including the patient’s
experiences, next of kin’s descriptions and the nurse’s assessment. The patient’s
nutritional status is found under the heading status with is the search term for
nutrition. Here, various aspects of nutrition can be found, for example appetite,
thirst, eating habits at mealtime, status of the mouth cavity, underweight,
overweight, patient experience, nausea and vomiting (Ehnfors et al., 2000).
Nutritional support
To prevent or treat malnutrition, different forms of nutritional support can be
provided and a combination may be needed during the course of the patient’s
illness. Ordinary food should always be the first option, but there are occasions
when the intake of food is insufficient or contradicted (Howard et al., 2006).
According to the ESPEN guidelines, nutritional support includes food
fortification, oral nutritional supplements (ONS), tubefeeding and parenteral
nutrition (PN) (Fig 1). The concept enteral nutrition includes ONS as well as
tube feeding via nasogastric, nasoenteral or percutaneous tubes (Lochs et al.,
2006). In this thesis, enteral nutriton is used in the meaning of tube feeding.
Nutritional support
Food fortification Enteral nutrition Parenteral nutrition
Tube feedingOral nutritional
supplements
Figure 1. Nutritional support, in accordance with ESPEN guidelines, modified
from Lochs et al., 2006.
21
Normal diet and special diet are not considered nutritional support in the
ESPEN guidelines (Lochs et al., 2006), while in Sweden, the concept nutritional
support includes normal food, enriched energy-protein diets, dietary
supplements, liquid dietary supplements, vitamin and mineral supplements,
enteral nutrition and parenteral nutrition (Rothenberg, 2000). While tube
feeding is considered medical treatment, ONS is sometimes considered medical
care and sometimes basic care in Europe. Provision of food and drink by
mouth, as well as feeding assistance, is in most instances considered basic care
(Korner et al., 2006).
Together with co-workers, RNs are responsible for the delivery of nutritional
support and regular diet. Aside from assessing the patient’s needs and
problems, the RNs must ensure that the right food and fluid is served to the
right patient in a pleasant and appetizing manner and that patients receive
necessary assistance when eating. Oral care, instructions and training are
important nursing interventions. Respecting the patients’ wishes regarding
companionship and seclusion during mealtime, creating an atmosphere that
facilitates the intake of food and establishing empathy, trust and confidence are
other essential nursing interventions. Co-operation between different health
care professionals, instructions and planning ahead of transfer, as well as a
positive attitude, are all factors contributing to good nutritional care (Unosson,
2000a).
The findings of McWirther and Pennington (1994) that nutritional screening of
patients at risk for depletion was not a routine procedure are echoed many
years later. A recent study found that nutritional assessment and intervention
were not sufficiently applied, neither by nurses, physicians nor medical students
(Bavelaar et al., 2008). When investigating nutritional practices in different
hospital settings in relation to ESPEN standards among Scandinavian nurses
and physicians, a discrepancy between nutritional attitudes and practice was
found. While 93% said that body weight measurement should be routine, 45%
said that body weight actually was measured in all patents. Overall, 89% said
that nutritional assessment should be routinely performed, while only 26% said
that it was routine (Mowe et al., 2006). In a Swedish study it was found that
94% of RNs and physicians thought that calculating the energy requirement of
a patient at risk of becoming malnourished should be routine, but only 29%
answered that it was done. The calculation of energy was considered difficult
according to half of them (52%) (Johansson et al., 2006).
22
Nursing interventions based on individual nutritional requirements, resources
and desires have been found to improve nutritional status and functional
capacity among older people with malnutrition (Christensson et al., 2001). The
implementation of a written food and meal policy stabilized the weight of the
residents in a Danish nursing home (Kuosma et al., 2008). Serving energy-dense
food to elderly in different types of institutional care had a positive impact on
activity of daily living function, while adding an additional evening meal had no
effect on energy intake, body weight or health- related quality of life (Ödlund
Olin, 2004). A summary of systematic reviews on nursing related issues in
twenty-nine studied with 4021 participants found that the use of oral
supplements added to normal diet can reduce undernutrition, improve weight
and arm muscle circumference in elderly patients (Vanderkroft et al., 2007).
Clinical nutrition does not fulfil accepted standards (Johansson et al., 2006;
Lindorff-Larsen et al., 2007; Mowe et al., 2006) and it is obvious that it is
difficult to implement good clinical practices (Mowe et al., 2006). However, a
significant positive change occurred after seminars, initiation of studies,
pamphlets and catalogues offering advice and ideas (Lindorff-Larsen et al.,
2007). A nutritional team (nurse and dietician), which attended to patients and
staff for motivation, detailed a care plan, assured delivery of food and gave
advice on EN or PN led to an increase of protein and energy intake of
nutritionally at-risk patients. This in turn led to a shortening of the part of the
length of stay that was considered to be sensitive to nutritional support among
patients with complications (Johansen et al., 2004).
Insufficient knowledge is the main barrier for good nutritional management,
according to nurses and physicians in Sweden, Denmark and Norway (Mowe et
al., 2008). Also, lack of interest and responsibility in combination with
difficulties in making nutrition plans influence the implementation of good
nutritional care (Lindorff-Larsen et al., 2007).
23
Nutritional care in the ICU
During the 1990s, intensive care was more specialized and the work load of
RNs expanded (Strömberg, 2004). Between 1998 and 2001 the work load in
intensive care units increased with 20% (Lindberg & Rosenqvist, 2005). There
were several reasons for the increased work load: RNs participated more in the
curing tasks and took over parts of the caring responsibilities, the latter due to a
reduction in the number of enrolled nurses. The expansion of medical
technology was another reason of the changes (Strömberg, 2004). In addition
the patients have become more severely ill and older than previously (Bergbom,
2007).
Most patients in the ICU are unable to maintain their own nutritional needs.
Patients with trauma, sepsis and multiple organ failure are both catabolic and
hypermetabolic, which leads to rapid development of malnutrition (Mossberg,
2000). The provision of nutritional support is of great importance. Early enteral
nutrition (EN) via feeding tube is a recommended and common nutritional
strategy for intensive care patients who are not expected to be taking full oral
diet within three days. When the patient cannot be fed completely enterally, the
deficit should be supplemented parenterally (Kreymann et al., 2006; Kreymann,
2008). Early enteral nutrition (<24 hours) improves gastrointestinal
permeability, improves wound healing, minimizes bacterial translocation and
reduces complications (Heyland, 1998). That there actually is a bacterial
translocation from the gastrointestinal tract to normal sterile tissue (such as the
mesenteric lymph nodes and other internal organs) initiating sepsis and organ
failure in human beings was recently showed in a study over a 13 year period
(MacFie et al., 2006).
Many studies report underfeeding among patients with EN (Adam & Batson,
1997; Binnekade et al., 2005; Elpern et al., 2004; McClave et al., 1999) and oral
feeding, often used at the end of the ICU stay (Berger et al., 1997; Villet et al.,
2005). The energy deficit is often built up during the patient’s first week in the
ICU and ventilated patients are more likely to be underfed than non-ventilated
patients (Kyle et al., 2006). This delay of nutritional support exposes the
patients to energy deficits that cannot be compensated later on and is
correlating with an increasing number of complications, mainly infections
(Villet et al., 2005), impaired ventilator drive and weakened respiratory muscles
(Pingleton, 2001). Delayed feeding is also associated with prolonged ventilator
dependency and increased length of stay (Nguyen et al., 2008).
24
The two main causes to underfeeding of the patient in the ICU are
underprescription by physicians and inadequate delivery/interruptions in
feeding. Studies have shown that physicians prescribe between 65%-78% of the
patients’ required amount of calories. Out of this, between 71% and 78% is
effectively delivered (De Jonghe et al., 2001; McClave et al., 1999). Factors
associated with low prescription rate is administration of vasoactive drugs,
central venous catherization, and the need of extra renal replacement (De
Jonghe et al., 2001). Other reasons for underprescription may be lack of
enthusiasm, personal bias and individual practices (McClave et al., 1999). The
interruptions in delivery of EN have many reasons: feeding intolerance, surgery,
procedures and various diagnostic examinations within and outside the ICU
(Adam & Batson, 1997; Berger et al., 1997; De Jonghe et al., 2001; Elpern et al.,
2004) as well as problems with the feeding tube (Engel et al., 2003).
Routine nursing care such as baths, dressing changes, changes of linen,
management of tracheostomy tubes and changing of empty infusion bags
contributes to up to 30% of all cessations (McClave et al., 1999). Precautionary
interruptions in enteral feeding, administration of medications (Elpern et al.,
2004) and measurement of gastric residual volumes (GRV) (Marshall & West,
2006) are other nursing procedures that contribute to interruptions.
There are variations and limitations in nutritional practices and procedures
across European ICUs (Fulbrook et al., 2007; Roynette et al., 2008). The
majority of ICUs (86.5%) do not use a nutritional risk score, and a daily
nutritional assessment (mostly in the form of body weight and serum albumin)
is only conducted by 35.4%. A minimal involvement of RNs performing
nutritional assessment or developing guidelines was found. The position of the
feeding tube following insertion was checked mainly by injecting air (72.6%),
followed by abdominal/chest X-ray (34.9%) (Fulbrook et al., 2007).
Gastrointestinal tolerance was assessed every day according to 79.4% of the
European ICUs (Roynette et al., 2008).
According to nurses, the use of nutritional feeding pumps, daily changes of
administration set, frequency of checking GRV and management of EN when
diarrhea occurres, varied when ICUs in five different hospitals in Belgium were
compared (Ista et al., 2002). Furthermore, checking the flow rate of EN,
flushing the feeding tube, methods of unclogging obstructed tubes, checking
GRV and administrating medications through feeding tube are all nursing
25
practices that vary, according to RNs in critical care and medical-surgical care at
a Midwestern university medical centre (Mateo, 1996).
When clinical, multidisciplinary nutritional guidelines were updated and
implemented, the evaluation showed variations in usage. Practical aspects of
nutritional support seemed to have a unified approach, whereas areas of
nutritional assessment and routine nutrition orders demonstrated a lack of
knowledge and unclear role responsibility (Hansson & Wenström, 2005).
Who does what (nutritionally) in an ICU?
The physician, usually an anaesthesiologist in the ICU, has an overall nutritional
responsibility, making sure that an assessment is performed and prescribing
nutritional treatment (fluid, energy, nutrition, choice of nutrition route) in
consultation with co-workers (Cederholm & Rothenberg, 2000). Especially
when it comes to tube feeding and oral intake, teamwork around the planning
and calculation is more common. Planning and calculation of the daily need of
energy, fat, protein and carbohydrates is documented in different kinds of
documents; medical records, nursing care records, special nutritional charts,
flow sheets and sometimes in all of them together (Martensson & Fridlund,
2002). The RN’s area of competence includes identifying, assessing and
documenting the critically ill patient’s nutritional problems and need of
nutritional interventions, suggesting and carrying out interventions and
evaluating and revising the care plan. Furthermore, they continuously monitor
and evaluate functional status, give information and initiate medical
interventions. They also give counselling regarding nutritional care to colleagues
within and outside of the ICU (Socialstyrelsen, 1996). The enrolled nurses’
qualifications are nursing and medical interventions, but also service tasks and
collaboration with co-workers. Their work includes for example feeding
assistance, observations, recording and reporting of what the patient eat and
drinks (Nyman, 2001; Socialstyrelsen, 2006; Thunborg, 1999), and on
delegation from the RNs, enteral tube feeding (SOSFS 1988:25). In the ICU,
the enrolled nurses also document observations, measurements and provided
care on the flow sheet.
26
The patients’ nutritional experience
When reviewing the literature during a 30 year period, from 1967 to 1997,
regarding patients’ experiences of being in the ICU, Stein-Parbury et al (2000)
found 28 articles reporting 26 studies. Initially, the studies were based on the
assumption that the experiences were of a problematic origin. From the 1990s,
the focus shifted toward more open-ended experiences, indicating that patients
expressed positive as well as negative experiences. The positive experiences
included a sense of safety promoted mainly by nurses. Negative experiences
included impaired cognitive functions and discomfort mainly in the form of
problems with sleeping, pain and anxiety, but also with thirst (Ballard, 1981;
Bradburn & Hewitt, 1980). Thirst among the patients in the ICU is also found
in later research (Hofhuis et al., 2008a; Magarey & McCutcheon, 2005;
Samuelson et al., 2007). Weight loss was a concern raised in a study focusing on
the patient’s body awareness and body image when mechanically ventilated
(Johansson & Fjellman Wiklund, 2005). They also found that the patients had
experienced weakness that affected holding the knife and fork when eating. At
ICU discharge, eating has been found to be significantly impaired when
compared to pre-ICU, hospital discharge and 6-months post-discharge (Elliott
et al., 2004). There are several studies regarding the patients’ experiences of
their ICU stay, but there are few studies focusing on the patients’ experiences
of nutritional care.
27
Rationale for the thesis
Nutrition is essential for patients’ health. It is obvious that malnutrition is a
significant problem in different health care settings. Nutritional nursing care is
important for the patients’ nutritional condition and may prevent malnutrition.
Previous studies have found that nutritional screening and assessment is not yet
a routine procedure. Few interventions are applied and nutritional
documentation is sparse. There is limited knowledge of patients’ nutritional
status, nutritional nursing documentation and screening/assessment tools, as
perceived by RNs, special medical nurses and first-line nurse managers (CNs),
within municipal care and county council care.
The patients in the ICU are at risk to develop malnutrition. Early EN is today
considered standard nutritional support for the patients in ICUs, but inadequate
delivery of energy and a cumulative energy deficit are implied. Most previous
research in ICUs focusing on nutritional care to patients with EN has revealed
obvious variations and limitations, lack of evidence-based care, unclear role
responsibilities and lack of knowledge. There are few studies regarding EN
focusing on nursing in an ICU. RNs have an overall responsibility for the
patients’ nutritional nursing care. On delegation from RNs, enrolled nurses
often administer the enteral feeding in ICU. Minimal attention has been paid to
how nutritional care is experienced by patients and perceived by RNs and
enrolled nurses.
28
General and specific aims
The overall aim of the thesis was to gain a deeper understanding of nutritional
nursing care in municipal care and county council care, with special focus on
enteral nutrition in the ICU.
The specific aims of the four studies were to:
I. study, within municipal care and county council care, 1) chief
nurses’ (CNs) and registrered nurses’ (RNs) perceptions of patient
nutritional status assessment and nutritional assessment/screening
tools, 2) registered nurses’ perceptions of documentation in relation
to nutrition and advantages and disadvantages with the VIPS
model.
II. examine 1) the registrered nurses’ (RNs) perceptions of
responsibility, knowledge and documentation focusing on enteral
nutrition and 2) nursing practice regarding enteral feeding in the
intensive care unit.
III. provide a theoretical understanding of the concerns and strategies
of nutritional nursing care for patients with enteral nutrition (EN)
in ICU.
IV. provide a theoretical understanding of nutritional experiences for
patients with enteral nutrition (EN) during their ICU stay.
29
METHODS
Study designs (I-IV)
To obtain perceptions among special medical nurses, first-line nurse manager
(CNs) and RNs about patient nutritional status assessment and documentation,
a combination of quantitative and qualitative methods were used in study I. To
examine the RNs perceptions of responsibility, knowledge, documentation and
nursing practice with focus on EN in the ICU, a quantitative approach was
chosen in study II. Grounded theory (GT) was used to explore RNs and
enrolled nurses’ perceptions (III) as well as patients experiences (IV) of
nutritional care in ICU. The method was chosen because this was unexplored
areas. For an overview of the studies, see Table 1. Table 1. Overview of the studies.
To strengthen the overall design and increase the ability to interpret the
findings, triangulation was used in this thesis. The strengths of one method may
compensate for the weakness of another, confirming the validity of the findings
(Speziale & Carpenter, 2007). Denzin (1970) described four types of
triangulation: data triangulation, investigator triangulation, theory triangulation
and method triangulation. A fifth type, multiple triangulations, was also
suggested. Later, even a sixth type of triangulation was described: analysis
triangulation (Kimchi et al., 1991).
In this thesis, data triangulation and method triangulation were used. Data
triangulation was performed in the form of person and space triangulation. In
person triangulation, data was collected from special medical nurses, first-line
Study
Design
Method
Care setting
Participants
Data collection
Methods of analysis
I Descriptive
Quantitative Qualitative
Municipal care County council care
27 first-line nurse managers 14 special medical nurses 131 RNs
Interviews Questionnaire
Statistics Qualitative content analysis
II Descriptive Quantitative Three ICUs 44 RNs
Questionnaire Protocol Bedside observations
Statistics
III Explorative Qualitative One ICU 8 RNs 4 enrolled nurses
Interviews Observations
Grounded theory
IV Explorative Qualitative One ICU 14 patients
Interviews Observations
Grounded theory
30
nurse managers and RNs (l) and RNs and enrolled nurses (III) and patients
(IV). In space triangulation, the participants represented both municipal care
and county council care (I) and three different hospitals (II).
Method triangulation was used in the form of between-method and within-
method. Between-method triangulation was used since both quantitative (I and
II) and qualitative methods (I, III and IV) were used. Within-method
triangulation was used as observations and questionnaires were used in study II;
and observations, interviews and memos were used in study III and IV. By
combining different methods, a more complete understanding and description
of the phenomenon (nutritional care) could be provided (Glaser & Strauss,
1967; Speziale & Carpenter, 2007).
Setting and participants (I and II)
Study I was conducted within municipal care and county council care in one
county in Sweden. At first, special medical nurses in municipal care and first-
line nurse managers in county council care, in the studies referred to as chief
nurses (CNs), were interviewed via a semi-structured interview guide. At
second, the RNs responded to a questionnaire (Figure 2).
Figure 2. Flow-chart of participants in study I .
Municipal Care
15 special medical nurses
(= 15 municipalities)
74 RNs (response rate 76%)
(= 14 municipalities)
Dropout: One municipality
County Council Care
57 RNs (response rate 67%)
(= 28 wards)
27 first-line nurse managers
(= 28 wards)
Telephone interviews Questionnaires
31
Telephone interviews
In municipal care, 15 special medical nurses (CNs) participated, representing 15
out of 16 municipalities. One of the special medical nurses declined
participation in the study and another accepted to participate in the interview,
but would not let us proceed with questionnaires to the RNs within her
municipality. These dropouts were due to an ongoing local process to develop
new nutritional guidelines, and the present study was felt to intervene with this.
In county council care, 27 first-line nurse managers (CNs), representing 28
wards from the three acute care hospitals, accepted participation in both being
interviewed themselves via telephone and by distributing questionnaires to the
RNs.
Questionnaires
As there was no database for RNs available, and the staffing in special housing
may vary considerably (from one to several RNs per special housing, while one
RN also can be responsible for one or several special housings), they were
therefore selected in different manners.
In municipal care, the special medical nurses were instructed to distribute the
questionnaires to one RN (on duty for the time of the study) per special
housing. In 2002, there were 502 RNs in municipal care within the county
under study (Andersson, 2004). This means that approximately one fifth of the
nurses were included in this study. In county council care, the first-line nurse
managers distributed the questionnaires to every fifth active RN on the 28
wards. In total, about 20% of the RNs in the hospital wards and in municipal
care were included. For demographic data, see table 2.
Table 2. Demographic data regarding the RNs. Total
(n = 131) Municipalities
(n = 74) County council
(n = 57) Student’s t-test p-value
Age M/SD
44.82/10.23
47.05/10.01
41.96/9.87
2.895 0.004
Years as an RN M/SD
16.71/10.81
18.9/10.34
13.86/10.83
2.692 0.008
University education in nutrition 7.5-15 ECTS (n)
7 3 4
Non- university education in nutrition (n)
7 5 2
32
Study II was conducted at three ICUs in three hospitals within one county
council. The conditions regarding the three ICUs were somewhat different.
Intensive care patients (surgical/medical), cardiac intensive care patients and
recovery and post-operative patients were admitted to the ICU in hospital A.
The number of ICU beds was six and it was possible to have two patients on a
ventilator at the same time. To the ICU in hospital B, intensive care patients
(surgical/medical) and postoperative patients were admitted. Eight beds and
eight ventilators were available. Cardiac intensive care patients were admitted to
a separate ward in the hospital. To the ICU in hospital C, intensive care patients
(surgical/medical), cardiac patients, internal medicine and postoperative
patients were admitted. There were six to eight beds. One ventilator was
available for a longer time, two ventilators for a shorter period. In hospital A, a
combination of paper-based records and Electronic Patient Record (EPR) was
used, in hospital B paper-based records were used and in hospital C, EPR was
used.
Data was collected by means of questionnaire distributed to all RNs (n = 63)
who worked in the three ICUs. Forty-four RNs answered the questionnaire
(70% response rate). The response rates for the three hospitals A, B and C were
50%, 71% and 100% respectively. For demographic data, see table 3.
Table 3. Demographic data regarding the RNs. Total
(n = 44) Hospital A
(n = 10)
Hospital B (n = 22)
Hospital C (n = 12)
Kruskal-Wallis test
Mann-Whitney U-test
M SD M SD M SD M SD X2 test P-value X2 test
P-value
Age
42.8 7.74 47.6 5.21 39.6 8.56 44.6 5.25 8.949 .011 2.625 A v B 0.009
Years of practice as an RN
17.4 9.54 19.1 11.41 15.3 9.26 19.8 8.27 2.092 .351
Years of practice as an ICU nurse
10.9 8.93 16.5 11.27 8.4 7.55 11.0 7.68 3.854 .146
Years of experience at present ICU
9.2 8.56 12.5 11.42 7.4 7.45 9.9 6.93 1.379 .502
RNs in hospital B were significantly younger than RNs in hospital A, otherwise
no statistical difference was found.
Observations (n = 40) of enteral nutritional nursing interventions were
performed in one of the three ICUs. The ICU with no cardiac intensive care
was chosen in order to maximize the events of tube feeding.
33
Data collection (I and II)
Interview guide, questionnaires and protocol
The interview guide (I), the questionnaires (I and II) and the protocol (II) were
developed purposely for the studies. The items were formulated based on
literature, research and professional experience (I and II). In study I the
interview guide comprised six items, and the questionnaire ten items. The
interview guide for CNs comprised items that were in accordance with the
questionnaire for the RNs: occurrence of malnutrition, nutritional assessment,
assessment/screening tools and guidelines. In addition, four items regarding
documentation were directed solely to the RNs.
The questionnaire in study II comprised 49 items and focused on the RNs
opinions in the following areas: knowledge of responsibility for nutrition,
source of knowledge regarding EN, responsibility, knowledge, documentation
and enteral feeding interventions. A type of five-point Likert scale (Likert,
1952) from 1 (never) to 5 (always) or from 1 (to a very small extent) to 5 (very
great extent) was used in the questionnaires (II).
Different fixed response alternatives and open-ended questions were used in
the interview guide (I) and in the questionnaires (I and II).
A research protocol influenced by a Swedish version of the Rush Medicus
Nursing Process Methodology (Ehrenberg, 1986) was constructed by the
authors (II). The research protocol consisted of 17 items concerning nursing
interventions regarding the following areas: tube-related problems,
gastrointestinal problems, aspiration and mix-up. In the protocol, the results of
the bedside observations were noted as yes/no/not applicable. Backrest
elevation, defined as the height of the head of the bed in degrees of elevation
above horizontal, was measured using a protractor.
Procedure (I and II)
The telephone interviews (I) were conducted by two of the authors (MWP and
CB). Each interview lasted between 20 and 30 minutes. We followed the semi-
structured interview guide and the answers were documented during the
interview. CNs distributed the questionnaires and gave the participants oral and
written information about the study. The data was collected during three weeks
in April, 2002. Two reminders were needed to achieve an acceptable response
34
rate. The questionnaires were returned anonymously in the addressed return
envelopes enclosed (stamped in municipal care, free local delivery within county
council care).
The observations (II) were performed by one of the authors (MWP) at daytime,
during both the morning and afternoon shifts, and took about 10-15 minutes
each. The CNs informed the RNs and distributed the questionnaires (II). Three
reminders were needed to achieve an acceptable response rate. The RNs were
instructed to answer the questionnaire in relation to care performed during
April 2001. In this way, questionnaire and bedside observations reflect the same
month.
Statistical analysis (I and II)
For statistical analyses the Statistical Package for Social Sciences (SPSS) version
14.0 (Norusis, 2006) was used.
Parametric statistical test. Students t-test was used for independent samples (I).
Non-parametric statistical tests. Differences between two independent groups were
analyzed using Mann Whitney U-test (I and II), Chi-square test (I) and Fisher’s
exact test (l) when appropriate. Kruskal-Wallis test was used to compare
differences between more than two groups (II). When a statistically significant
difference was found, further comparisons were performed using the Mann-
Whitney U-test.
P-value. Statistical results (of bivariate analyses) were interpreted with the level
of significance set at p < 0.05 (Polit & Hungler, 1999; Streiner & Norman,
2003).
Bonferroni. When three pair-wise comparisons were analyzed (II), the Bonferroni
correction was used to protect against type 1 errors (Munro, 2001). This
involves dividing the desired level of significance by the number of
comparisons that were made (.05/3=.0167).
Logistic regression analysis. As RNs in municipal care were significantly older than
RNs in county council care, an adjustment for the age regarding three items
(occurrance of malnutrition, assessment of malnutrition and documentation of
nutritional judgement) was performed with logistic regression analysis.
Homogeneity was assessed with the Cronbach’s alpha coefficient (II) (Cronbach,
1951).
35
Qualitative content analysis (I)
In study I, the qualitative content analysis was made in line with the steps
proposed by Graneheim and Lundman (2004) to reveal manifest and latent
content regarding strategies used by RNs when deciding which patients should
be nutritionally assessed, and advantages and disadvantages with the VIPS
model. First, all notes (varying from a few words or phrases to several
sentences), which constituted the unit of analysis, were read through to obtain a
sense of whole. The text was divided into meaning units that were condensed,
abstracted and labelled with a code. Then the various codes were compared
based on differences and similarities and sorted into categories, and sub-
categories when appropriate. As a category mainly refers to a descriptive level
of content, it is considered an expression of the manifest content. The first
author and two of the co-authors (BWL and MLHL) compared the categories
and revised them until agreement was reached and the latent content of the
categories, which is a thread of the underlying meaning on an interpretative
level, was formulated into a theme.
Reliability and validity (I and II)
The interview guide (I), questionnaires (I and II) and protocol (II) were tested
for face validity, content validity and clarity. Experienced RNs were asked to
judge whether the issues appeared to be reasonable, covering relevant and
important data with clarity (Polit & Beck, 2004; Streiner & Norman, 2003). In
study I, the four RNs were recruited from both municipal care and county
council care. In study II, four experienced ICU nurses and one registered nurse
teacher with long experience of intensive care were recruited according to
personal knowledge. The internal consistency, measured by Cronbach’s alpha,
was regarding responsibility 0.86, knowledge 0.90 and documentation 0.86 (II).
In accordance with the Rush Medicus Nursing Process Methodology
(Ehrenberg, 1986), different aspects of what should be considered good care
regarding EN (II) were identified. During the bedside observations, performed
by the author, it was noted whether these aspects had been considered or not.
36
Trustworthiness (I)
Measures proposed by Graneheim and Lundman (2004) to achieve
trustworthiness in qualitative content analysis include credibility, dependability
and transferability. In order to achieve credibility, RNs from various care settings
were included. Furthermore, all relevant data and quotations were used. During
the whole analysis, the first author and two of the co-authors were judging
similarities and differences between categories. For dependability all RNs received
exactly the same open-ended questions and there was a limited time for
responding. To facilitate transferability, the contexts, the included informants, the
study process and the result with its quotations, have been clearly described.
Grounded theory (III and IV)
Since the aims of the studies (III and IV) were to provide theoretical
understanding of nutritional nursing care, the GT approach was used. The
specific nature of GT is the four criteria set on the relation between theory and
data; that the theory must fit, work, be relevant and be possible to modify
(Glaser, 1978).
Setting, participants and data collection
The last two studies were carried out in hospital B (for description, please see
study II). The chief physician, an anesthetist, had the legal responsibility for the
overall care in cooperation with the patient’s physician from the ordinary unit.
RNs and enrolled nurses were usually caring for one to two patients, with the
enrolled nurses functioning under the supervision of the RNs. Following the
RNs’ three years of university studies, where a Bachelor’s degree is earned and a
licence is executed by The National Board of Health and Welfare, one
additional year of nursing specialization in intensive care nursing is required for
working in an ICU. For enrolled nurses educated in an upper secondary school
health care programme for three years, there is limited access to intensive care
training.
In study III, the choice of informants was decided by their bedside presence in
the ICU. In the text, all informants are referred to as nurses, when not
specified. Data obtained was based on interviews with nurses and observations
of nursing care related to nutrition. Informants in study III were initially
37
recruited from study IV, but for a deeper understanding related to the analysis
progress, further RNs and enrolled nurses were interviewed (theoretical
sampling). A total of eight RNs and four enrolled nurses were interviewed, all
but one female, ranging from 33 to 51 years (Md 39.5 years). Years as a nurse
ranged from 6 to 29 (Md 14 years) and years in the ICU ranged from <0.5 years
to 28 (Md 8). Years as a specialist RN in intensive care ranged from <0.5 years
to 16 years (Md 7 years).
In study IV the nurse managers identified patients who met the inclusion
criteria (see below) and then approached the RN in charge of the patient for
confirmation regarding the inclusion criteria. The nurse manager obtained
informed consent from the patients. All but one patient agreed to participate.
The inclusion criteria for the patients were that the patients had to be > 18
years old and Swedish speaking with a period of at least three days of treatment
in the ICU, had experience of ongoing or recently discontinued enteral
nutrition, and that the patient had to be conscious, oriented in space and time
and judged by the RN in charge to be in such a condition that they could
respond to questions and provide informed consent.
A total of 14 patients were interviewed; eleven women and three men (Md 65
years), ranging from 38 to 80 years old. Eight patients were interviewed once,
while follow-up interviews were made with six of the patients (five were
interviewed twice and one three times). The follow-up interviews were made
within one day from the first interview. The reasons for the ICU admission
were surgery or pulmonary, cardiovascular and infectious diseases. Number of
days from admission to interview ranged from 5 to 39 days (Md 21 days). All
patients were on oral fluids, but some were allowed to eat as well. Four of the
patients had a combination of oral, enteral and intravenous nutritional delivery.
Six patients had oral and enteral nutrition, two oral and intravenous, and two
managed solely on oral nutrition. The patients interviewed were cared for in
two-bed rooms.
Data collection was carried out from December 2005 until June 2008 (III), and
from December 2005 until January 2008 (IV). In the data collection, the
multimethod principle, the multisensory principle and the principle of aesthetic
distance were used to increase the theoretical sensitivity (Starrin et al., 1997).
The use of more than one method was considered particularly beneficial, as it
provides multiple perspectives on an issue, supplies more information on
38
emerging concepts, allows for cross-checking and yields stronger substantiation
of structures (Glaser & Strauss, 1967). In addition, the use of as many senses as
possible during the data collection and to be neither too distant nor too close in
relation to what is studied, encourages perception abilities and increases the
capacity to sort information (Starrin et al., 1997).
The observations of nutritional aspects regarding nutritional care (III and IV),
made by the researcher (MWP) as an observer, were later followed up in the
interviews. The observations were not identical, but varied depending on each
situation and could vary between 45 minutes to several hours. Field notes were
made during or immediately following the observation. The observer made 21
observations of 14 patients during different shift and with different nurses,
regarding nutritional care (III and IV) of what was experienced at bedside, in
expedition, during reporting between nurses and during rounds, and was, when
appropriate, later followed up in the interviews.
The interviews started with the patients’ experiences of their intake of food and
fluid (IV) and how the nurses had experienced nutritional care of the patients
(III). The themes of the questions and the topics that the informants addressed
during the interviews guided relevant follow-up and probing questions. The
observations were followed up, when relevant, during the interview in order to
compare and contrast. Observational data is not considered to be enough, as it
is the meaning of the informants’ actions that are of interest (Glaser, 1992). The
interviews were further developed in line with analyzing and emerging results,
so that categories and their dimensions could be more fully explored. The
interviews (patients/nurses) were audiotape-recorded, transcribed verbatim and
analyzed before the next interview was made by the researcher (MWP).
Analysis
Basic principles in GT include the constant comparison of analyses, theoretical
sensitivity, theoretical sampling, theoretical saturation and memo writing
(Glaser & Strauss, 1967). In this thesis, data was analyzed (III and IV)
consecutively by the first author (MWP) according to “the constant
comparative method of analyses”, meaning that data collection and data
analysis were carried out concurrently (Glaser & Strauss, 1967). The process
moved back and forth between data and emergent pattern, constantly moving
between inductive and deductive thinking, yet trying to stay open, and
39
categories were reviewed, renamed and consolidated during the whole analysis.
The emergent categories from observations and interviews were constantly
compared and contrasted with the subsequent data to see if they worked, fitted
and were relevant and theoretically saturated (Glaser & Strauss, 1967).
Memos about the researchers’ ideas, reflections and hypothesis based on the
data, were noted during the analysis, since the use of memos increases the
theoretical sensitivity (Glaser, 1978) and is considered a vital link between
coding and the emerging of a theory or model (Glaser & Strauss, 1967). In
accordance with the grounded theory methodology, observational and interview
data were coded into two types of codes: substantive and theoretical. While
substantive codes conceptualize the empirical substance, theoretical codes
conceptualize how substantive codes may relate to each other as hypotheses to
be integrated into the theory (Glaser, 1978). In open coding, data was analyzed
line by line along with a constant coding of each sentence carrying meaning into
substantive codes. Effort was put on coding different incidences into as many
substantive codes as possible. These substantive codes were compared for
similarities, differences and grade of consistency and codes with similar
meanings were clustered into broader, more comprehensive and abstract
categories. The set of questions asked of the data were: “What is this data a
study of?”, “What category does this incidence indicate?” and “What is actually
happening here?”.
The core category was central, coped with the entire data, and seemed to be
wise. Open coding ended when the core category was discovered and the
selective coding begun. From now on, only those categories that related to the
core category in sufficiently significant ways were used (Glaser, 1978). The core
category became a guide to further data collection, so that categories and their
dimensions could be more fully explored, and continued until saturation was
reached. The relations between the core category and its categories were
searched for and described by theoretical codes. Then a preliminary substantive
theory was outlined. The analysis was performed mainly by MWP, but all
authors discussed the codes and categories during the whole process.
The research process, including the data collection, the data analysis, and theory
building, were all related. By using the “constant comparative method of
analysis” (Glaser & Strauss, 1967), the analysis also guided the data collection
and new ideas inspired new questions to be asked. The nurses (III) were
40
initially recruited from the patient study (IV), that is nurses caring for patients
being interviewed, and volunteered to participate in the study. However, the
analysis guided an interest for interviewing certain nurses; so called theoretical
sampling. The initial plan was to let the analysis guide which patient should be
interviewed next, but the limited amount of patients made us include all
available patients.
Trustworthiness
Sandelowski (1986) emphasizes two main strategies for ensuring rigor in
qualitative research: auditability and ensuring credibility and fittingness. Lincoln
and Guba (1985) presented evaluation criteria for qualitative research
comprising credibility, dependability, confirmability and transferability (Lincoln
& Guba, 1985).
According to Glaser and Strauss (1967), credibility can be seen as inherent in
the method, as the emerging theory is based on the method of constant
comparison, in which concepts and categories repeatedly emerge and guide the
continuing research. Furthermore, they suggest two main criteria for judging
the adequacy of the emerging theory, which is that it must fit the substantive
area to which it will be applied, here the ICU, and that it works. Only when
carefully induced from diverse data, the theory will be closely related to the
daily realities. In this way the theory will make sense and be understandable.
Using the multimethod principle (Glaser & Strauss, 1967; Starrin et al., 1997)
was another way to improve the credibility, and the combination of
observations, interviews and memos made our data rich and extensive.
Furthermore, the analysis has been discussed by the authors throughout the
process.
Ethical considerations
All studies were conducted according to common ethical principles applied in
human clinical research, i.e. the principle of respect for autonomy, the principle
of non-maleficence, the principle of beneficence and the principle of justice
(Beauchamp & Childress, 2001; Northern Nurses Federation, 2003; World
Medical Association Declaration of Helsinki, 1964). Potential ethical issues
were considered when planning ahead of the studies.
41
The principle of respect for autonomy
The first principle to take into consideration is the principle of respect for
autonomy. Information about the first two studies was given to special medical
nurses (I) and first-line nurse managers (I and II), who in turn informed the
RNs. The RNs and enrolled nurses were informed during staff meetings about
the last two studies (III and IV). The oral and written information about the
studies, given to all possible participants, included a short rationale, aim of the
studies, method, responsible researcher and contact person. Information also
included the confidentiality policy and information about that the participants
were participating on a voluntary basis and could withdraw from the study at
any time (I-IV). The first-line nurse manager obtained informed consent from
the patients (IV). Autonomy also entails respect for privacy and confidentiality
of personal data. This was obtained by coding the questionnaires and
transcribing interviews and keeping the transcripts locked away safely. During
the interviews, the use of names was avoided. The interviews with the RNs and
enrolled nurses took place in rooms chosen by the informants (III). The
patients were interviewed in the patients’ room (IV).
The principle of non- maleficence and the principle of beneficence
The consequences of being interviewed must be given attention (III and IV).
Therefore, great concerns for the patients’ physical and psychological condition
were addressed during the interviews. The researcher has not been involved in
the care of the patients. Even if the patients in the second study did not fill the
role of a subject (II), they did require significant consideration while observing
nursing interventions carried out at bedside. Patients and relatives present
during the observations were given oral information about the study. Prior to
the studies, the researcher had worked as an RN at one of the ICUs and was
hereby well acquainted with the context; the situation of the patients, next of
kin and health professionals, as well as the care and environment. In addition,
both co-authors have previous experience of carrying out research within the
ICU context. The findings may be biased when the researcher is familiar with
the actual setting, here an ICU, but it can also be seen as an advantage, as it
makes it possible to identify and reflect on nutritional matters that might have
escaped the attention of a researcher without such a background (Lykkeslet &
Gjengedal, 2007).
42
The principle of justice
The special medical nurses in 16 municipalities in one county and Chief of
Departments of 32 wards in the three hospitals in one county council were
invited to participate (I). As there was no available database for RNs, the
selection procedure differed in municipal care and in county council care. But
approximately one fifth from both areas were addressed in the study. All active
RNs at the intensive care units in one county council were included according
to the same criteria (II). The three groups of informants, RNs, enrolled nurses
(III) and patients (IV), may be considered equal, as the same themes were
discussed in all interviews, creating opportunities for comparisons and
mirroring. Furthermore, the researchers have also considered the risks versus
benefits of the studies.
Approvals
In county council care, eight Chief of Departments representing 28 wards from
the three acute care hospitals, accepted participation in the study, while two,
representing four wards, declined participation for unknown reasons.
Permission to conduct the other studies was obtained from the Chief of
Department of Anaesthesia and Intensive Care (II) and the Chief of
Department of Anaesthesia and Intensive care and The Head of Department of
Anaesthesia and Intensive Care (III and IV). Approvals by the ethical research
committee at Karlstad University were obtained (document number F 49/01
regarding study II and C 2005/421 regarding study III and IV). At the time of
study I it was not considered necessary to have ethical approval, as the study
did not include patients, but was directed to health care staff, and did not
comprise questions that could be considered ethically problematic.
43
MAIN FINDINGS
In this section, the main findings from each study are presented separately and
consecutively, followed by a comprehensive result.
Study I
Firstly, the results of CNs’ and RNs’ perceptions of occurrence of malnutrition,
awareness of guidelines and assessment of nutritional status are presented, then
the results from the RNs exclusively (nursing documentation and
assessment/screening tools).
Occurrence of malnutrition and awareness of guidelines
Malnourished patients occur to a varying extent, according to the perceptions
of CNs and RNs. In municipal care this ranged from 43% (CNs) to 58% (RNs)
and in county council care from 80% (CNs) to 87% (RNs). There were
significantly more CNs/RNs in county council care (p = 0.001) who answered
that malnourished patients occur in their field of activity, compared to
CNs/RNs in municipal care. According to the majority of CNs/RNs (66%),
there were no guidelines, while 13% did not know (all RNs) if there were any.
In county council care CNs/RNs answered that they had guidelines
significantly more (p = 0.005).
Assessment of nutritional status
In municipal care, performance of nutritional assessment of all patients ranged
from 13% (CNs) to 18% (RNs) and in county council care from 32% (RNs) to
44% (CNs). Significantly more CNs/RNs in county council care (p = 0.008)
nutritionally assessed all patients compared to CNs/RNs in municipal care.
Among the CNs/RNs (n = 115) who answered that not all but significant patients
were nutritionally assessed, 88% specified which these patients were. When
analyzing the answers, content analysis was used to reveal the theme
“exposed/vulnerable patients are subject for assessment of nutritional status”.
The theme derived from four categories: the patient’s condition, diagnosis,
care/treatment and age (Figure 3).
44
Figure 3. RNs’ and CNs’ perceptions of assessment of nutritional status.
The CNs and RNs also reported when the assessment of the patients had been
performed. Most respondents assessed the patients on admission and/or during
special housing stay/hospital stay, but seldom at discharge.
The use of assessment/screening tools was sparse. Two out of twelve
respondents named the tools MNA and SGA. Furthermore, one CN
mentioned a nutritional chart and another CN a combination of documentation
of food intake and BMI. Remaining respondents mentioned unspecified tools.
Nursing documentation
The majority of the RNs documented nausea/vomiting, ability to eat and drink,
diarrhea and difficulties in chewing and swallowing. Energy intake, BMI,
metabolic changes and subcutaneous fat/muscle mass were items rarely
documented. It was also found that when caring for patients with a feeding
The patient’s condition
The patient’s diagnosis
The patient’s care/treatment
The patient’s age
Exposed/vulnerable patients are subject for assessment of nutritional status
The elderly Type of care
Length of stay
Artificial nutrition
Mixed/selected diagnosis
Nutritional diagnosis
Decreased abilty to eat and drink
Deteriorated general condition
Changes in weight
Presence of wounds
All patients are assessed (33%) Significant patients are assessed (67%).
88% specified Dropout 12%
45
tube, reflux in feeding tube and gastric residual volume was documented by
18% of the RNs.
Another issue was whether or not the RNs documented their clinical judgement
of the nutritional status. The result showed that 23.9% of the RNs in municipal
care replied that they always and 59.2% sometimes documented that patients
were malnourished. In county council care, 14.5% of the RNs replied that they
always and 56.4% sometimes that they documented the corresponding data.
All of the RNs in county council care (100%) and the majority of RNs in
municipal care (97%) used the VIPS model for nursing documentation. In
municipal care, the original VIPS model was used by 51%, while a modified
version for primary health care, the Prim-VIPS, was used by 42%. For RNs,
perceived advantages and disadvantages with the VIPS model where formulated
as two themes: “Guidance” and “Obstructs exchange of information” (Figure
4). The results also indicated that there were relations between the categories.
By facilitating the writing, the patient’s condition was easy to grasp when
reading, and nursing care was supported. If the RNs were annoyed with the
notes, the reading gave no clear picture of the patient, which in turn could have
a negative impact on nursing care. Guidance
(Advantage) Obstructs exchange of information (Disadvantage)
At ease when writing
Annoyed when writing
Gives adequate content/structure Is unified Is easy to use Is organized in accordance with the nursing process
Headlines - confuses when choosing - are not specific enough - are not used in the same way - does not cover everything - does not fit with the practice
Is time consuming Is circumstantial
Writing
Is repeatedly used Is rigid Reading
Makes the patient’s condition easy to grasp when reading
Gives no clear picture of the patient when reading
It is easy to find information about the patient Makes it difficult to find information about the patient Is well arranged Makes it difficult to get a comprehensive picture of the patient Caring
Supports nursing care
Makes nursing care fade out
Evaluation is made easier Impaired evaluation The nursing care is made lucid
Figure 4. RNs’ perceived advantages and disadvantages with the VIPS model.
46
Study II
The results from the RNs’ responses to the questionnaires are presented first,
and then the bedside observations.
Responsibility, knowledge and documentation
The majority of RNs (91%) answered that there were written guidelines
regarding EN in their ICU and that there was a nurse responsible for nutritional
issues. RNs’ primary sources of knowledge were consultation with colleagues.
In hospital A, no RN answered that there was a nutritional team in their ICU,
in hospital B all RNs answered that there was a nutritional team, and in hospital
C, two out of 12. RNs from hospital B scored higher in relation to knowledge
from in-service training compared with nurses from the other two hospitals.
The Swedish Handbook of Pharmaceuticals (FASS) was the primary source of
information and knowledge regarding administration of medication through
feeding tube, according to 30 out of 44 (68%), while 18 RNs (41%) consulted a
brochure from the pharmacy. Physicians and colleagues were consulted by 14
(32%), and 3 (7%) consulted the pharmacy service about recommended
techniques.
To what extent (mean value) the total group of RNs and RNs from each
hospital perceived to have responsibility, knowledge and support from the
documentation structure, in relation to the nutritional nursing process, is shown
in figure 5-7.
Responsibility. RNs from hospital B scored significantly higher regarding
responsibilities for prevention of complications (A vs B: Z = 2.640 p = 0.008; B vs C: Z =
2.683 p = 0.007) and evaluation (A vs B: Z = 3.510 p = 0.001; B vs C: Z = 3.477 p = 0.001)
compared with the RNs from the other two hospitals.
Knowledge. The RNs from hospital B scored significantly higher regarding
knowledge about assessment (B vs C: Z = 2.427 p = 0.015) and goal (B vs C: Z = 3.458
p = 0.001) than the RNs from hospital C, and for prevention of complication (A vs B:
Z = 2.506 p = 0.012; B vs C: Z = 2.650 p = 0.008) and evaluation (A vs B: Z = 0.001 p =
0.001; B vs C: Z = 3.107 p = 0.002) compared with the RNs from hospital A and C.
Documentation. The RNs from hospital B felt significantly higher support
from the documentation regarding assessment, (B vs C: Z = 2.431 p = 0.015), planning
and implementation of interventions (B vs C: Z = 2.405 p = 0.016) and evaluation (B vs C: Z
= 3.438 p = 0.001) than the RNs from hospital C.
47
R e s p o n s i b i l t y
1
2
3
4
5
A s s e s s m e nt G o a l P la nn ing a ndim p le m e nta t io n
P re v e nt io n E v a lua t io n
T o ta l
H o s p ita l A
H o s p ita l B
H o s p ita l C
K n o w l e d g e
1
2
3
4
5
A s s e s s m e nt G o a l P la nn ing a ndim p le m e nta t io n
P re v e nt io n E v a lua t io n
T o ta l
H o s p ita l A
H o s p ita l B
H o s p ita l C
D o c u m e n t a t i o n
1
2
3
4
5
A s s e s s m e nt G o a l P la nn ing a ndim ple me nta tio n
Pre v e ntio n E v a lua tio n
T o ta l
H o s pita l A
H o s pita l B
H o s pita l C
Scales could range from 1 (very small extent) to 5 (very great extent). Figure 5-7. RNs’ perceptions of responsibility, knowledge and documentation in relation to assessment, goal, planning and implementing interventions and evaluation (mean value, total group and hospital A, B and C).
48
Prescription of enteral nutrition
The planning of the patients’ nutritional care in the ICU was made on a daily
basis. According to the majority of RNs, the physicians prescribed lactobacillus
and the amount, type and rate of EN for the patients (Figure 8). About half of
the RNs considered themselves involved in decisions regarding type, rate and
lactobacillus. Dieticians, enrolled nurses and others (the kitchen staff) were
rarely involved.
Figure 8. Who is prescribing the amount, type and rate of EN, and lactobacillus.
n n
49
Enteral nutritional nursing care
The results from the questionnaire showed to what extent (mean value) enteral
feeding interventions were performed in accordance with what was considered
good nutritional nursing care. Scores could range from 1 (never) to 5 (always)
(Figure 9). A low score was considered good regarding “medications that
should not be crushed are administered in crushed form through feeding tube”.
A continuous feed, with a night rest, was preferred ahead of bolus feed, at the
time of the study, and checking of gastric residual volumes was not
recommended. Confirmation of tube placement before delivery was almost
always performed.
RNs from hospital A (Z = 2.805; p = 0.005), and B (Z = 3.230; p = 0.001), to a
significantly higher extent than RNs from hospital C, answered that the feeding
schedule allowed for a night’s rest. RNs from hospital B cleaned the syringe
after use to a significantly higher extent than RNs from hospital A (Z = 3.546;
p = 0.000).
1 2 3 4 5
Flush tube after administration
Clean syringe after each use
Confirm tube placement
Use of feeding pump
Daily inspection of nostrils
Continuous feed
Feeding schedule allow for anight rest
Flush tube beforeadministration
Check gastric residual
Bolus feed
Medications not to be crushedare administred in chrushedform through feeding tube
Total
Hospital A
Hospital B
Hospital C
FFigure 9. RNs’ perceptions of enteral nutritional nursing care (mean value, total group and hospital A, B and C).
50
The results from the questionnaires also showed that most RNs, 42 out of 44
(95%), answered that they used a specific position for patients during enteral
feeding, but only 11 RNs specified the backrest elevation to be 30 degrees or
more. An open question about how the small bore tube position was checked
after insertion, revealed that the majority of the RNs, 38 out of 44 (86%),
auscultate over the abdomen with a stethoscope, while insufflating air through
the tube. Thirty-two out of 44 (73%) responded that the position of the tube
was checked by x-ray. Less than one fourth, 23%, aspirated gastric contents.
Other answers were that the RNs “check pH level” and “put the tube in
water”.
The results from the observations showed that the feeding tube was always
securely fastened without risk of damaging the eye or being taped over
damaged skin. In all observations except one, the feeding tube was positioned
in such a way that it did not strain the nose. The feeding tube was taped onto
the cheek in one observation. A small bore feeding tube was used on seven
occasions on two different patients. There was no case of percutaneous
endoscopic gastrostomy or gastrojejunostomy during the study. None of the
feeding tubes were labelled in accordance with recommendations.
An infusion line for enteral nutrition was always used. All feeding pumps used
(n = 37) during bedside observations were labelled “for enteral use only” but
only 18 in Swedish. A syringe was used at bedside (for administering enteral
nutrition, medications and checking GRV) in 38 out of 40 observations. The
syringe was replaced within 24 hours in 30 out of 38 observations, according to
the labelling of date and time for replacement. The syringe was labelled “for
enteral nutrition” in 31 out of 38 observations.
Seven out of 40 bedside observations revealed a backrest elevation of 30
degrees or more. Mean backrest elevation was 20.7 (SD 8.9). Twenty-nine out
of 40 observed patients were mechanically ventilated and only 3 out of those 29
had an elevation of the head of 30 degrees or more. Mean backrest elevation
was 19.2 (SD 6.92). There were no significant differences in backrest elevation
between ventilated and non-ventilated patients. Patients positioned on right
lateral position (n = 5) had significantly lower backrest elevation compared to
patients positioned on their back (n = 29) (Z = 2.413; p = 0.016). The
endotracheal tube was cuffed so that no air leakage could be heard.
51
Study III
The developed substantive theory of RNs and enrolled nurses concerns and
strategies of nutritional nursing care for patients with EN, includes the core
category “to have and to hold nutritional control – balancing between
individual care and routine care” and the categories “knowing the patient”,
“facilitating the patients’ involvement”, “being a nurse in the team”, “having
professional confidence” and “having a supportive organization”. All five
categories are related to the core category and to each other.
To have and to hold nutritional control over the patient’s nutritional care was found to be
balancing between individual care and routine care. When having balance between
individual care and routine care, nurses felt that the patient’s well-being, security
and quality of care improved. In addition, it made the nurses feel proud and
satisfied that they did a good job. When the balance was not achieved, or when
it was disturbed, such as when the routine care was felt to take precedence over
the unique patient’s individual care, disappointment was expressed.
To know the patient’s nutritional history, needs and preferences, and feeding
tolerance in combination with professional confidence and collaboration within
the health care team, helped nurses to facilitate patient’s involvement in
nutritional care. By creating options for nutritional choices and encouragement
the patient could take part in decisions. The next of kins were invited to
participate and thereby further enhance the patient’s nutritional intake. Nurses
connected the individual patient’s nutritional need and preferences to their
earlier experiences and knowledge of similar types of patients. The patients’
general condition was also taken into consideration. Being aware of one’s own
knowledge regarding nutritional matters, gave nurses confidence in their own
ability. Limited knowledge and experiences in combination with an open mind
for new solutions led them to seek dialogue and cooperation with team
members. The team was ruled by responsibilities, providing influence, but also
challenging the nurses through attitudes and values. Within the organization
some important factors were highlighted, such as the environment, tools,
continuity and channels of information.
The nurses’ daily nutritional care was based on knowing the patient. Being familiar
with the nutritional history of the patient was of importance, as it often had an
impact on the actual situation in the ICU. Next of kin were contributing with
information about the patient’s nutritional history. To know the patient’s
52
individual nutritional needs and preferences continuously during the ICU stay,
was considered of great importance, giving the nurses a base for providing
nutritional care. The patients’ individual need of energy, preferably measured
via indirect calorimetric, gave the nurses feelings of security and control, as this
measure could be compared with the actual intake. The patients’ feelings of
hunger and appetite were welcomed signs of nutritional improvement; it
emerged as a milestone in the nutritional care as the nurses then felt that the
patients “were feeling better”. A close monitoring and evaluation of the
patients’ individual feeding tolerance was another property. The feeding
tolerance varied according to the patient’s condition, leading to adjustments in
the nutritional care.
Facilitating the patients’ involvement. Creating options for choices and decisions
were of importance, as these nutritional decisions could be some of the few
decisions the patients were able to make. Giving time for reflection was a
strategy used by the nurses when creating options for choices and decisions.
The strategies for encouraging intake of food and fluids were to listen carefully
to what the patient said and to explain things in a clear manner. An effort was
made to motivate the patient, to make him or her realize that they must give it a
try. Sometimes distractive maneuvers were performed. The nurses felt that they
sometimes abandoned the encouraging maneuver. When the patients started to
eat and/or drink, the next of kins were invited to participate. The nurses
encouraged the next of kins to talk about food and fluid with the patient, to
find out what the patient wanted now and what they were yearning for.
Being a nurse in a team. The nurses were seeking dialogue and cooperation
regarding nutritional matters among or outside their own profession. The teams
were of various constellations and shifted from time to time. Even the staff at
the ward was sometimes part of the team mentioned, as a kind of extended
team. However, the nurses were also aware that the nutritional knowledge
among fellow workers could vary something that could affect the safety of the
nutritional care. One strategy used to handle this and hereby secure the care,
was to remind each other about what to do. The nurses were challenged by
attitudes and values in their daily nutritional work. They felt that nutrition in
general was not considered as important as other treatments. Yet, nurses with
long experience had noticed an increase in positive attitude among all staff
members towards nutritional issues. The nurses felt that nutritional nursing care
must be more than just about which pump to use. Going beyond the routine
53
could be a dilemma. The nurses had experienced that they were ruled by
responsibilities within the team. Enteral feeding was often delegated from the
RNs to the enrolled nurses, while the RNs were mainly handling the parenteral
nutrition. This routine is a way of sharing responsibility, which worked
smoothly and securely, but some RNs experienced a loss of control when EN
was delegated to the enrolled nurse. Some enrolled nurses had experienced loss
of control when RNs took over the checking of the location of the feeding
tube. Communication and trust in each other was needed. Having influence
within the ICU team meant that the nurses could suggest improvements. They
were pleased when they felt that there was an open atmosphere to express
wishes. Ahead of the patients’ transfer to their home ward, extended concerns
were raised regarding the nutritional care.
Having professional confidence in the form of having knowledge was of importance
in the daily nutritional care. With awareness of the complexity of the patients’
conditions, however, and the rapid changes that could occur, the nurses
expressed openness for new ways of solving problems. Having experience of
different types of patients helped the nurses to separate the standard patient, or
the so-called “easy ones” in need of standard care, from the more ill or specific
patient, in need of special attention. It made them confident enough to
sometimes go beyond the framework, to deviate from guidelines and attitudes.
Lack of former experience, expressed by nurses with short experience of
intensive care, made it more difficult to know what to expect.
The nurses addressed several factors within the supportive organization as valuable
for nutritional care. The environment, such as placing the patient in an ICU
module, in an armchair during meals and serving the food and fluid in attractive
way had impact on the patients’ nutritional intake. Tools like guidelines,
documentation and feeding pumps were all supportive to the nutritional care,
but they could also be an obstacle. Guidelines regarding nutrition and gut
motility were considered clear. Deviations from current guidelines were also
described and observed. The use of nutritional feeding pumps led to slower,
continuous delivery, leading to fewer complications such as diarrhoea.
Malfunctioning pumps caused a lot of irritation putting patients at risk..
Continuity in the nurses’ schedules, enhanced nutritional care of the patient and
having channels of information was needed in order to provide secure care,
while lack of appropriate information channels led to rumours and confusion
about what to do.
54
Study IV
The patients’ experiences of nutritional care within intensive care is here
presented in the form of a substantive theory, based on one core category and
three categories, all related to each other. The core category “grasping nutrition
during the recovery process” was reflected in and related to the categories
“facing nutritional changes”, “making sense of the nutritional situation” and
“being involved with nutritional care”. While grasping the nutritional situation,
the patients were emotionally shifting between worry, fear and failure, and relief
and hope.
Grasping nutrition during the recovery process became a goal for the patients in order
to return to their normal lives or to come through the ICU period. They found
themselves facing nutritional changes they could not solve themselves,
indicating their dependency of care. The nutritional changes differed according
to their general health condition and treatment, meaning that the problems
could come and go, succeed one another or be present all at the same time.
Feelings of relief were expressed when certain cutting points were reached,
giving hope for further improvements. When making sense of what was going
on nutritionally, the patients reflected on the meaning of nutrition as a whole
and in relation to their present condition and their ability to get well. They used
their former and present experiences of nutritional care. Ever-new challenges in
their nutritional condition were compared and evaluated according to their
earlier experiences, resulting in feelings of satisfaction or dissatisfaction. Being
involved with nutritional care was described as a progression from handing
over nutritional care to the health care professionals to having a voice of
choice. Furthermore, the patients involved their next of kin to take part in their
nutritional care. The patients’ ability to be involved with their care also varied in
accordance with their nutritional status.
The nutritional changes they were facing were of varying degree and could come and
go in accordance with their general health condition during the recovery
process. Inherent in the awareness of having nutritional changes was also their
awareness of need of care. Being thirsty was a prominent problem and strong
feelings of longing to quench their thirst were expressed. Once allowed to
drink, patients felt relief and hope. They also experienced difficulties in eating
and swallowing. Their eating difficulties showed a wide range of impairments
that affected their ability to eat, from handling food on the plate and to the
mouth, handling it in the mouth, to swallowing. Changes in their appetite were
55
also expressed, from having no appetite at all and thereby not wanting to have
anything to eat, to being so hungry that the food could not be served fast
enough. The smell and taste of enteral feeding formula as well as of food and
fluid had an impact on their appetite. Nicely served food enhanced their
appetite. Having abdominal discomfort, like changed bowel activity, bad
smelling wind and pain was other unpleasant experiences. Turning points were
regaining the appetite, getting rid of the feeding tube and regaining a
functioning gut.
The patients put a lot of effort into how to make sense of their nutritional situation,
and of what they had experienced, by deliberately using different strategies.
Feelings that were expressed ranged from being dissatisfied to being satisfied.
When considering the meaning of nutrition they found that food and nutrition
was essential in their lives in general and a must for their recovery process. The
patients’ former experience of nutritional impairments and care was a source of
knowledge, for recognition and comparison, and could make their nutritional
situation comprehensible and understandable during their ICU stay. The
outcome of nutritional care during the ICU stay was mentioned in relation to
having their nutritional needs satisfied, their weight kept stable and experienced
support from health care professionals, resulting in feelings of satisfaction or
dissatisfaction. The patients emphasized the importance of being informed,
listened to and encouraged. This made them feel at ease, supported and safe.
Being involved in nutritional care was reflected in a gentle progression from not
being involved at all to being somewhat involved in the nutritional care. This
progression was intertwined in their general condition and trust in the health
care professionals. Some patients are handing over their nutritional care to the
health care professionals because they were too ill and could not manage, or
they did not want to. Having a voice of choice was experienced when they had
been given opportunities to make choices and were invited to take part in
nutritional decisions and care. When the patients were being served food and
fluid they did not like, they were getting more specifically involved in the
nutritional care, by setting limits. The patients were involving their next of kin
by asking them to bring them their favourite food and fluid and to assist them
when eating.
56
Comprehensive understanding
When analyzing the four studies as a whole, the findings show that nutritional
nursing care is related to the interactions between the nurse and the patient,
between the nurse and the team members, and between the nurse and the
organization.
Nutritional nursing care and the nurse-patient interactions
Assessment, intervention, evaluation and documentation of nutritional nursing
care are important for the patients’ nutritional condition and experiences. The
patients and nurses are thinking and reasoning, using their experiences and
knowledge in relation to nutritional nursing care. Patients express two different
facets of involvement in nutritional nursing care. The nurses encourage the
patients’ involvement in nutritional nursing care.
Nutritional nursing care and the nurse-team interaction
Individuals and the team(s) are interwoven in the nutritional nursing care.
Within the team the nurses are both supporting and challenging. Depending on
the team members’ knowledge, experience, attitudes, values and decisions the
nutritional nursing care may vary. Nurses are seeking dialogue and cooperation
among the team members and are being ruled by responsibilities.
Nutritional nursing care and the nurse-organization interaction
The nurses interact with different factors of importance for the nutritional
nursing care, provided and maintained by the organization. Guidelines,
documentation, assessment/screening tools, environment, nutritional team and
continuity can all be supportive. If the factors are not fully implemented, being
insufficient or not individually adjustable, they might have a negative impact on
the nutritional nursing care.
57
DISCUSSION
General discussion
The overall aim of the thesis was to gain a deeper understanding of nutritional
nursing care in municipal care and county council care, with special focus on
enteral nutrition in the ICU. When analyzing the four studies as a whole (I-IV),
nutritional nursing care appears in interaction processes between the nurse and
the patient, between the nurse and the team, and between the nurse and the
organization. Interaction is a central concept in nursing. Interaction is
important for building relationships with the patient and for assessment of the
patient’s needs and resources (Meleis, 2007; Travelbee, 1971).
Study IV showed that grasping the nutrition during the recovery process can be
a way to regain some control in a situation where the patients are highly
dependent on professional care. Being treated in an ICU is an extreme life
situation as the threat of death overshadows everything and perforates the
patients’ existence (Almerud et al., 2007). Therefore, having control of one’s life
is an important part of feeling safe in the ICU (Hupcey, 2000). To have and to
hold nutritional control – balancing between routine care and individual care
was found to be the core category of nutritional nursing care according to the
nurses (III). Having control is known to be central to expert clinical and ethical
judgement (Benner et al., 1999) but in study III this was found among nurses,
whether they were beginners or had worked at the ICU for a long time.
Nutritional nursing care and the nurse-patient interaction
The patients’ nutritional condition, patients’ and nurses’ thinking and reasoning,
and patients’ involvement are parts of nutritional care and the nurse-patient
interaction.
The patients’ nutritional condition
Facing nutritional changes like thirst, changed appetite and hunger, eating and
swallowing difficulties, and abdominal discomfort were bothersome
experiences for the patients in the ICU (IV). This is a more nuanced picture
than described earlier. Nutritional support, like EN and PN, is considered
standard care during the ICU stay (Kreymann et al., 2006). However, along the
recovery process, the patients are also likely to start with fluid and food orally
58
(Berger et al., 1997; Villet et al., 2005). Interestingly, PN did not cause the
patients any worries, while EN and oral nutrition did (IV). Changes in appetite-
related gut hormones in patients in the ICU have been found, which might
explain the continuing nutritional deficits (Nematy et al., 2006). This might in
turn explain why it was such a relief when the appetite returned (IV). Recently,
Karlsson and Forsberg (2008) found that when patients who were conscious
during ventilator treatment in the ICU started to feel better, the first sign of
yearning became evident in the form of yearning for different tastes and smells.
In study I an assessment of a patient’s nutritional condition was not always
performed. According to the RNs and the special medical nurses and the first-
line nurse managers (CNs) less than half of all the patients in municipal care
and county council care were routinely assessed. Instead, the patient’s
condition, diagnosis, care/treatment and age were taken into consideration as
reasons for assessment. A low performance of nutritional assessment was also
found recently among nurses in Amsterdam (29.9%) (Bavelaar et al., 2008) and
in Denmark (40%) (Lindorff-Larsen et al., 2007).
The RNs in the three ICUs scored low for the first phase of the nursing
process; the assessment, with regard to knowledge, responsibility and
documentation, when compared with other phases of the nursing care process
(II). This finding is not in accordance with another study which found that
nutritional assessment was considered a nursing responsibility (Perry, 1997).
Our results might indicate a focus on treatment and preventive interventions
rather than assessment, and that the assessment may be a weak link in nursing.
The reasons might be found in inadequate knowledge and skill, or perceived
lack of resources, such as assessment tools and structured documentation
specialized for nutritional assessment. In addition, nurses might think that
nutritional assessment is not part of their role, something which has been
discussed recently (Adams et al., 2008).
Assessing the patient’s feeding tolerance is a concern for nurses in the ICU,
because impaired gastro intestinal motility, altered cough and gag reflex, and
endotracheal and nasogastric tubes increases the risk of aspiration (Marshall &
West, 2004). Despite this, there is no consensus regarding assessment of
feeding tolerance (Reintam et al., 2008). The management of monitoring
tolerance to enteral feeding, like withholding EN in patients with diarrhea and
ceasing EN when GRV is high, may result in inadequate delivery of nutrition
59
(Marshall & West, 2004). Further research addressing the assessment and
management of feeding tolerance is therefore required.
Knowing the patients’ nutritional conditions was the basis of the nurses’ daily
nutritional care in the ICU (III). RNs and enrolled nurses considered the return
of the patients’ appetite as a milestone in their recovery. However, the patients’
appetite should not only be assessed. A care plan has to be set up and followed,
but individual testing of the patient’s favourite foods and fluids is also an
important nursing task that can help enhance the intake. The congruence in
perception of nutritional needs between nurses and patients was not studied
here, but Florin (2005) found that nutritional problems, described as severe or
very severe by patients, were not identified by RNs in acute setting (Florin et al.,
2005).
Feelings of worry and fear were bothersome for the patients (IV) and the
nurses talked about the importance of information and to really listen to the
patient (III). Nursing caring behaviour, like relieving the patient from worry
and fear, is found to be most valuable to the patients (Hofhuis et al., 2008b).
Thinking and reasoning
The patients’ ability to recognize former experiences enabled them to react
when different experiences occurred in a new situation. The patients put a lot
of effort into making sense of what was going on nutritionally and to avoid
bothersome experiences (IV). This is of importance to the patients in order to
find out if they possess the motivation and desire to cope with their nutritional
changes (Antonovsky & Elfstadius, 2005). To help the patients find meaning in
these experiences and to cope with them, is crucial in nursing care (Travelbee,
1971). RNs have a key role in preventing and reducing the bothersome
experiences and in strengthening the patient’s own ability to handle the
situation.
The patients were considering the outcome of the nutritional care provided
during the ICU stay and they thought that their needs of nourishment had been
satisfied (IV). This is interesting, as this phase is associated with low energy
delivery according to the literature (Adam & Batson, 1997; Binnekade et al.,
2005; McClave et al., 1999; Villet et al., 2005). It is also known that patients
expect the nurses to be familiar with their condition, to provide them with
60
adequate care all the time and to always be there when needed (Staniszewska &
Ahmed, 1999). Apart from weight changes and feelings of being sated, the
outcome in form of safe, supportive nutritional care, reflecting successful
nutritional care was expressed (IV). A feeling of safety among patients reflects
supportive care settings (Edvardsson et al., 2005), which may decrease the
patients’ vulnerability (McKinley et al., 2002).
The RNs’ and enrolled nurses’ combination of knowing the patients condition
over time and being aware of, and reflecting over their own knowledge in
connection with former experiences regarding nutritional care, gave confidence
in how to handle the present situation (III). This confirms the findings of
Benner (1996), who found that nursing actions in the ICU were response-
based, relying on intuition of what had worked in similar situations in the past,
individually modified in accordance with the patient’s individual response.
Furthermore, the nurses were proud of their achievements regarding the
patients’ nutritional care. Having confidence when dealing with patients, next of
kins and other professionals is of importance (Endacott, 1999).
The RNs and enrolled nurses were also aware that they did not always fully
embrace the patient’s complexity of problems and needs, or the options of
nutritional care (III). They admitted that they might not know everything
regarding nutrition and were trying to find new solutions, which could lead
them to seek dialogue with fellow workers. According to Benner (1999), they
remain open to the fact that they might be wrong and make an inaccurate
judgement, and they admit that their preconceptions must be reconsidered.
Being able to recognize when one does not have a good grasp of a situation is a
perceptual skill. A good clinician is thinking in action and reasoning through
transitions in the patients’ condition.
The RNs’ primary source of knowledge about EN in study II was consultations
with colleagues, while scientific journal articles and study programme in nursing
contributed to a small extent. Also in municipal care the use of research
findings in daily practice is low (Boström, 2007). The team share knowledge
from each other, because it is not only individual knowing that is needed to
carry out intensive care (Wikström & Larsson, 2004). When looking into what
counts as evidence in nursing care, it was found that effective patient-centred
nursing care can be achieved by not only using research, but also by clinical
experience, patient experience, and information (Rycroft-Malone et al., 2004).
61
A common cause for insufficient nutritional care is the lack of knowledge
(Hansson & Wenström, 2005; Lindorff-Larsen et al., 2007; Mowe et al., 2008;
Olsson et al., 1998; Perry, 1997) and insufficient education (Council of Europe,
2003). In nursing education in Sweden, nutritional content and extent varies.
Nutrition is usually integrated with other topics and under different headings
(Unosson, 2000b).
Involvement
The findings showed that there were two different facets for patients’
involvement in the nutritional care. The patients were either involved in at least
some nutritional decision, or they were handing over the care to professionals.
Having a voice of choice meant that the patients had been informed about
alternatives and options so that they could choose, for example between
different types of dishes and fluids, size of portions and rate and amount of
enteral feeding (IV). Another study found that patients in an ICU do not want
to feel responsible for control over medication or care instructions, while
everyday things, such as personal hygiene and position in the bed were
important to have some influence over (Wåhlin et al., 2006). Perioperatively,
the patients deliver themselves over to the hands of the staff, resulting in
feelings of well-being when being received and protected by the staff (Lindwall,
2004). Even patients in an infectious disease ward preferred a rather passive
role in clinical decision-making in general nursing care (Florin et al., 2006).
Within the area of withdrawing or withholding life-sustaining treatment,
patients in the ICU are involved in decisions regarding nutritional support
(Happ et al., 2007). Study III showed that nurses perceived that the patients
were involved in the daily nutritional care. Encouraging and stimulating the
patient’s own ability and will to eat (III) may be a part of strengthening and
stimulating the patient’s inherent joy of life and will to fight while being in the
ICU (Wåhlin et al., 2006).
The findings also showed that there sometimes was a dilemma between doing
good and taking the patient’s own will/autonomy into account. Strictly
following nutritional guidelines and traditions could sometimes contradict the
patient’s own will (III). The nurses felt that they sometimes abandoned the
encouraging maneuver, even if they did not like to do so, in favour of a very
persistent pressing to make the patient drink or eat. It is known from other
areas that when the patient’s own will is not obvious, the staff is using the
62
principle of doing good, while situations where the patient’s will is clearly
grasped, the more respectful the staff becomes about the patient’s right to self-
determination (Jansson & Norberg, 1989; Jansson & Norberg, 1992).
The next of kins were found to be invited to participate in the nutritional care
by both patients (IV) and nurses (III). Finding a niche appeared to be
important for the next of kins, as it provided them with a sense of control and
enabled them to support and look after the patient. The next of kin expressed a
need to participate in the daily care in some way, because they wanted to do
something more than just being there (Hupcey, 1999). Next of kin contributed
with information about the patient’s eating habits and preferences, which made
it easier for the nurses to individualize the care for the patient (III). The next of
kins are found to be of importance for both the patient and the staff in the ICU
and are actually taken for granted (Engström & Söderberg, 2007). Regarding
the next of kin as contributors in nutritional care, this involvement is a highly
relevant nursing issue. Nurses need to look after this opportunity and
understand how their actions can help to improve this collaboration.
Nutritional nursing care and the nurse- team interaction
Seeking dialogue and cooperation, being challenged by attitudes and values and
being ruled by responsibilities, are all parts of the nutritional nursing care and
the nurse-team interaction.
Seeking dialogue and cooperation
Being a nurse among team members was a support for RNs and enrolled nurses
(III). They were seeking dialogue and cooperation regarding nutritional matters,
among or outside their own profession. Within the ICU team, it is known that
communication, teamwork and mutual support are factors of importance for
the care (Wilkin & Slevin, 2004). Also nurses’ own abilities to see the problems
and the environment, and finding relevant supporting ways of dissolving the
problems are also crucial (Wikström & Larsson, 2004).
There is greater nurse-physician collaboration among critical care nurses
compared to generalist nurse colleagues (Chaboyer & Patterson, 2001).
Enrolled nurses collaborate mainly with RNs in the ICU, while the RNs also
collaborate with other RNs and physicians in the ICU, as well as with RNs and
physicians on other wards (Thunborg, 1999).
63
Depending on the team members taking part in the rounds or which RN and
enrolled nurse that worked the shift before, decisions and care vary (III).
Nurses experienced how ranks within the team influenced the quality of the
decision-making (Currey et al., 2006). Different levels of skills and acquisitions
to function as a team member have been found to be barriers for teams
working in acute health care. Assertiveness and confidence are essential skills
that are needed in order to function as an effective team member (Atwal &
Caldwell, 2006).
Challenged by attitudes and values
The nurses were challenged by attitudes and values of nutritional issues in the
team, which influenced the daily nutritional care (III). Nutritional issues are
found to have low priority among health care professionals (Lennard-Jones et
al., 1995; Xia & McCutcheon, 2006). Another study found that the attitude of
the staff towards nutritional nursing care was overall positive, mainly regarding
the importance of food. (Christensson et al., 2003). In another study, RNs and
nurse aids did not show an unequivocally positive attitude regarding their
nutritional responsibility (Bachrach-Lindström et al., 2007). In our study
though, RNs and enrolled nurses with long experience emphasized that
nutrition had higher importance nowadays than before. Increased awareness
and knowledge, along with the introduction of a nutritional team on the ward,
were factors mentioned as the reason for this (III).
Ruled by responsibilities
The division of responsibility led to different feelings, and highlighted the
demands on communication and trust, because if that failed, they expressed
feelings of fear of losing control (III). Despite the fact that nutritional
responsibility is divided between several health care professionals, the nurses
scored higher for having responsibility compared with having knowledge (II).
Having a sense of control over nutritional care and being supported within the
team is an important cornerstone in nutritional care, because minimal control
and little support from colleagues results in increased stress among nurses
(Berland et al., 2008). Team work involves not only one’s own role, but also the
role of other team members. Understanding the multidisciplinary concept and
agreeing on common purposes is needed to become an effective team. The
team also needs to value each individual contribution to the team. Leaders must
64
allow team members to express their opinions, even controversial ones (Atwal
& Caldwell, 2006).
A wish of having a prolonged nutritional responsibility ahead of a patient’s
discharge from the ICU was expressed. The RNs and enrolled nurses were
concerned with the patient’s nutritional well-being, even after transfer to the
ward (III). There may be some justification for their concern, because patients
transferred from ICUs to surgical wards have expressed a significant shift in
security. Despite stressful situations in the ICU, the patients felt safe, while
after transfer to the ward feelings of insecurity dominated (Hoghaug &
Fagermoen, 2007).
Nutritional care is complex and coincides partly with other health care
professionals. Therefore, a multi-professional working team is fundamental in
nutritional care. Having a patient-centred approach, using evidence-based care,
procedures and protocols, paying attention to records, monitoring progress and
outcomes, communication, ability to maximise the individual attributes of each
team member, having a collaborative approach, creativity, and supportive
culture are some factors mentioned as important in the ESPEN guidelines
(Howard et al., 2006).
Nutritional nursing care and the nurse-organization interaction
Guidelines, documentation, assessment/screening tools, the nutritional care
environment, nutritional team and continuity are parts of the nutritional nursing
care and the nurse-organization interaction.
Guidelines
The study of enteral feeding interventions (II) showed some deviations from
the current guidelines. The use of a backrest elevation of 30 degrees or greater
was for example minimal, a finding correlating with other studies (Grap et al.,
1999; Grap et al., 2003). The reason for this could be the difficulties in
estimating the bed angle (McMullin et al., 2002), but yet another study found
that RNs are accurate in estimating backrest elevation (Dillon et al., 2002). This
indicates that there might be other explanations, such as insufficient awareness
of its benefits, real and perceived deterrents, poor agreement about
65
implementation responsibility and lack of enabling and reinforcing strategies
(Cook et al., 2002).
The nurses considered the guidelines regarding nutrition used in the ICU to be
clear, available, uniform, easy to handle and well used, and hereby supportive in
the daily care of the patients. Some deviations were deliberately made to better
suit the patients’ needs, while other routines were simply not followed due to
forgetfulness (III). When reviewing the diffusion of innovations in organi-
zations, it was found that there is little research regarding why and how people
and organizations reject an innovation after adopting it (Greenhalgh et al.,
2004).
Interestingly, the result of study I showed that, among RNs, special medical
nurses and first-line nurse managers (CNs), there was a low awareness of
guidelines regarding malnutrition, while the majority of RNs working in the
three ICUs in study II answered that there were guidelines about EN. Being
familiar with guidelines does not automatically mean that they are used (Wallin
et al., 2000). RNs and physicians do not always adhere to nutritional guidelines
(Mowe et al., 2006; Rasmussen et al., 1999). Guidelines are unlikely to change
practice without an active implementation strategy. Evidence, context and
facilitation are found to be the three elements for successful implementation in
health care (Kitson et al., 1998; Rycroft-Malone et al., 2002). Implementing
clinical guidelines is a dynamic and complex process. It involves motivation of
initiating, facilitation, factors influencing compliance and use, motives and
necessity of evaluation and values of successful implementation (Bahtsevani,
2008).
Nutritional guidelines in Europe are mostly developed by physicians (54%)
when compared to nurses (21%) and multiprofessionals (16%) (Fulbrook et al.,
2007). The development of nutritional guidelines is further challenged by the
lack of evidence supporting nutritional nursing practice recommendations
(Williams & Leslie, 2004; Williams & Leslie, 2005). Despite this, The National
Board of Health and Welfare just recently found that there is already an
extensive amount of regulations and standardizations regarding nutrition
(Socialstyrelsen, 2007b). This implies that RNs need to intensify the use of
already existing guidelines, but also that RNs should consider both standards
and individual judgements as important to the patient’s nutritional safety
(Berland & Natvig, 2005). The education of RNs, physicians and enrolled
66
nurses must be ongoing in order to promote the use of guidelines (Bourgault et
al., 2007).
Documentation and assessment/screening tools
The result of study I showed that the minimum level of recommended
nutritional assessment and documentation, including BMI, weight loss, mouth
and eating problems (Unosson & Rothenberg, 2000), all allowed in the VIPS
model, were not fulfilled. Important nutritional notes have been found missing
in other studies (Ehrenberg & Birgersson, 2003; Söderhamn et al., 2007).
Emanuelsson (2000) found that notes on nutrition were made in 87% of acute
medical care records, while the notes on nutrition in municipality care were
rare. The majority (84 %) of health care staff in a neurological intensive care
unit thought that the fluid balance was documented in accordance with
guidelines, but commented that the nutritional content could be poorly
documented (Hansson & Wenström, 2005). The two major risk factors for
malnutrition in elderly hospitalised patients; recent weight loss and appetite,
were poorly documented in a recent study (Adams et al., 2008).
Reasons for the low frequency of documentation (I) might be that nutritional
problems remain unidentified by the RNs (Florin et al., 2005) and that there is a
lack of nutritional knowledge (Hansson & Wenström, 2005; Kowanko et al.,
1999; Lindorff-Larsen et al., 2007; Mowe et al., 2008). The complexity of
documenting nutritional issues were further highlighted in study II, where RNs
scored highest for documentation of planning and implementation of
interventions and lowest for documentation of assessment. This indicates that
some parts of the structure of the documentation may be more supportive than
others or more known than others.
The finding that the VIPS model is a guide (I), according to the RNs in
municipal care and county council care, is in agreement with the aim of the
model, while perceiving the model as obstructing information exchange in
writing, reading and care are new phenomena, as far as we know. It is also
striking that what is praised can also be criticized, and that those who talked
about advantages and disadvantages were not separated into different groups.
On the contrary, RNs who noted advantages also noted disadvantages. This
may reflect that RNs are familiar with the model’s strengths and weaknesses,
but also that nursing documentation needs further development. For example,
67
the flow sheet did not cover all important nutritional issues (II). Finding
important information is difficult due to the amount of routine nursing notes
(Törnvall & Wilhelmsson, 2008). The structure of the VIPS model influences
the scope of thinking and actions of the individual nurse in various ways
(Söderhamn & Köhler, 2005). If notes relevant to the patient’s nutritional status
are not recorded, patients at risk may not be identified (Söderhamn et al., 2007)
and it is difficult to verify on what grounds decisions and interventions have
been made (Karkkainen & Eriksson, 2005).
One reason for the limited use of assessment/screening tools (I), confirmed by
other studies (Alfengård & Klevsgård, 2005), could be that they maybe not so
easy to use (Söderhamn, 2006) and that there is a lack of instructions and
guidelines (Kondrup et al., 2002). Another reason could be that the special
medical nurses/first-line nurse managers (CNs) and RNs simply trust their
clinical judgement and therefore abandon the tools.
However, according to the majority of the RNs, with or without
assessment/screening tools they documented whether the patient was well-
nourished, at risk of being malnourished or malnourished (always or
sometimes) (I). In another study where the nutritional notes in the nursing
documentation were compared with the results of a screening instrument
(NUFFE), deficiencies were found, which indicated that patients at risk of
becoming malnourished were not identified (Söderhamn et al., 2007). There is a
positive impact on nutritional documentation and an increase of nutritional care
when using assessment/screening tools, but it may not be the magic bullet to
improve nutritional outcome (Jordan et al., 2003). Nutritional screening and
assessment tools should support, but never replace, the nurse’s clinical
judgement (Weekes et al., 2004) and be linked to a care plan (Elia et al., 2005).
Interestingly, the patients in study IV were well aware of nutritional
documentation and thought it made nutritional care more secure.
Nutritional team
The lack of a nutritional team in the ICU (II) is in line with other studies
(Bottoni et al., 2008; Preiser et al., 1999). Furthermore, only 9.7% of the
nutritional teams in Europe are led by nurses (Fulbrook et al., 2007), and nurses
often view their role in the nutritional team as incidental (Rodriguez, 2004).
According to the majority of RNs, there was a nurse with nutritional
68
responsibility in all three ICUs (II), but this does not compensate for the lack
of nutritional teams.
The nutritional care environment
The patients’ intake of fluid increased when fluid was served in attractive ways,
for example with nice glasses on foot and with decorations, according to the
nurses (III), and this made the patients more satisfied (IV). In nursing home
settings it is found that drinking glasses and meals served on dishes at the table
have a significant impact on the intake (Nijs et al., 2006). Having the equipment
for serving the meals in a nice way made the nurses pleased with their care
(III). This was hopefully mirrored in the care, because it has been found that
within a positive environment, the patients feel safe, are receiving extra care and
participate in their care (Wåhlin et al., 2006). Reflecting on routines and
adjusting them in accordance to the patient’s needs and creating cozy eating
environments are prerequisites for improved nutritional intake and well-being
(Sidenvall, 2003).
Continuity
Having continuity in the nurses’ schedules was experienced as making them
take more responsibility. Continuity made them more aware of the patient’s
nutritional need and they made sure that the patients’ gut motility was in order,
thereby facilitating the delivery of enteral feeds (III). When evaluating
organizational changes in ICU in the form of dividing nursing staff into caring
teams, the amount of care each patient required affected the number of patients
each nurse was responsible for. The quality of care improved according to the
changes (Boström et al., 1992).
Leadership
The leadership was not explicitly revealed in this thesis, neither by nurses nor
by patients. This might be explained by the constant referring to the team, that
they include the leaders in the team, but also by an invisible leadership in
nutritional issues. Leadership is however known to be closely related to
organizational change, improvements in care (Kitson et al., 1998; Rycroft-
Malone et al., 2004; Wallin, 2003), work satisfaction (Gardulf et al., 2008) and
research use (Boström et al., 2007; Kajermo et al., 2001). However, the
69
implementation of evidence-based nursing care into practice is a complex
activity involving not only individual but also organizational factors (Boström et
al., 2007). There is a significant link between the context and the research
utilization, meaning that the better the contextual conditions are, the higher the
use of research findings (Kitson et al., 1998; Wallin et al., 2006). Creating
strategies for supporting nurses’ professional development (Kajermo et al.,
2008) and having a learning and supportive professional environment that
involves staff in decision-making at the unit level are factors that improve the
organizational potential of getting research into practice (Wallin et al., 2006).
70
Methodological considerations
Multiple data sources or data triangulation in the form of space triangulation
were used in study I. With another design, we could have strengthened this
form of triangulation further. It has been argued that simply collecting data
from multiple sites, without cross validation, is not considered actual use of
space triangulation (Halcomb & Andrew, 2005). Another form of data
triangulation was used in study I and III, called person triangulation. Data was
collected from two levels of RNs, comparing RNs and special medical
nurses/first-line nurse managers (I). In study III data was collected from RNs
and enrolled nurses. Data was used from one level of nurses to validate data
from the other level of nurses, which increased understanding and gave a more
nuanced picture.
Methodological triangulation at design level is referred to as between-method
triangulation, and at data collection as within-method triangulation (Denzin,
1970). In this thesis, a design with both qualitative and quantitative methods in
different studies was used to reflect the nutritional care (between-method
triangulation). When using the within-method triangulation, the weaknesses of
the questionnaire (I) were somewhat compensated for by the strengths of the
qualitative content analysis of the open-ended question regarding nutritional
assessment. Hereby a greater insight into the meaning behind the findings
obtained from the closed-ended questions regarding nutritional assessment was
achieved. In the same way, bedside observations and questionnaires (II) partly
compensated each other. The combination of observations, interviews and
memos (III and IV) is common in GT and strengthens the credibility.
The number of participants in our studies might be considered low, yet some
interesting results were noted. Perhaps designs with larger sample sizes could
have been desirable.
Response rates of 76% (municipal care) and 67% (county council care) in study
I and 70% in study II are considered sufficient (Polit & Tatano Beck, 2008).
The combination of initial covering letter, addressed return envelopes (stamped
in municipal care, free local delivery within county council care), two (I) and
three (II) follow-ups, and personal information about the studies from the
special medical nurses (I) and the first-line nurse managers (I and II) might
have motivated the RNs to participate in the study (Polit & Tatano Beck, 2008;
71
Streiner & Norman, 2003). In addition, only RNs on duty at the time of the
study were included, which ruled out those who were sick or on leave.
However, in study I the external dropouts might be due to high workload and
lack of time, which several RNs commented in returned, but unanswered
questionnaires. Due to anonymous responses, no analysis of dropouts could be
performed. Internal dropout rates were low for questions with fixed response
alternatives, ranging from 2% to 16% (with one exception: tools 49%), and
from 17% to 50% for open-ended questions (I).
The varying response rates between the three hospitals in study II might be due
to organizational changes during 2001. After all, they do participate a on
voluntary basis. The age of all RNs who worked in the studied ICU was
compared to the responding RNs and no significant differences were found.
Other factors, such as education, personality and experience could also have
influenced the result. In study II, the time gap between the month under study
and the return of the questionnaires was longer for some respondents than
others and might therefore have affected the results.
Special medical nurses and first-line nurse managers (CNs) were chosen for the
telephone interviews because of their overall nutritional nursing responsibilities
in municipal care and county council care respectively. The concept chief nurse
was used for both special medical nurses and the first-line nurses, because they
were analyzed together (I).
Telephone interviews (I) were chosen because it can be seen as a convenient
method for collecting specific information for the relatively brief semi-
structured interview guide that was used, and it combines low costs (Polit &
Tatano Beck, 2008) with high response rates (Streiner & Norman, 2003).
Furthermore, the telephone interviews gave a broad representative sample of
special medical nurses and first-line nurse managers, the number of omitted
items was reduced, open-ended questions could be asked, and it saved time
(Streiner & Norman, 2003). The challenge of maintaining participant
involvement and clear communication was kept in mind during the whole
interview (Musselwhite et al., 2007).
The questionnaires proved to be useful, cost saving, offered anonymity, and
reached a large and geographically diverse sample (Polit & Tatano Beck, 2008).
It could however be discussed whether some response alternatives could have
72
been more specific. In study I, for example, when answering the question about
assessing the patient ahead of discharge, there should have been separated
response alternatives for a patient discharged at home and for another
caregiver. The questions concerning the VIPS model were not specifically
concerning nutrition. However, one of the areas in the VIPS model is nutrition.
In study II, some questions were related to the nursing process, but a
modification was made. Nursing diagnosis was excluded, since the patients’
problem and needs were documented under the subheading status in the studied
ICUs (Feldt, 1999). A question about prevention of complications was added,
since prevention is an important nursing task. If planning and implementation
would have been separated, differences between these phases might have been
noted.
The use of observations was a way to collect data about nutritional care, but
there is always a risk of observational bias (Polit & Tatano Beck, 2008). The
various findings, however, might indicate that this was not the case.
From literature, research and professional experience, an interview guide (I), a
protocol (II) and questionnaires (I and II) were specifically devised and tested
for face validity, content validity and clarity, which can be seen as a strength of
the studies (Polit & Tatano Beck, 2008). In addition, the use of an interview
guide that includes very much the same items as the questionnaire can be seen
as a way to validate the content and clarity of the items. Both questionnaires
and bedside observations reflected the same month in study II, something that
strengthens the validity. The internal consistency regarding responsibility,
knowledge and documentation was acceptable (II), because normal value is
between 0.70 and 0.90 according to Streiner and Norman (2003). Perhaps the
relatively high value could be due to redundancy from two items asking almost
the same question, namely, complications and planning/implementation. Items
regarding sources of knowledge and enteral feeding interventions were not
considered to be measuring the same aspects, which is why homogeneity was
not analyzed. By using an observational procedure, including established criteria
in study II, bias regarding observer reliability has been eliminated as much as
possible.
The result of the scores on the Likert type scale (II) was not considered
severely skewed. Therefore, data was analyzed as if there were intervals without
introducing severe bias, despite the fact that there are no guarantees that the
73
true distance between successive categories are the same. The reliability drops
as fewer categories are used, therefore (the minimum of) five categories was
used in the scale (Streiner & Norman, 2003).
Since three pair-wise comparisons were made (II), we needed to consider the
chance of a type 1 error. To protect against that error, we used a Bonferroni
correction (Munro, 2001). The main weakness with Bonferroni is that the
interpretation of a finding depends on the number of other tests performed
(Perneger, 1998). For small numbers of comparisons (up to five) the use of
Bonferroni is reasonable, but for large numbers it is highly conservative and
would suggest poorly specified research objectives (Altman, 1991). Another
problem is that type I errors cannot decrease without inflating type II errors
(Perneger, 1998).
A combination of latent and manifest content analysis makes the analysis richer,
and interviews and observational protocols are considered the optimum units
of analyses (Graneheim & Lundman, 2004), but in our case, the responses from
open-ended questions were analyzed. A limitation might be that RNs
sometimes tend to write quite briefly, which in a sense makes some of the
answers condensed already and more difficult to interpret (I).
To achieve trustworthiness in the form of credibility, we chose to include special
medical nurses from all municipalities and first-line nurse managers and RNs
from a broad spectrum of contexts. When analyzing, we selected the most
suitable meaning unit. Furthermore, the first author and two of the co-authors
(BWL and MLHL) compared the codes and revised them until agreement was
reached. Dependability in this study was achieved in that all respondents were
given the same information and that the data collection period was quite short.
The findings in the study may be transferable to similar Swedish municipalities
and county councils (I). This is in the eye of the beholder. Furthermore, an
effort was also made to achieve confirmability, the fourth concept, often used
within trustworthiness, by clearly illustrating the evidence and analysis process
that led to the final result (Speziale & Carpenter, 2007).
A limitation might have been that RNs and enrolled nurses (III) and patients
(IV) from only one ICU participated in the GT studies. An over-representation
of women in the study is not in accordance with the ICU in focus, where there
is an over-representation of men, something that might have influenced the
74
result. The median age of 65 years is close to female patients in the studied ICU
during 2006, were the median age was 64 years (men 58 years). Corresponding
for the whole country was 61 years for both women and men (Nolin & Mårdh,
2007).
The reason for interviewing patients with ongoing or recently discontinued EN
(IV), while still in the ICU, was to make sure that the nutritional experiences
dealt with their ICU stay and were not mixed up with nutritional care at the
ward. The data collection period was long, as it was difficult to find patients
alert enough to participate. In study IV, the initial plan was to let the analysis
guide who should be interviewed next (theoretical sampling), but the small
group of patients lead to the decision of including all of them. The difficulty to
find patients also had impact for choosing informants among the nurses. This
highlights one of the problems of studying this group of patients. The
interviews with often performed with one or two enrolled nurses and/or an RN
present in the room during the interviews with the patient. This might have had
an inhibitory effect and influenced the results, but their presence did not seem
to be disturbing, and the result shows a nuanced picture of the nutritional
experiences.
Conducting interviews with patients with communication difficulties can be
challenging and therefore needs extra attention (Philpin et al., 2005). When the
first author, experienced in intensive care and communicating with people with
speech difficulties, such as those following a tracheostomy tube and general
weakness, conducted the interviews, some practical strategies were used.
Despite careful planning of the timing of the interview together with the
patient, the RN and the enrolled nurse, there were unavoidable interruptions
during almost every interview. For example, the patients started to cough and
needed suction or they felt uncomfortable and needed assistance to change
position in bed. In addition, the interview as a scientific method might be
tiresome for a vulnerable patient in an ICU. When a patient became tired or felt
uneasy in some way, the conversation was discontinued and the patient was
allowed to rest. In three out of six interviews with patients who had a
tracheostomy tube, a follow-up interview was carried out to continue
interrupted interviews. For some of the patients the use of their “speaking
valve” was of great help. For others, miming, writing on a paper or using a
pointing board was more convenient.
75
In GT, credibility may be seen as inherent in the method, as the emerging
theory is based on the method of constant comparison in which concepts and
categories repeatedly emerge and guide the continuing research (Glaser &
Strauss, 1967). In this study, the use of the multi-method principle was a way to
further improve the credibility, and the combination of observations, interviews
and memos made the data rich and extensive. In addition, the analysis and
preliminary results were continuously discussed with the two co-authors.
Prior to these studies, the researcher had worked as an RN at the ICU in focus
(III and IV). Being familiar with the actual ICU can be seen as an advantage, as
it makes it possible to identify and reflect on nutritional matters that might have
escaped the attention of a researcher without such a background (Lykkeslet &
Gjengedal, 2007). But the findings may also be biased due to this pre-
understanding. In GT, it is of importance to be aware of one’s pre-
understanding, but also to be able to put it aside. Again, the strength is that
there were ongoing discussions in the research group during the analysis
process.
When saturation was achieved, another two interviews were performed. Had
not this been the case, additional informants might have been necessary. All
participants were Swedish (III and IV), something which might have influenced
the results. There is little known about how persons from other cultures
experience nutritional nursing care in ICU.
However, the studies do not have the ability to embrace every aspect of
nutritional care in an ICU. More research is therefore needed in other ICU
settings to further develop these substantive theories.
76
CONCLUSIONS AND IMPLICATIONS FOR PRACTICE
In conclusion, the findings of this thesis show that the quality and safety of
nutritional nursing care is related to the interactions between the nurse and the
patient, between the nurse and the team members and between the nurse and
the organization.
Nutritional nursing care and the nurse-patient interaction
• The patients’ efforts to make sense of their bothersome nutritional
changes in combination with their involvement indicate a need for
nutritional nursing care focusing on physical, emotional and social
needs. Nurses have a key role in preventing and reducing these
bothersome experiences and in strengthening the patient’s own ability to
handle the situation.
• RNs’ assessments of the patients’ nutritional condition seems to be a
weak link in the nutritional nursing care. Nutritionally compromised
patients may hereby remain unidentified and thus not properly cared for.
Furthermore, the results of the screening and assessment must be a base
for the patient’s care plan.
• The return of the appetite was identified as a milestone in the recovery
process, by the patient and the nurses.
• The patients’ ability to grasp their nutritional situation in different ways
can be promoted by continuous information and explanations to the
patient from an early stage, and throughout the whole recovery process.
It is important to listen to the patient’s preferences and offer options, so
that the patient can make choices. Encouraging the involvement of next
of kins can also be a way of involving the patient.
• In order to have and to hold nutritional control, nurses need to balance
between individual care and routine care.
Nutritional nursing care and the nurse-team interaction
• The teamwork can be both challenging and supporting to the
maintenance and development of nutritional nursing care.
• Good communication between the team members is important for the
patient’s safety.
77
• Nurses and the team members need continuous time for reflection,
development and training in nutritional nursing care.
• Providing safe, supportive nutritional nursing care is indeed a challenge for nurses and team members.
Nutritional nursing care and the nurse-organization interaction
• Guidelines are more well-known among RNs/CNs in county council
care compared to municipal care. Nurses must be aware of and intensify
the use of already existing guidelines.
• Assessment/screening tools are used to a small extent in county council
care and municipal care. The VIPS model can be a guide in the nursing
care for the RNs, but also obstruct the information exchange, indicating
a need for further development. Nutritional nursing care needs to be
improved regarding assessment, screening, intervention and
documentation.
• The quality and safety of nutritional nursing care could be improved by
having a care organization, creating opportunities for continuous
reflection, education and training.
78
Future research
• A quantitative study with a larger sample size to examine nurses’
perceptions of responsibility, knowledge, documentation and
nursing practice regarding enteral nutrition.
• Qualitative and quantitative studies from patients’ as well as
nurses’ and nurse managers’ perspectives on how safe nutritional
care is maintained from ICU to discharge from the hospital.
• A qualitative study focusing on the next of kin’s involvement in
nutritional care within the ICU.
• Qualitative studies on how RNs, enrolled nurses and nurse
managers deal with nutritional matters.
• Further, to develop the substantive theories in other ICU
settings.
• Intervention studies, focusing on nutritional nursing care in
relation to interactions between the nurse and the patient, the
nurse and the team members and the nurse and the organization.
79
SUMMARY IN SWEDISH
Bakgrund
Det övergripande syftet var att erhålla en djupare förståelse av omvårdnad
relaterat till nutrition inom kommunernas och landstingets hälso- och sjukvård
med speciellt fokus på enteral nutrition inom intensivvård. Olika designer och
metoder har använts. Avhandlingen omfattar fyra delstudier vilka refereras till i
texten med romerska siffror (I-IV).
Tillgång till adekvat, säker nutritionsvård av hög kvalitet är en fundamental
rättighet för patienter inom kommunernas och landstingets hälso- och sjukvård.
Tidigare studier visar att bedömning, åtgärder och dokumentation av patienters
näringstillstånd inte alltid görs. Trots tillgång till riktlinjer, olika former av
näringsbehandling och ett multiprofessionellt arbetssätt upptäcks inte alltid
undernärda patienter.
Flertalet patienter på IVA kan inte själva tillgodose sitt behov av näring. Tidig
enteral nutrition (EN) betraktas som en standardbehandling på flertalet
intensivvårdsavdelningar. Svårigheter med tillförsel av näring medför bristande
energiintag för patienterna. Tidigares studier inom intensivvård avseende
nutritionsvård till patienter med EN, har funnit att det är brister avseende
evidensbaserad vård, ansvarsfördelning och kunskaper hos personalen.
Sjuksköterskor har det övergripande ansvaret för patienternas omvårdnad. Att
ge EN delegeras ofta till undersköterskor. Det finns lite forskning om hur
patienter upplever omvårdnad och hur sjuksköterskor och undersköterskor
uppfattar omvårdnaden relaterat till nutrition.
Metod
Kvantitativa och kvalitativa metoder har använts. Telefonintervjuer om
bedömning av patienters nutritionstillstånd genomfördes med medicinskt
ansvariga sjuksköterskor (MAS) (n=14) i fjorton kommuner inom ett län och
första-linjenchefer (n=27) på 28 avdelningar inom ett landsting. Sjuksköterskor
i kommunerna (n=74) och landstinget (n=57) besvarade en enkät angående
nutritionsbedömning och dokumentation (I). Sjuksköterskor (n=44) vid tre
intensivvårdavdelningar besvarade en enkät om ansvar, kunskaper,
dokumentation och omvårdnadsåtgärder för patienter med EN. Observationer
(n=40) av omvårdnadsåtgärder till patienter med pågående EN genomfördes
80
(II). Sjuksköterskor (n=8) (III), undersköterskor (n=4) (III) och patienter
(n=14) (IV) intervjuades (III) och nutritionsvården observerades (III-IV) vid en
intensivvårdsavdelning.
Huvudresultat
Studie I
I kommunerna var det enligt MAS 43% och enligt sjuksköterskorna 58% av
patienterna som var undernärda. Inom landstingets hälso- och sjukvård var
motsvarande siffror för första-linjencheferna 80% och för sjuksköterskorna
87%. Totalt sett var det signifikant fler undernärda patienter inom landstingets
hälso- och sjukvård jämfört med kommunal vård (p= 0.001).
Patienternas nutritionstillstånd bedömdes inte alltid. I kommunerna var det
13% av MAS och 18% av sjuksköterskorna som svarade att samtliga patienter
bedömdes. Inom landstinget svarade 44% av första-linjencheferna och 32% av
sjuksköterskorna att samtliga patienter bedömdes. Signifikant fler inom
landstinget svarade att en nutritionsbedömning gjordes (p = 0.008). Av de 115
chefer/sjuksköterskor som svarade att det endast var särskilda patienter som
bedömdes, angav 88% att det var patientens tillstånd, diagnos, vård/behandling
och ålder som var avgörande för om patienterna bedömdes eller inte. De flesta
bedömningarna genomfördes vid ankomsten och/eller under vårdtiden.
Sextiosex procent av cheferna/sjuksköterskorna svarade att det inte fanns
riktlinjer för nutritionsvården och 13% svarade att de inte kände till om det
fanns riktlinjer. Det var framförallt chefer/sjuksköterskor inom landstinget som
svarade att det fanns riktlinjer (p = 0.005).
Samtliga sjuksköterskor inom landstinget (100%) och flertalet i kommunerna
(97%), svarade att de använde VIPS-modellen för att dokumentera patienternas
omvårdnad. Sjuksköterskor uppfattade VIPS-modellen som en vägledning i
omvårdnadsarbetet men också som ett hinder för informationsutbyte.
Det som vanligtvis dokumenterades angående patienternas nutritionstillstånd
var illamående och kräkning, förmåga att äta och dricka, diarré och svårigheter
att tugga och svälja. Vid omvårdnad av patienter med EN var reflux och
kvarvarande vätskemängd i ventrikeln sällan dokumenterade. Inom
81
kommunerna svarade 23,9% av sjuksköterskorna att de alltid och 59,2% att de
ibland dokumenterade om patienterna var undernärda. I landstinget svarade
14,5% av sjuksköterskorna att de alltid och 56,4% att de ibland dokumenterade
motsvarande uppgifter.
Användandet av instrument för bedömning/screening var lågt inom såväl
kommunal som landstingets hälso- och sjukvård.
Studie II
Flertalet sjuksköterskor vid tre intensivvårdsavdelningar svarade att det fanns
skriftliga riktlinjer för enteral nutrition (EN) och att det var en sjuksköterska
med särskilt ansvar för nutritionsfrågor på intensivvårdsavdelningen.
Sjuksköterskornas kunskaper om EN hade erhållits framförallt av kollegor. Det
var skillnader mellan sjuksköterskornas uppfattningar med avseende på deras
ansvar, kunskaper och dokumentation vid de olika intensivvårdsavdelningarna.
Sjuksköterskorna hämtade information om medicinering genom sond från
FASS (68%), broschyr tillhandahållen av apoteket (41%), läkare och
sjuksköterskor (32%) och apoteket (7%).
Efter nedläggning av sond kontrollerade sjuksköterskorna sondläget genom
inblåsning av luft i sonden samtidigt som de med ett stetoskop lyssnade över
magen (86%). Sondens läge kontrollerades också med röntgen (73%), eller
genom aspiration av magsäcksinnehåll (23%).
Flertalet sjuksköterskor (95%) svarade att patienterna placerades i en speciell
ställning i sängen under tiden EN pågick. Det var elva procent som
specificerade att patientens huvudända höjdes till 30 grader eller mer.
Observationerna visade att huvudändan var höjd 30 grader eller mer vid sju av
40 observationer. I genomsnitt var höjningen av huvudändan 20.7 grader.
Observationerna visade att sonden tejpades fast ordentligt. Vid 39 av obser-
vationer var sonden tejpad så att den inte “drog” i näsan. Sonden var dock inte
märkt vid någon av observationerna.
Vid samtliga observationer användes sondmatningsaggregat och alla sond-
matningspumparna var märkta med “endast för sond”, dock inte alltid på
82
svenska. Trettioen av 38 sondmatningssprutor var märkta med “endast för
sond” och 30 av 38 observationer visade att sondsprutan var bytt inom det
senaste 24 timmarna.
Studie III
En substantiv teori utvecklades över sjuksköterskors och undersköterskors
omsorg och strategier avseende deras omvårdnad relaterat till nutrition för
patienter med EN inom IVA. Denna inkluderar kärnkategorin ”att få och behålla
kontroll over nutritionen – en balans mellan individuell vård och rutinstyrd vård” och
kategorierna ”känna patienten”, ”underlätta patientens medverkan”, ”vara en i teamet”,
”vara trygg i yrkesrollen” och ”ha en stödjande organisation”. För att sjuksköterskor
och undersköterskor ska uppleva kontroll över patientens omvårdnad i relation
till nutrition krävs balans mellan rutinstyrd och individuell vård. När balansen
uppnås, känner sjuksköterskorna och undersköterskorna att patientens
välmående, trygghet och vårdkvalitet ökar. När balansen inte uppnås,
exempelvis när den rutinstyrda vården tar över den individuella vården, känner
sjuksköterskorna och undersköterskorna sig inte nöjda.
Att känna till patientens nutritionstillstånd avseende historia, behov och önskemål,
samt hur de tolererar den nutritionsbehandling som ges är utgångspunkt för
omvårdnaden. Genom att skapa möjligheter för patienten att göra val kan
hans/hennes delaktighet i omvårdnaden underlättas. Patienten uppmuntras till att
själva äta och dricka. Om riktlinjer följs till punkt och pricka kan det innebära
att patientens egen vilja inte tillgodoses. Att vara en i teamet innebär att det finns
möjlighet att söka dialog och samarbete, inom eller utanför den egna
yrkesgruppen. Teamets kunskaper, attityder och värderingar påverkar
omvårdnaden. Känslan av att vara trygg i sin yrkesroll är relaterat till kunskaper
och erfarenheter. Att ha en stödjande organisation som tillhandahåller en
stimulerande miljö, diverse olika metoder och tekniker, kontinuitet bland
personalen samt kanaler för informationsutbyte är av betydelse för att
patienterna ska erhålla näringsintag på ett säkert sätt.
Studie IV En substantiv teori utvecklades över patienters erfarenheter av nutritionsvård.
Teorin inkluderar kärnkategorin ”att få grepp om nutritionen under tillfrisknandet”
och kategorierna ”möta nutritionsförändringar”, ”förstå nutritionssituationen” och ”delta
i nutritionsvården”. Patienterna skiftar känslomässigt mellan oro, rädsla och
83
misslyckande och lättnad och hopp. När aptiten återvänder, sonden avlägsnas
och magen och tarmarna kommer igång upplevs det som vändpunkter och att
de är på bättringsvägen. Resultatet visar att det är ett mål för patienterna att få
grepp om sin egen nutrition under tillfrisknandet. Nutritionsutmaningarna varierar
och kan komma och gå beroende på deras allmänna hälsotillstånd. Patienterna
försöker förstå sitt nutritionsstillstånd och sina upplevelser, genom att medvetet
använda sig av olika strategier. Deras involvering i nutritionsvården speglar en
process som går från att inte alls vara involverad till att delvis vara involverad
och som hänger ihop med patienternas allmänna tillstånd.
Nutritionsförändringar gör patienterna medvetna om att de behöver
nutritionsvård. Att vara törstig är ett uttalat bekymmer, förenat med en stark
längtan efter att få dricka sig otörstiga. Det är därför en stor lättnad när de får
börja dricka, även om det visar sig vara svårt att dricka tillräckligt. Patienternas
ätproblem varierar från att ha svårigheter med att hantera maten på tallriken,
föra maten till munnen samt att svälja. Rädsla för misslyckanden beskrevs. Att
ha förändrad aptit innebär allt från att inte ha någon aptit alls till att vara väldigt
hungrig. Hur maten luktar och smakar, liksom på vilket sätt den serveras, är av
betydelse för patienternas aptit. Besvär i form av illaluktande gaser, magsmärtor
och problem med tarmtömning, diarre och förstoppning upplevs som
obehagligt och påverkar ätandet negativt. Att försöka förstå nutritionstillståndet
behövs för att återfå något av greppet om nutritionen. När patienterna
reflekterar över sin situation finner de att mat och näring är en viktig del i deras
liv och för att tillfriskna. Nutritionsvården jämförs med deras tidigare
erfarenheter. Patienterna vill också förstå i vilken utsträckning de får sitt
näringsbehov mättat och hur vikten påverkas. Känslorna under denna fas
pendlar mellan oro och trygghet. Att delta i nutritionsvården är ytterligare en
strategi som beskrivs för att återfå greppet om nutritionen. Det finns patienter
som inte vill vara med och ta några beslut beträffande sin nutritionsbehandling.
Detta överlåter de till personalen. Beslutet baseras på att de är för sjuka, inte
orkar eller inte vill, samtidigt som de litar på personalen. Andra patienter gör sin
stämma hörd och påverkar exempelvis vilken mat och dryck de ska äta, samt
hur stora portionerna ska vara.
84
Sammanfattningsvis visar resultaten av avhandlingen att kvalitet och säkerhet vid omvårdnad relaterat till nutrition omfattas av interaktion mellan sjuksköterska/undersköterska och patient, mellan sjuksköterska/under-sköterska och teamet, samt mellan sjuksköterska/undersköterska och organisationen.
Omvårdnad relaterat till nutrition och interaktionen mellan sjuksköterska/undersköterska
och patient
• Patientens försök att erhålla förståelse för sina obehagliga nutritionsförändringar i kombination med deras egen delaktighet indikerar att det finns behov av omvårdnad i relation till nutrition med fokus på fysiska, känslomässiga och sociala behov. Sjuksköterskor har en viktig roll i att förebygga och minska dessa obehagliga erfarenheter och att stärka patientens egen förmåga att hantera situationen.
• Sjuksköterskornas bedömningar av patienternas nutritionstillstånd framstår som en svag länk i omvårdnaden relaterat till nutrition. Patienter med försämrad nutrition kan därmed förbli oidentifierade och inte få adekvat omvårdnad. Patientens vård ska planeras och genomföras utifrån bedömningarna.
• När patienterna återfår sin aptit betraktas det som en milstolpe för tillfrisknandet, av såväl patienter som sjuksköterskor och undersköterskor.
• Patienternas förmåga att förstå sitt nutritionstillstånd kan underlättas om patienterna får kontinuerlig information under hela vårdtiden. Det är viktigt att lyssna på patientens önskemål och erbjuda alternativ. Att uppmuntra närståendes delaktighet kan också vara ett sätt att engagera patienten.
• För att kunna behålla kontrollen över nutritionen behöver sjuksköterskor och undersköterskor balansera mellan individuell vård och rutinstyrd vård.
85
Omvårdnad relaterat till nutrition och interaktionen mellan sjuksköterska/undersköterska
och teamet
• Teamets samarbete kan både vara utmanande och stödjande för att upprätthålla och utveckla omvårdnad relaterat till nutrition.
• Bra kommunikation mellan medlemmarna i teamet är viktigt för patientsäkerheten.
• Sjuksköterskor, undersköterskor och övriga medlemmar i teamet behöver tid för kontinuerlig reflektion, utveckling och träning.
• Att tillhandahålla säker och stödjande nutrition är en utmaning för sjuksköterskor, undersköterskor och övriga teammedlemmar.
Omvårdnad relaterat till nutrition och interaktionen mellan sjuksköterska/
undersköterska och organisationen
• Fler sjuksköterskor/första-linjenchefer inom landstingets hälso- och sjukvård känner till att det finns riktlinjer för nutritionsvård jämfört med sjuksköterskor/MAS inom kommunal vård. Sjuksköterskorna måste bli medvetna om och i större omfattning använda existerande riktlinjer.
• Bedömningsinstrument används i liten utsträckning inom landstingets och kommunernas hälso- och sjukvård. VIPS-modellen kan vara en vägledning i omvårdnadsarbetet för sjuksköterskorna, men hindrar också informationsutbyte. Detta indikerar behovet av VIPS-modellens utveckling. Omvårdnad relaterat till nutrition måste förbättras när det gäller screening/ bedömning, intervention och dokumentation av patientens nutritionsstatus.
• Kvaliteten och säkerheten avseende omvårdnad relaterat till nutrition kan förbättras om det finns en organisation som möjliggör kontinuerlig reflektion, utbildning och träning.
86
ACKNOWLEDGEMENT
This thesis was carried out at the Department of Nursing, Karlstad University. I wish to express my sincere gratitude to all those who have supported me in the studies. In particular I am grateful to: All the respondents who participated in the studies. Without you, this research would not have been possible. Associate Professor Marie Louise Hall-Lord, my principal supervisor (initially my supervisor) and Professor Bodil Wilde-Larsson, my supervisor (initially my principal supervisor) for excellent scientific guidance and mentorship, and for sharing your knowledge, experience and wisdom. Mrs Annelie Ekberg-Andersson for years of invaluable help with reference, articles, EndNote and RefWorks. Mrs Katarina Wiberg-Hedman for statistical guidance. Mrs Ellinor Larsen for language revision throughout the work. Also Jeanette Palm for revising a manuscript. Camilla Pålsson for IT support. Anki Ramberg for administrative help. The University of Karlstad, Faculty of Social and Life Sciences, Department of Nursing. Professor Elsy Athlin for accepting me as a doctoral student and Professor Gun Nordström, thank you for giving me the opportunity to complete my PhD. Thank you both for sharing your scientific knowledge during seminars. Head of Department Anki Normarker for interest and support. All senior lecturers, lecturers and administrative staff, thank you for your support and friendship. My former colleagues at the ICU, the Central Hospital in Karlstad, for support in my research and for friendship over the years. It was here my interest for nutritional nursing care and documentation began and was allowed to expand. Carina Bååth, my co-author and friend, for your interest in nutrition and assessment and for lively discussions about everything under the sun. Fellow doctoral students during the years: Ann-Kristin “Fia” Sandin-Bojö, Anna Josse Eklund, Anna Nordin, Ann Karin Helgesen, Bente Thyli, Bente Weimand, Carina Bååth, Catarina Wallengren-Gustavsson, Cecilia Olsson, Ingrid From, Karin Högberg, Kaisa Bjuresäter, Kristina Rosengren, Lina Palmér, Linda Kvist, Maria Larsson, Maria Henricsson, Monica Björkström, Patrice Anderberg, Randi Ballangrud, Reidun Hov, Sepideh Olausson, Sigrid Wangensteen and Vigdis Abrahamsen-Grøndahl. Thank you for all the lively, inspiring discussions and valuable criticism at seminars. Bo Nilsson for support and interesting discussions about research. My family and friends. Thank you for all your support, nice get-togethers and fun. You gave me energy when I needed it most.
87
Inga my mother, for always believing in me and being caring and supportive. My dear sister Marie with family. Thank you for support and happy moments throughout the years. Max and Yvonne, thank you for all your encouragement and interest in my research and for all the fabulous football matches you have involved me in. Thank you for reminding me what is important in life. Andreas and Erik, for always being positive and supporting. Daniel, for marrying me in the midst of my studies, for always being there, patient, listening, encouraging and loving. I love you! Wilma, our Newfoundland dog, a friend indeed. Lastly I would like to express my gratitude for financial support received from the Centre for Clinical Research at the Central Hospital of Karlstad, the Swedish Association of Health Professionals, the County Council of Värmland and Karlstad University.
88
REFERENCES
Adam, S. (2000). Standardization of nutritional support: Are protocols useful? Intensive & Critical Care Nursing, 16(5), 283-289.
Adam, S., & Batson, S. (1997). A study of problems associated with the delivery of enteral feed in critically ill patients in five ICUs in the UK. Intensive Care Medicine, 23(3), 261-266.
Adams, N. E., Bowie, A. J., Simmance, N., Murray, M., & Crowe, T. C. (2008). Recognition by medical and nursing professionals of malnutrition and risk of malnutrition in elderly hospitalised patients. Nutrition & Dietetics, 65(2), 144-150.
Akner, G., Cederholm, T., Mossberg, T., & Rothenberg, E. (2000). Behandling av undernäring inom äldreomsorgen. In. Näringsproblem i vård & omsorg: Prevention och behandling: SoS-rapport 2000:11 (pp. 70-85). Stockholm: Socialstyrelsen.
Alfengård, K., & Klevsgård, R. (2005). Nutrition in somatic and social care investigation of routines and needs for education about nutrition in somatic care at hospitals and somatic and social care of elderly patients in one county in the south of Sweden. Vård i Norden: Nordic Journal of Nursing Research, 25(2), 42-47.
Allison, P., & Stanga, Z. (2004). Organization of nutritional care. In. L. Sobotka (Ed.), Basics in clinical nutrition (3rd ed. pp. 135-139). Prague: Galen (ESPEN Book).
Almerud, S., Alapack, R. J., Fridlund, B., & Ekebergh, M. (2007). Of vigilance and invisibility - being a patient in technologically intense environments. Nursing in Critical Care, 12(3), 151-158.
Altman, D. (1991). Practical statistics for medical research. London: Champman & Hall.
Andersson, C. (2004). Kvalitetsuppföljning av sjukskötersekprogrammet vid Karlstads universitet. Karlstad: Institutionen för hälsa och vård, Karlstads universitet.
Antonovsky, A., & Elfstadius, M. (2005). Hälsans mysterium [Unraveling the mystery of health.] (2nd ed.). Stockholm: Natur och kultur.
Atwal, A., & Caldwell, K. (2006). Nurses’ perceptions of multidisciplinary team work in acute health-care. International Journal of Nursing Practice, 12(6), 359-365.
89
Bachrach-Lindström, M., Jensen, S., Lundin, R., & Christensson, L. (2007). Attitudes of nursing staff working with older people towards nutritional nursing care. Journal of Clinical Nursing, 16(11), 2007-2014.
Bahtsevani, C. (2008). In search of evidence-based practices: Exploring factors influencing evidence-based practice and implementation of clinical practice guidelines. Diss. Malmö: Faculty of Health and Society.
Ballard, K. S. (1981). Identification of environmental stressors for patients in a surgical intensive care unit. Issues in Menthal Health Nursing, 3(1-2), 89-108.
Barendregt, K., Soeters, P. B., & Allison, S. P. (2004). Influence of malnutrition on physiological function. In. L. Sobotka (Ed.), Basics in clinical nutrition (3rd ed. pp. 18-20). Prague: Galen (ESPEN Book).
Bavelaar, J. W., Otter, C. D., Bodegraven, A. A., Thijs, A., & Schueren, M. A. (2008). Diagnosis and treatment of (disease-related) in-hospital malnutrition: The performance of medical and nursing staff. Clinical Nutrition, 27(3), 431-438.
Beauchamp, T., & Childress, J. (2001). Principles of biomedical ethics. New York: Oxford University Press.
Beck, A. M., Balknas, U. N., Furst, P., Hasunen, K., Jones, L., Keller, U., et al. (2001). Food and nutritional care in hospitals: How to prevent undernutrition-report and guidelines from the Council of Europe. Clinical Nutrition, 20(5), 455-460.
Benner, P., Stannard, D., & Hooper-Kyriakidis, P. (1999). Clinical wisdom and interventions in critical care : A thinking-in-action approach. Philadelphia: W. B. Saunders.
Benner, P., Tanner, C. A., & Chesla, C. A. (1996). Expertise in nursing practice : Caring, clinical judgment, and ethics. New York, NY: Springer Pub. Co.
Bergbom, I. (2007). Intensive and critical care nursing. Intensive and Critical Care Nursing, 23(3), 121-123.
Berger, M. M., Chiolero, R. L., Pannatier, A., Cayeux, M. C., & Tappy, L. (1997). A 10-year survey of nutritional support in a surgical ICU: 1986-1995. Nutrition, 13(10), 870-877.
Berland, A., & Natvig, G. K. (2005). Ensuring patient safety [norwegian]. Vård i Norden: Nordic Journal of Nursing Research, 25(3), 33-38.
Berland, A., Natvig, G. K., & Gundersen, D. (2008). Patient safety and job-related stress: A focus group study. Intensive & Critical Care Nursing, 24(2), 90-97.
90
Binnekade, J. M., Tepaske, R., Bruynzeel, P., Mathus-Vliegen, E., & de Hann, R. J. (2005). Daily enteral feeding practice on the ICU: Attainment of goals and interfering factors. Critical Care, 9(3), 218-225.
Bliss, D. (1882). Feeding per rectum. The Medical Record, 22, 64-67.
Boström, A. (2007). Evidence-based care of older people - utopia or reality? healtcare personnel's perceptions of using research in their daily practice. Stockholm: Department of neurobiology, care sciences and society, division of nursing Karolinska institutet.
Boström, A., Wallin, L., & Nordström, G. (2007). Evidence-based practice and determinants of research use in elderly care in sweden. Journal of Evaluation in Clinical Practice, 13(4), 665-673.
Boström, I., Hall-Lord, M., Larsson, G., & Wilde, B. (1992). Nursing theory based on changes of work organisation in an ICU: Effects on quality of care. Intensive and Critical Care Nursing, 8(1), 10-16.
Bottoni, A., Bottoni, A., Cassulino, A. P., Biet, F., Sigulem, D. M., Oliveira, G., et al. (2008). Impact of nutrition support teams on hospitals' nutritional support in the largest south american city and its metropolitan area. Nutrition, 24(3), 224-232.
Bourgault, A. M., Ipe, L., Weaver, J., Swartz, S., & Dea, P. J. (2007). Development of evidence-based guidelines and critical care nurses' knowledge of enteral feeding. Critical Care Nurse, 27(4), 17.
Bradburn, B. G., & Hewitt, P. B. (1980). The effect of the intensive therapy ward environment on patients' subjective impression: A follow-up study. Intensive Care Medicine, 7(1), 15-18.
Brantervik, A. M., Jacobsson, I. E., Grimby, A., Wallen, T. C. E., & Bosaeus, I. G. (2005). Older hospitalised patients at risk of malnutrition: Correlation with quality of life, aid from the social welfare system and length of stay? Age and Ageing, 34(5), 444-449.
Bruun, L. I., Bosaeus, I., Bergstad, I., & Nygaard, K. (1999). Prevalence of malnutrition in surgical patients: Evaluation of nutritional support and documentation. Clinical Nutrition, 18(3), 141-147.
Bullough, V. L., & Bullough, B. (1979). The care of the sick: The emergence of moderns nursing. London: Neale Watson Academic Publications.
Cederholm, T. (2006). Undernäring inom svensk sjukvård: Värdering av evidensläget ger tydligt resultat: Hög tid satsa på klinisk nutrition! Läkartidningen, 21-22(103), 1713-1717.
91
Cederholm, T., & Rothenberg, E. (2000). Diagnostik, behandling och uppföljning. In. Näringsproblem i vård & omsorg: Prevention och behandling: SoS-rapport 2000:11 (pp. 41-44). Stockholm: Socialstyrelsen.
Chaboyer, W. P., & Patterson, E. (2001). Australian hospital generalist and critical care nurses' perceptions of doctor-nurse collaboration. Nursing & Health Sciences, 3(2), 73-79.
Christensson, L., Ek, A., & Unosson, M. (2001). Individually adjusted meals for older people with protein-energy malnutrition: A single-case study. Journal of Clinical Nursing, 10(4), 491-502.
Christensson, L., Unosson, M., Bachrach-Lindström, M., & Ek, A. (2003). Attitudes of nursing staff towards nutritional nursing care. Scandinavian Journal of Caring Sciences, 17(3), 223-231.
Christensson, L., Unosson, M., & Ek, A. (2002). Evaluation of nutritional assessment techniques in elderly people newly admitted to municipal care. European Journal of Clinical Nutrition, 56(9), 810.
Christensson, L., Ödlund Olin, A., & Unosson, M. (2007). Kvalitetsindikatorer för prevention av undernäring. In. E. Idvall (Ed.), Kvalitetsindikatorer inom omvårdnad (pp. 155-165). Stockholm: Gothia.
Clendening, L. (1942). Source book of medical history. New York: Dover Publications.
Cook, D. J., Meade, M. O., Hand, L. E., & McMullin, J. P. (2002). Toward understanding evidence uptake: Semirecumbency for pneumonia prevention. Critical Care Medicine, 30(7), 1472-1477.
Correia, M. I., & Waitzberg, D. L. (2003). The impact of malnutrition on morbidity, mortality, length of hospital stay and costs evaluated through a multivariate model analysis. Clinical Nutrition, 22(3), 235-239.
Council of Europe. (2003). Resolution ResAP(3) on food and nutritional care in hospitals. Retrieved 09/03, 2008, from http://www.nutritionday.org/uploads/media/Resolution_of_the_Council_of_Europe.pdf
Cronbach, L. (1951). Coefficient alpha and the internal structure of tests. Psychometrika, 16, 297-334.
Currey, J., Browne, J., & Botti, M. (2006). Haemodynamic instability after cardiac surgery: Nurses’ perceptions of clinical decision-making. Journal of Clinical Nursing, 15(9), 1081-1090.
92
De Jonghe, B., Appere-De-Vechi, C., Fournier, M., Tran, B., Merrer, J., Melchior, J. C., et al. (2001). A prospective survey of nutritional support practices in intensive care unit patients: What is prescribed? What is delivered? Critical Care Medicine, 29(1), 8-12.
Denzin, N. K. (1970). The research act : A theoretical introduction to sociological methods. Chicago: Aldine Publishing.
Detsky, A. S., McLaughlin, J. R., Baker, J. P., Johnston, N., Whittaker, S., Mendelson, R. A., et al. (1987). What is subjective global assessment of nutritional status? Journal of Parenteral and Enteral Nutrition, 11(1), 8-13.
Dillon, A., Munro, C. L., & Grap, M. J. (2002). Nurses' accuracy in estimating backrest elevation. American Journal of Critical Care, 11(1), 34-37.
Dudek, S. G. (2006). Nutrition essentials for nursing practice. Philadelphia: Lippincott.
Eckerlund, I., & Stig, K. (2000). Hälsoekonomiska aspekter på undernäring. In. Näringsproblem i vård & omsorg: Prevention och behandling: SoS-rapport 2000:11 (pp. 59-65). Stockholm: Socialstyrelsen.
Edvardsson, J. D., Sandman, P., & Rasmussen, B. H. (2005). Sensing an atmosphere of ease: A tentative theory of supportive care settings. Scandinavian Journal of Caring Sciences, 19(4), 344-353.
Ehnfors, M., Ehrenberg, A., & Thorell-Ekstrand, I. (2000). VIPS-boken. Stockholm: Vårdförbundet.
Ehnfors, M., Thorell Ekstrand, I., & Ehrenberg, A. (1991). Towards basic nursing information in patient records. Vård i Norden: Nordic Journal of Nursing Research, 11(3), 12-31.
Ehrenberg, A. (1986). Mätning av omvårdnadskvalitet. Falun: Falu lasarett.
Ehrenberg, A., & Birgersson, C. (2003). Nursing documentation of leg ulcers: Adherence to clinical guidelines in a swedish primary health care district. Scandinavian Journal of Caring Sciences, 17(3), 278-284.
Ehrenberg, A., Ehnfors, M., & Thorell Ekstrand, I. (1996). Nursing documentation in patient records: Experience of the use of the VIPS model. Journal of Advanced Nursing, 24(4), 853-867.
Elia, M. (Ed.). (2000). Guidelines for detection and management of malnutrition (1st ed.). Maidenhead: Malnutrition Advisory Group (MAG). A Standing Committee of BAPEN.
93
Elia, M., Zellipour, L., & Stratton, R. J. (2005). To screen or not to screen for adult malnutrition? Clinical Nutrition, 24(6), 867-884.
Elliott, D., Mudaliar, Y., & Kim, C. (2004). Examining discharge outcomes and health status of critically ill patients: Some practical considerations. Intensive & Critical Care Nursing, 20(6), 366-377.
Elmståhl, S. (2000). Undernäring- prevalence och incidens. In. Näringsproblem i vård & omsorg: Prevention och behandling: SoS-rapport 2000:11 (pp. 110-117). Stockholm: Socialstyrelsen.
Elpern, E. H., Stutz, L., Peterson, S., Gurka, D. P., & Skipper, A. (2004). Outcomes associated with enteral tube feedings in a medical intensive care unit. American Journal of Critical Care, 13(3), 221-227.
Emanuelsson, K., & Lindencrona, C. (2000). Elderly and nutrition: Documentation in acute medical community care. A case-study of when cared for in own home [corrected] [published erratum appears in VÅRD I NORDEN 2000; 20(3): 28] [swedish]. Vård i Norden: Nordic Journal of Nursing Research, 20(2), 29-34.
Endacott, R. (1999). Roles of the allocated nurse and shift leader in the intensive care unit: Findings of an ethnographic study. Intensive and Critical Care Nursing, 15(1), 10-18.
Engel, J. M., Muhling, J., Junger, A., Menges, T., Karcher, B., & Hempelmann, G. (2003). Enteral nutrition practice in a surgical intensive care unit: What proportion of energy expenditure is delivered enterally? Clinical Nutrition, 22(2), 187-192.
Engström, Å, & Söderberg, S. (2007). Close relatives in intensive care from the perspective of critical care nurses. Journal of Clinical Nursing, 16(9), 1651-1659.
Feldt, A. (1999). Sjuksköterskans dokumentation inom intensivvården. Karlstad: Landstinget i Värmland.
Florin, J., Ehrenberg, A., & Ehnfors, M. (2005). Patients' and nurses' perceptions of nursing problems in an acute care setting. Journal of Advanced Nursing, 51(2), 140-149.
Florin, J., Ehrenberg, A., & Ehnfors, M. (2006). Patient participation in clinical decision-making in nursing: A comparative study of nurses' and patients' perceptions. Journal of Clinical Nursing, 15(12), 1498-1508.
Fulbrook, P., Bongers, A., & Albarran, J. W. (2007). A European survey of enteral nutrition practices and procedures in adult intensive care units. Journal of Clinical Nursing, 16(11), 2132-2141.
94
Furåker, C., & Berntsson, L. (2003). Ward managers' goals and work content [swedish]. Vård i Norden Nordic Journal of Nursing Research, 23(3), 27-32.
Gardulf, A., Orton, M., Eriksson, L. E., Undén, M., Arnetz, B., Kajermo, K. N., et al. (2008). Factors of importance for work satisfaction among nurses in a university hospital in sweden. Scandinavian Journal of Caring Sciences, 22(2), 151-160.
Giner, M., Laviano, A., Meguid, M. M., & Gleason, J. R. (1996). In 1995 a correlation between malnutrition and poor outcome in critically ill patients still exists. Nutrition, 12(1), 23-29.
Glaser, B. (1978). Theoretical sensitivity: Advances in the methodology of grounded theory. Mill Valley, Calif.: The Sociology Press.
Glaser, B. (1992). Basics of grounded theory analysis : Emergence vs forcing. Mill Valley, Calif.: Sociology Press.
Glaser, B. G., & Strauss, A. L. (1967). The discovery of grounded theory : Strategies for qualitative research. Chicago: Aldine.
Graneheim, U. H., & Lundman, B. (2004). Qualitative content analysis in nursing research: Concepts, procedures and measures to achieve trustworthiness. Nurse Education Today, 24(2), 105-112.
Grap, M. J., Cantley, M., Munro, C. L., & Corley, M. C. (1999). Use of backrest elevation in critical care: A pilot study. American Journal of Critical Care, 8(1), 475-480.
Grap, M. J., Munro, C. L., Bryant, S., & Ashtiani, B. (2003). Predictors of backrest elevation in critical care. Intensive and Critical Care Nursing, 19, 68-74.
Green, S. M., & Watson, R. (2005). Nutritional screening and assessment tools for use by nurses: Literature review. Journal of Advanced Nursing, 50(1), 69-83.
Greenhalgh, T., Robert, G., MacFarlane, F., Bate, P., & Kyriakidou, O. (2004). Diffusion of innovations in service organizations: Sytematic review and recommendations. The Milbank Quarterly, 82(4), 581-629.
Guigoz, Y., Vellas, B., & Garry, P. (1994). Mini nutritional assessment: A practical assessment tool for grading the nutritional state of elderly patients. In. B. Vellas (Ed.), The mini nutritional assesment (MNA) (pp. 15-59). Paris: Serdi Publisher.
Halcomb, E., & Andrew, S. (2005). Triangulation as a method for contemporary nursing research. Nurse Researcher, 13(2), 71-82.
95
Hansson, A., & Wenström, Y. (2005). Implementing clinical guidelines for nutrition in a neurosurgical intensive care unit. Nursing & Health Sciences, 7(4), 266-272.
Happ, M. B., Swigart, V. A., Tate, J. A., Hoffman, L. A., & Arnold, R. M. (2007). Patient involvement in health-related decisions during prolonged critical illness. Research in Nursing & Health, 30(4), 361-372.
Henderson, V. (1991). The nature of nursing : A definition and its implications for practice, research, and education : Reflections after 25 years. New York: National League for Nursing.
Heyland, D. K. (1998). Nutritional support in the critically ill patients. A critical review of the evidence. Critical Care Clinics, 14(3), 423-440.
Hofhuis, J. G. M., Spronk, P., van Stel, H., Schrijvers, A. J. P., Rommes, J., & Bakker, J. (2008a). Experiences of critically ill patients in the ICU. Intensive and Critcal Care Nursing, 24(5), 300-313.
Hofhuis, J. G. M., Spronk, P. E., Van Stel, H. F., Schrijvers, G. J. P., Rommes, J. H., & Bakker, J. (2008b). The impact of critical illness on perceived health-related quality of life during ICU treatment, hospital stay, and after hospital discharge. Chest, 133(2), 377-385.
Hoghaug, G., & Fagermoen, M. (2007). Overflytting fra intensivavdelnling til sengpost: Pasienters erfaringer og informasjonsbehov. Norsk Tidsskrift for Sykepleieforskning, 9(3), 3-14.
Howard, P., Jonkers-Schuitema, C., Furniss, L., Kyle, U., Muehlebach, S., Ödlund-Olin, A., et al. (2006). Managing the patient journey through enteral nutritional care. Clinical Nutrition, 25(2), 187-195.
Hupcey, J. E. (1999). Looking out for the patient and ourselves - the process of family integration into the ICU. Journal of Clinical Nursing, 8(3), 253-262.
Hupcey, J. E. (2000). Feeling safe: The psychosocial needs of ICU patients. Journal of Nursing Scholarship, 32(4), 361-367.
Ista, P., Jassin, S., Noel, F., & Preiser, J. (2002). Management and knowledge of enteral nutrition in intensive care units in a city in Belgium. Nutrition in Clinical Practice, 17(1), 32-37.
Jain, M. K., Heyland, D., Dhaliwal, R., Day, A. G., Drover, J., Keefe, L., et al. (2006). Dissemination of the Canadian clinical practice guidelines for nutrition support: Results of a cluster randomized controlled trial. Critical Care Medicine, 34(9), 2362-2369.
96
Jansson, L., & Norberg, A. (1989). Ethical reasoning concerning the feeding of terminally ill cancer patients: Interviews with registered nurses experienced in the care of cancer patients. Cancer Nursing, 12(6), 352-358.
Jansson, L., & Norberg, A. (1992). Ethical reasoning among registered nurses experienced in dementia care. Scandinavian Journal of Caring Sciences, 6(4), 219-227.
Jeejeebhoy, K. N. (2000). Nutritional assessment. Nutrition, 16 (7/8), 585-590.
Johansen, N., Kondrup, J., Plum, L. M., Bak, L., Norregaard, P., Bunch, E., et al. (2004). Effect of nutritional support on clinical outcome in patients at nutritional risk. Clinical Nutrition, 23(4), 539-550.
Johansson, L., & Fjellman Wiklund, A. (2005). Ventilated patients' experiences of body awareness at an intensive care unit. Advances in Physiotherapy, 7(4), 154-161.
Johansson, U., Larsson, J., Rothenberg, E., Stene, C., Unosson, M., & Bosaeus, I. (2006). Nutritionsbehandling inom slutenvården: Svenska sjukhus klarar inte europaradets riktlinjer. Läkartidningen, 103(21-22), 1718-1724.
Jones, J. M. (2002). The methodology of nutritional screening and assessment tools. Journal of Human Nutrition and Dietetics: The Official Journal of the British Dietetic Association, 15(1), 59-71.
Jordan, S., Snow, D., Hayes, C., & Williams, A. (2003). Introducing a nutrition screening tool: An exploratory study in a district general hospital. Journal of Advanced Nursing, 44(1), 12-23.
Kajermo, K. N., Nordström, G., Krusebrant, A., & Lützén, K. (2001). Nurses' experiences of research utilization within the framework of an educational programme. Journal of Clinical Nursing, 10(5), 671-681.
Kajermo, K. N., Undén, M., Gardulf, A., Eriksson, L. E., Orton, M., Arnetz, B. B., et al. (2008). Predictors of nurses’ perceptions of barriers to research utilization. Journal of Nursing Management, 16(3), 305-314.
Karkkainen, O., & Eriksson, K. (2005). Recording the content of the caring process. Journal of Nursing Management, 13(3), 202-208.
Karlsson, V., & Forsberg, A. (2008). Health is yearning-experiences of being conscious during ventilator treatment in a critical care unit. Intensive & Critical Care Nursing, 24(1), 41-50.
Kayser-Jones, J. (2002). Malnutrition, dehydration, and starvation in the midst of plenty: The political impact of qualitative inquiry. Qualitative Health Research, 12(10), 1391-1405.
97
Kimchi, J., Polivka, B., & Stevenson, J. S. (1991). Triangulation: Operational definitions. Nursing Research, 40(6), 364-366.
Kitson, A., Harvey, G., & McCormack, B. (1998). Enabling the implementation of evidence based practice: A conceptual framework. Quality in Health Care, 7(3), 149-158.
Kondrup, J., Allison, S. P., Elia, M., Vellas, B., & Plauth, M. (2003). ESPEN guidelines for nutrition screening 2002. Clinical Nutrition, 22(4), 415-421.
Kondrup, J., Johansen, N., Plum, L. M., Bak, L., Larsen, I. H., Martinsen, A., et al. (2002). Incidence of nutritional risk and causes of inadequate nutritional care in hospitals. Clinical Nutrition, 21(6), 461-468.
Korner, U., Bondolfi, A., Buhler, E., Macfie, J., Meguid, M. M., Messing, B., et al. (2006). Ethical and legal aspects of enteral nutrition. Clinical Nutrition, 25(2), 196-202.
Kowanko, I., Simon, S., & Wood, J. (1999). Nutritional care of the patient: Nurses' knowledge and attitudes in an acute care setting. Journal of Clinical Nursing, 8(2), 217-224.
Kreymann, K. G. (2008). Early nutrition support in critical care: A european perspective. Current Opinion in Clinical Nutrition and Metabolic Care, 11(2), 156-159.
Kreymann, K. G., Berger, M. M., Deutz, N. E., Hiesmayr, M., Jolliet, P., Kazandjiev, G., et al. (2006). ESPEN guidelines on enteral nutrition: Intensive care. Clinical Nutrition, 25(2), 210-223.
Kuosma, K., Hjerrild, J., Pedersen, P., & Andresson Hundrup, Y. (2008). Assessment of the nutritional status among residents in a danish nursing home - health effects of a formulated food and meal policy. Journal of Clinical Nursing, 17(17), 2288-2293.
Kyle, U. G., Genton, L., Heidegger, C. P., Maisonneuve, N., Karsegard, V. L., Huber, O., et al. (2006). Hospitalized mechanically ventilated patients are at higher risk of enteral underfeeding than non-ventilated patients. Clinical Nutrition, 25(5), 727-735.
Kyle, U. G., Pirlich, M., Schuetz, T., Luebke, H. J., Lochs, H., & Pichard, C. (2003). Prevalence of malnutrition in 1760 patients at hospital admission: A controlled population study of body composition. Clinical Nutrition, 22(5), 473-481.
Larsson, J., Akner, G., Bosaeus, I., Cederholm, T., Essén, P., Ljungqvist, O., et al. (2004). In Larsson J. (Ed.), Nutritionsbehandling i sjukvård och omsorg. Stockholm: Dietisternas riksförbund; Nutritionsnätet för sjuksköterskor;
98
Svensk förening för Klinisk Nutrition; SWESPEN (Swedish Society Clinical Nutrition and Metabolism).
Larsson, J., Åkerlind, I., Permerth, J., & Hörnqvist, J. (1994). The relation between nutritional state and quality of life in surgical patients. The European Journal of Surgery, 160(6-7), 329-334.
Lennard-Jones, J. E., Arrowsmith, H., Davison, C., Denham, A. F., & Micklewright, A. (1995). Screening by nurses and junior doctors to detect malnutrition when patients are first assessed in hospital. Clinical Nutrition, 14(6), 336-340.
Likert, R. (1952). A technique for the development of attitude scales. Educational and Psychological Measurement, 12, 313-315.
Lincoln, Y. S., & Guba, E. G. (1985). Naturalistic inquiry. Beverly Hills: Sage Publications.
Lindberg, E., & Rosenqvist, U. (2005). Implementing TQM in the health care service: A four-year following-up of production, organisational climate and staff wellbeing. International Journal of Health Care Quality Assurance, 18(4), 370-384.
Lindorff-Larsen, K., Hojgaard Rasmussen, H., Kondrup, J., Staun, M., & Ladefoged, K. (2007). Management and perception of hospital undernutrition - a positive change among danish doctors and nurses. Clinical Nutrition, 26(3), 371-378.
Lindwall, L. (2004). Kroppen som bärare av hälsa och lidande. Diss. Åbo: Åbo Akademi.
Livsmedelsverket. (2003). Mat och näring för sjuka inom vård och omsorg. Uppsala: Livsmedelsverket.
Lochs, H., Dejong, C., Hammarqvist, F., Hebuterne, X., Leon-Sanz, M., Schutz, T., et al. (2006). ESPEN guidelines on enteral nutrition: Gastroenterology. Clinical Nutrition, 25(2), 260-274.
Lumbers, M., Driver, L. T., Howland, R. J., Older, M. W., & Williams, C. M. (1996). Nutritional status and clinical outcome in elderly female surgical orthopaedic patients. Clinical Nutrition, 15(3), 101-107.
Lundman, T., Olsson, S., Andersson, B. L., Hulter-Asberg, K., Kjellstrom, T., & Lindgren, S. (2001). Inventering av internmedicinen i Sverige: Medicinsk säkerhet äventyras av stor omsättning per vårdplats. Läkartidningen, 98(30-31), 3342-3344.
99
Lykkeslet, E., & Gjengedal, E. (2007). Methodological problems associated with practice-close research. Qualitative Health Research, 17(5), 699-704.
Lyne, P. A., & Prowse, M. A. (1999). Methodological issues in the development and use of instruments to assess patient nutritional status or the level of risk of nutritional compromise. Journal of Advanced Nursing, 30(4), 835-842.
MacFie, J., Reddy, B. S., Gatt, M., Jain, P. K., Sowdi, R., & Mitchell, C. J. (2006). Bacterial translocation studied in 927 patients over 13 years. The British Journal of Surgery, 93(1), 87-93.
Magarey, J. M., & McCutcheon, H. H. (2005). ‘Fishing with the dead’—Recall of memories from the ICU. Intensive and Critical Care Nursing, 21(6), 344-354.
Marshall, A., & West, S. (2004). Nutritional intake in the critically ill: Improving practice through research. Australian Critical Care, 17(1), 6-15.
Marshall, A., & West, S. (2006). Enteral feeding in the critically ill: Are nursing practices contributing to hypocaloric feeding? Intensive and Critical Care Nursing, 22(2), 95-105.
Martensson, I. E., & Fridlund, B. (2002). Factors influencing the patient during weaning from mechanical ventilation: A national survey. Intensive and Critical Care Nursing, 18(4), 219-229.
Martin, C. M., Doig, G. S., Heyland, D. K., Morrison, T., & Sibbald, W. J. (2004). Multicentre, cluster-randomized clinical trial of algorithms for critical-care enteral and parenteral therapy (ACCEPT). Canadian Medical Association Journal, 170(2), 197-204.
Mateo, M. A. (1996). Management of enteral tubes: Nursing management of enteral tube feedings. Heart & Lung, 25(4), 318-323.
McClave, S. A., Sexton, L. K., Spain, D. A., Adams, J. L., Owens, N. A., Sullins, M. B., et al. (1999). Enteral tube feeding in the intensive care unit: Factors impeding adequate delivery. Critical Care Medicine, 27(7), 1252-1256.
McKinley, S., Nagy, S., Stein Parbury, J., Bramwell, M., & Hudson, J. (2002). Vulnerability and security in seriously ill patients in intensive care. Intensive and Critical Care Nursing, 18(1), 27-36.
McMullin, J. P., Cook, D. J., Meade, M. O., Weaver, B. R., Letelier, L. M., Kahmamoui, K., et al. (2002). Clinical estimation of trunk position among mechanically ventilated patients. Intensive Care Medicine, 28(3), 304-309.
McWhirter, J. P., & Pennington, C. R. (1994). Incidence and recognition of malnutrition in hospital. British Medical Journal, 308(6934), 945-948.
100
Meier, R., & Stratton, R. (2004). Epidemiology of malnutrition. In. L. Sobotka (Ed.), Basics in clinical nutrition (3rd ed. ). Prague: Galen ESPEN Book.
Meleis, A. I. (2007). Theoretical nursing : Development and progress (4.th ed.). Philadelphia: Lippincott Williams & Wilkins.
Mossberg, T. (2006). Klinisk nutrition självklar del av modern sjukvård: Metabol behandling kan minska komplikationer och mortalitet. Läkartidningen, 103(21-22), 1697-1698.
Mossberg, T. (2000). Enteral eller parenteral näringstillförsel i samband med operation och vid intensivvård. In. Näringsproblem i vård & omsorg: Prevention och behandling: SoS-rapport 2000:11 (pp. 200-203). Stockholm: Socialstyrelsen.
Mowe, M., Bosaeus, I., Rasmussen, H. H., Kondrup, J., Unosson, M., Rothenberg, E., et al. (2008). Insufficient nutritional knowledge among health care workers? Clinical Nutrition, 27(2), 196-202.
Mowe, M., Bosaeus, I., Rasmussen, H. H., Kondrup, J., Unosson, M., & Irtun, O. (2006). Nutritional routines and attitudes among doctors and nurses in Scandinavia: A questionnaire based survey. Clinical Nutrition, 25(3), 524-532.
Munro, B. H. (2001). Statistical methods for health care research. Philadelphia: Lippincott.
Musselwhite, K., Cuff, L., McGregor, L., & King, K. M. (2007). The telephone interview is an effective method of data collection in clinical nursing research: A discussion paper. International Journal of Nursing Studies, 44(6), 1064-1070.
Natsch, S., & van der Meer, J. W. M. (2003). The role of clinical guidelines, policies and stewardship. Journal of Hospital Infection, 53(3), 172-176.
Nematy, M., O'Flynn, J. E., Wandrag, L., Brynes, A. E., Brett, S. J., Patterson, M., et al. (2006). Changes in appetite related gut hormones in intensive care unit patients: A pilot cohort study. Critical Care, 10(1), R10.
Nguyen, N. Q., Fraser, R. J., Bryant, L. K., Burgstad, C., Chapman, M. J., Bellon, M., et al. (2008). The impact of delaying enteral feeding on gastric emptying, plasma cholecystokinin, and peptide YY concentrations in critically ill patients. Critical Care Medicine, 36(5), 1469-1474.
Nightingale, F. (1969). Notes on nursing: What it is, and what it is not. The United Kingdom: Dover Publications, Inc.
Nijs, K. A., de Graaf, C., Siebelink, E., Blauw, Y. H., Vanneste, V., Kok, F. J., et al. (2006). Effect of family-style meals on energy intake and risk of malnutrition in dutch nursing home residents: A randomized controlled
101
trial. Journals of Gerontology Series A: Biological Sciences & Medical Sciences, 61A(9), 935-942.
Nolin, T., & Mårdh, C. (2007). Swedish intensive care register. annual report 2006. (svenska intensivvårdsregistret-SIR. årsrapport). Retrieved 10/06, 2008, from http://www.icuregswe.org
Northern Nurses Federation. (2003). Ethical guidelines for nursing research in the nordic countries. Vård i Norden: Nordic Journals of Nursing Research, 23(4), 1-19.
Norusis, M. J. (2006). SPSS 14.0 guide to data analysis. New Jersey: Prentice Hall.
Nyman, U. (2001). In Eriksson R. (Ed.), 2000-talets undersköterska: Undersköterskans yrkesroll inom NU-sjukvården i västra götalandsregionen. Uddevalla: NU-sjukvården: FoU-enhetens rapportserie 2001:4.
Olsson, U., Bergbom Engberg, I., & Ahs, M. (1998). Evaluating nurses' knowledge and patients' energy intake after intervention. Clinical Nurse Specialist, 12(6), 217-225.
Perneger, T. (1998). What's wrong with bonferroni adjustments. British Medical Journal, 316(7139), 1236-1238.
Perry, L. (1997). Nutrition: A hard nut to crack: An exploration of the knowledge, attitudes and activities of qualified nurses in relation to nutritional nursing care. Journal of Clinical Nursing, 6(4), 315-324.
Philpin, S. M., Jordan, S. E., & Warring, J. (2005). Giving people a voice: Reflections on conducting interviews with participants experiencing communication impairment. Journal of Advanced Nursing, 50(3), 299-306.
Pingleton, S. K. (2001). Nutrition in chronic critical illness. Clinics in Chest Medicine, 22(1), 149-163.
Polit, D. F., & Beck, C. T. (2004). In 7 (Ed.), Nursing research: Principles and methods. Philadelphia: Lippincott Williams & Wilkins.
Polit, D. F., & Hungler, B. P. (1999). Nursing research: Principles and methods (6th ed.). Philadelphia: Lippincott.
Polit, D. F., & Tatano Beck, C. (Eds.). (2008). Nursing research: Generating and assessing evidence for nursing practice (8th ed.). Phiadelphia: Lippincott Williams & Wilkins.
Preiser, J. C., Berre, J., Carpentier, Y., Jolliet, P., Pichard, C., Van Gossum, A., et al. (1999). Management of nutrition in European intensive care units: Results of a questionnaire. Intensive Care Medicine, 25(1), 95-101.
102
Rasmussen, H. H., Kondrup, J., Ladefoged, K., & Staun, M. (1999). Clinical nutrition in Danish hospitals: A questionnaire-based investigation among doctors and nurses. Clinical Nutrition, 18(3), 153-158.
Reintam, A., Parm, P., Kitus, R., Starkopf, J., & Kern, H. (2008). Gastrointestinal failure score in critically ill patients: A prospective observational study. Critical Care, 12(4), R90.
Rice, T. W., Swope, T., Bozeman, S., & Wheeler, A. P. (2005). Variation in enteral nutrition delivery in mechanically ventilated patients. Nutrition, 21(7), 786-792.
Rodriguez, L. (2004). Nutritional status: Assessing and understanding its value in the critical care setting. Critical Care Nursing Clinics of North America, 16(4), 509-514.
Rothenberg, E. (2000). Behandling av undernäring-praktiska synpunkter. In. Näringsproblem i vård & omsorg: Prevention och behandling: SoS-rapport 2000:11 (pp. 39-44). Stockholm: Socialstyrelsen.
Roynette, C. E., Bongers, A., Fulbrook, P., Albarran, J. W., & Hofman, Z. (2008). Enteral feeding practices in European ICUs: A survey from the european federation of critical care nursing associations (EfCCNa). E-SPEN, the European e-Journal of Clinical Nutrition and Metabolism, 3(2), e33-e39.
Rubenstein, Z., Harker, J., Guigoz, Y., & Vellas, B. (1999). Comprehensive geriatric assessment (CGA) and the MNA: An overview of CGA, nutritional assessment, and development of a shortened version of the MNA. In. B. Vellas, P. J. Garry & Y. Guigoz (Eds.), Mini nutritional assessment (MNA): Research and practice in the elderly (Nestlé Nutrition Workshop Series Clinical & Performance Programme ed. pp. 101-116). Basel: Karger AG.
Rycroft-Malone, J., Harvey, G., Seers, K., Kitson, A., McCormack, B., & Titchen, A. (2004). An exploration of the factors that influence the implementation of evidence into practice. Journal of Clinical Nursing, 13(8), 913-924.
Rycroft-Malone, J., Kitson, A., Harvey, G., McCormack, B., Seers, K., Titchen, A., et al. (2002). Ingredients for change: Revisiting a conceptual framework. Quality and Safety in Health Care, 11(2), 174-180.
Saletti, A., Johansson, L., Yifter-Lindgren, E., Wissing, U., Österberg, K., & Cederholm, T. (2005). Nutritional status and a 3-year follow-up in elderly receiving support at home. Gerontology, 51(3), 192-198.
103
Samuelson, K. A. M., Lundberg, D., & Fridlund, B. (2007). Stressful experiences in relation to depth of sedation in mechanically ventilated patients. Nursing in Critical Care, 12(2), 93-104.
SFS 1982:763. Hälso- och sjukvårdslag svensk författningssamling. Stockholm: Liber.
SFS 1985:562. Patientjournallagen. Stockholm: Liber.
SFS 1998:531. Lag om yrkesverksamhet på hälso- och sjukvårdens område. Stockholm: Fakta Info Direkt.
SFS 2008:355. Patientdatalag. Stockholm: Socialdepartementet.
Sidenvall, B. (2003). Äldres måltidsvanor. In. A. Westergren (Ed.), Svårigheter att äta (pp. 27-36). Lund: Studentlitteratur.
Sjukvårdsrådgivningen. (2005). Nutrition. Retrieved 08/29, 2008, from http://www.1177.se/handboken/
Socialstyrelsen. (1996). Kompetensbeskrivningar för sjuksköterskor och barnmorskor. Stockholm: Fritze.
Socialstyrelsen. (2000). Näringsproblem i vård och omsorg: Prevention och behandling: Sos-rapport 2000:11. Stockholm: Socialstyrelsen.
Socialstyrelsen. (2002). Tillsynsärenden inom äldreomsorgen 1999: En jämförande studie mellan åren 1998 och 1999. Stockholm: Socialstyrelsen.
Socialstyrelsen. (2003). Kommunernas kost- och nutritionsarbete. Stockholm: Socialstyrelsen.
Socialstyrelsen. (2005). Kompetensbeskrivning för legitimerad sjuksköterska. Retrieved 09/29, 2008, from http://www.socialstyrelsen.se/Publicerat/2005/8673/2005-105-1.htm
Socialstyrelsen. (2006). Vård-och omsorgsassistenters kvalifikationer: Grundläggande nivå. Stockholm: Socialstyrelsen.
Socialstyrelsen. (2007a). Current developments in care of the elderly in sweden. Stockholm: Socialstyrelsen.
Socialstyrelsen. (2007b). Regeringens uppdrag att ge nationellt stöd för kvalitetsutvecklingen i måltids- och näringsfrågor inom vård och omsorg av äldre. Stockholm: Socialstyrelsen.
Socialstyrelsen. (2008). Statistikdatabas. Retrieved 09/29, 2008, from http://www.socialstyrelsen.se/Statistik/statistikdatabas/
104
Soeters, P. B., Reijven, P. L. M., van Bokhurst-d van der Schureren,M.A.E., Schols, J. M. G. A., Halfens, R. J. G., Meijers, J. M. M., et al. (2008). A rationale approach to nutritional assessment. Clinical Nutrition, doi:10.1016/j.clnu.2008.07.009
SOSFS 1988:25. Föreskrifter och allmänna råd om ansvarsfördelning inom den slutna hälso- och sjukvården vid sondmatning samt vid användning av intravasal kateter och epiduralkateter. Stockholm: Socialstyrelsen.
SOSFS 1997:10. Socialstyrelsens allmänna råd: Medicinskt ansvarig sjuksköterska i kommunernas hälso-och sjukvård. Stockholm: Socialstyrelsen.
SOSFS 2005:12. Ledningssystem för kvalitet och patientsäkerhet i hälso- och sjukvården. Stockholm: Socialstyrelsen.
Spain, D. A., McClave, S. A., Sexton, L. K., Adams, J. L., Blanford, B. S., Sullins, M. E., et al. (1999). Infusion protocol improves delivery of enteral tube feeding in the critical care unit. Journal of Parenteral and Enteral Nutrition, 23(5), 288-292.
Speziale, H. S., & Carpenter, D. R. (2007). Qualitative research in nursing : Advancing the humanistic imperative (4.th ed.). Philadelphia: Lippincott Williams & Wilkins.
SSF. (2007). ICN:S etiska kod för sjuksköterskor. Stockholm: Svensk sjuksköterskeförening (SSF).
Staniszewska, S., & Ahmed, L. (1999). The concepts of expectation and satisfaction: Do they capture the way patients evaluate their care? Journal of Advanced Nursing, 29(2), 364-372.
Starrin, B., Dahlgren, L., Larsson, G., & Styrborn, S. (1997). Along the path of discovery: Qualitative methods and grounded theory. Lund: Studentlitteratur.
Stratton, R. J., Green, C. J., & Elia, M. (2003). Disease-related malnutriton. Wallinfoord: CABI.
Streiner, D. L., & Norman, G. R. (2003). Health measurement scales. Oxford: Oxford University Press.
Strömberg, H. (2004). Sjukvårdens industrialisering: Mellan curing och caring- sjuksköterskearbetets omvandling. Diss Umeå: Umeå Studies in Economic History 29 Umeå Universitet.
Söderhamn, U. (2006). Nutritional screening of older patients. developing, testing and using the nutritional form for the elderly (NUFFE). Diss Linköping: Department of Medicine and Care, Division of Nursing Science, Faculty of Health Sciences Linköping University.
105
Söderhamn, O., & Köhler, V. (2005). Nurses' opportunities for work integrated learning when using a classification system in electronic patient records. Theoria Journal of Nursing Theory, 14(3), 4-9.
Söderhamn, U., & Söderhamn, O. (2001). Developing and testing the nutritional form for the elderly. International Journal of Nursing Practice, 7(5), 336-341.
Söderhamn, U., & Söderhamn, O. (2002). Reliability and validity of the nutritional form for the elderly (NUFFE). Journal of Advanced Nursing, 37(1), 28-34.
Söderhamn, U., Bachrach-Lindström, M., & Ek, A. (2007). Nutritional screening and perceived health in a group of geriatric rehabilitation patients. Journal of Clinical Nursing, 16(11), 1997-2006.
Thunborg, C. (1999). Lärande av yrkesidentiteter : En studie av läkare, sjuksköterskor och undersköterskor. Diss. Linköping: Department of Education and Psychology No 64 Linköpings Universitet.
Travelbee, J. (1971). Interpersonal aspects of nursing (2.th ed.). Philadelphia: Davis.
Törnvall, E., & Wilhelmsson, S. (2008). Nursing documentation for communicating and evaluating care. Journal of Clinical Nursing, 17(16), 2116-2124.
Ulander, K., Jeppsson, B., & Grahn, G. (1998). Postoperative energy intake in patients after colorectal cancer surgery. Scandinavian Journal of Caring Sciences, 12(3), 131-138.
Unosson, M. (2000a). Förebyggande och behandling av undernäring-omvårdnadsaspekter. In. Näringsproblem i vård & omsorg: Prevention och behandling: Sos-rapport 2000:11 (pp. 45-53). Stockholm: Socialstyrelsen.
Unosson, M. (2000b). Sjuksköterskeutbildning. In. Näringsproblem i vård & omsorg: Prevention och behandling: SoS-rapport 2000:11 (pp. 82-85). Stockholm: Socialstyrelsen.
Unosson, M., & Rothenberg, E. (2000). Bedömning av patientens näringstillstånd. In. Näringsproblem i vård & omsorg: Prevention och behandling: SoS-rapport 2000:11 (pp. 18-38). Stockholm: Socialstyrelsen.
Wallin, L. (2003). Knowledge utilisation in swedish neonatal nursing. Diss. Uppsala: Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine 1272.
Wallin, L., Bostrom, A. M., Harvey, G., Wikblad, K., & Ewald, U. (2000). National guidelines for Swedish neonatal nursing care: Evaluation of
106
clinical application. International Journal for Quality in Health Care, 12(6), 465-474.
Wallin, L., Ewald, U., Wikblad, K., Scott-Findlay, S., & Arnetz, B. B. (2006). Understanding work contextual factors: A short-cut to evidence-based practice? Worldviews on Evidence-Based Nursing, 3(4), 153-164.
Vanderkroft, D., Collins, C. E., FitzGerald, M., Lewis, S., Neve, M., & Capra, S. (2007). Minimising undernutrition in the older inpatient. International Journal of Evidence-Based Healthcare, 5(2), 110-181.
Weekes, C. E., Elia, M., & Emery, P. W. (2004). The development, validation and reliability of a nutrition screening tool based on the recommendations of the british association for parenteral and enteral nutrition (BAPEN). Clinical Nutrition, 23(5), 1104-1112.
Wikström, A. C., & Larsson, U. S. (2004). Technology - an actor in the ICU: A study in workplace research tradition. Journal of Clinical Nursing, 13(5), 555-561.
Wilkin, K., & Slevin, E. (2004). The meaning of caring to nurses: An investigation into the nature of caring work in an intensive care unit. Journal of Clinical Nursing, 13(1), 50-59.
Villet, S., Chiolero, R. L., Bollmann, M. D., Revelly, J., Cayeux, M., Delarue, J., et al. (2005). Negative impact of hypocaloric feeding and energy balance on clinical outcome in ICU patients. Clinical Nutrition, 24(4), 502-509.
Williams, T. A., & Leslie, G. D. (2004). A review of the nursing care of enteral feeding tubes in critically ill adults: Part 1. Intensive and Critical Care Nursing, 20(6), 330-343.
Williams, T. A., & Leslie, G. D. (2005). A review of the nursing care of enteral feeding tubes in critically ill adults: Part II. Intensive and Critical Care Nursing, 21(1), 5-15.
Woolf, S. H., Grol, R., Hutchinson, A., Eccles, M., & Grimshaw, J. (1999). Potential benefits, limitations, and harms of clinical guidelines... first in a series of four articles. British Medical Journal, 318(7182), 527-530.
World Medical Association Declaration of Helsinki. (1964). Ethical principles for medical research involving human subjects. Retrieved 09/09, 2008, from http://www.Wma.net/e/policy/b3.htm
Wåhlin, I., Ek, A., & Idvall, E. (2006). Patient empowerment in intensive care-an interview study. Intensive & Critical Care Nursing, 22(6), 370-377.
107
Wøien, H., & Bjørk, I. T. (2006). Nutrition of the critically ill patient and effects of implementing a nutritional support algorithm in ICU. Journal of Clinical Nursing, 15(2), 168-177.
Xia, C., & McCutcheon, H. (2006). Mealtimes in hospital - who does what? Journal of Clinical Nursing, 15(10), 1221-1227.
Ödegård, S. (2006). Säker vård: Patientskador, rapportering och prevention. Diss. Göteborg: Nordiska högskolan för folkhälsovetenskap.
Ödlund Olin, A. (2004). Nutritional and functional effects of energy-dense food in the frail elderly. Diss. Stockholm: Division of surgery, Center for Surgical Sciences and Neurotec Department, Division of Clinical Geriatrics Karolinska institutet.
Karlstad University StudiesISSN 1403-8099
ISBN 978-91-7063-201-3
Faculty of Social and Life SciencesNursing Science
DISSERTATION
Karlstad University Studies2008:41
Mona Wentzel Persenius
Nutritional Nursing Care
Mona W
entzel Persenius N
utritional Nursing C
are
Nurses’ interactions with the patient, the team and the organization
Nutritional Nursing Care
Mona Wentzel Persenius is a registered nurse, with a Master’s Degree in nursing, specialized in anaesthesia and intensive care. She has worked for several years in medical wards and intensive care units in Sweden and Saudi Arabia. She has also worked at the Unit of Elderly Care at the National Board of Health and Welfare. For the past few years, she has been engaged in doctoral studies in combination with teaching at the nursing programme at the Department of Nursing at Karlstad University.
Nutrition is essential for patients’ health. It is obvious that malnutrition is a significant problem in different health care settings. Nutritional nursing care is important to the patient’s nutritional condition and may prevent malnutrition. Therefore, the overall aim of this thesis was to gain a deeper understanding of nutritional nursing care in municipal care and county council care, with special focus on enteral nutrition in intensive care.
Quantitative and qualitative methods were used in this thesis. The results showed that assessment of nutritional status was not performed on all patients. Malnourished patients were estimated to occur to a varied extent. There were differences between the registered nurses’ opinions about their responsibility, knowledge and documentation. Deviations from recommended nursing care interventions occurred. In order for registered nurses and enrolled nurses to have a sense of control over the patients’ care in relation to nutrition, a balance between routine care and individual care was required. It was important for the patients to grasp nutrition during their recovery process. The patients alternated emotionally between worry, fear and failure, and relief and hope during the process.
The thesis shows that quality and safety in relation to nutritional nursing care is dependent on the interaction between the nurse and the patient, between the nurse and the team, and between the nurse and the organization.
Faculty of Social and Life Sciences, Department of Nursing,Karlstad University SE-651 88 Karlstad, Sweden. E-mail: [email protected]
