Undernutrition in older people in Australia Abstract
Despite being preventable and treatable, undernutrition remains a problem for many older people in tertiary healthcare settings. Nurses have a crucial role in assisting people who are unable to eat independently and are uniquely positioned to implement solutions that will lead to better nutritional care. However, what is known about the management of undernutrition is not informing nursing practice. This study used action research, underpinned by the ‘participatory world view’, to address the theory-practice gap. Data and between-method triangulation were used to collect and analyse qualitative non-participant observations and action research group data. Set Up Ready For Dining (SURFD) was developed and implemented by nurses to improve patient mealtimes. Findings show that nursing practice in nutritional care is influenced by technique within the healthcare context that emphasises operational efficiency, and by the choices that nurses made around being the patient advocate during mealtimes. Key words: Nutrition ■ Malnutrition ■ Older people ■ Nursing practice
T
he prevalence of undernutrition in older adults is reported to be a common occurrence in tertiary health care settings (Banks et al, 2007). The reasons for undernutrition are multifactorial and connected to: the history of nursing and the widening gap between nursing practice and the act of nourishing; current views around whose role it is to provide nutritional care; and technique within the healthcare context that ‘emphasise[s] a primacy of means, efficiency, and rational order’ (Barnard and Sandelowski, 2001: 372).
Background Australia’s population is set to change significantly over the next 50 years. According to the Productivity Commission Report (2011), the number of people aged 65 years and over is expected to more than double, from 2.7 million to 6.3 million, and will represent 24% of the total population in 30 years from now. Current evidence shows that older people Sandra Ullrich, Lecturer, School of Nursing and Midwifery, University of South Australia, Adelaide; Helen McCutcheon, Professor of Nursing, Florence Nightingale School of Nursing and Midwifery, King’s College London; Barbara Parker, Programme Director, School of Nursing and Midwifery, University of South Australia, Adelaide Accepted for publication: January 2015
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are the biggest users of tertiary healthcare facilities compared with their younger counterparts (Productivity Commission Report, 2011). Therefore, the ageing of Australia’s population and the health of Australia’s older population can be expected to affect both the demand for, and provision of, healthcare services. Consequently, healthcare organisations will face increasing pressures to provide better and more efficient health care. Internationally, the prevalence of undernutrition in older patients ranges from 12% to 84% (Stratton et al, 2003) with a study into medical records showing that up to 70% of cases go undiagnosed (Kelly et al, 2000). Australian studies show that the prevalence of undernutrition in tertiary healthcare settings ranges between 12% and 53% (Middleton et al, 2001; Lazarus and Hamlyn, 2005; Thomas et al, 2007). These findings indicate a real need for recognising patients at nutritional risk and implementing effective management strategies to optimise clinical outcomes (Kelly et al, 2000; Middleton et al, 2001; Weekes et al, 2004; Kyle et al, 2005). Although there is no single reason for poor nutritional intake, it appears that the act of including machinery and equipment (i.e. technology) in nursing practice introduces patterns of technological activity that, by their very nature, change or modify nursing behaviour (Barnard, 1996). Some authors suggest that changes in the design and layout of hospitals, geared to the functional and technological, convey mixed social and psychological messages to both nurses and patients (Canter and Cooper, 1988). On the one hand, healthcare organisations symbolise warmth and caring as the foundation for treatment; on the other, they have come to symbolise the curative power of technology. It is this paradox that may cause nurses to distance themselves from patients as a way of resolving this conflict (Canter and Cooper, 1988; Bowers et al, 2001). By contrast, Barnard and Sandelowski (2001) argue that it is technique within the healthcare context that has increasingly structured collective behaviour and professional perspectives. Technique within the healthcare context—with its emphasis on a primacy of means, efficiency and rational order— influences the choices that are made, and these choices do not necessarily attend to such phenomena as the human and cultural differences, feelings and meanings associated with mealtimes (Bastone, 1983; Barnard and Sandelowski, 2001; Kitson, 2010). Therefore, it is technique within the healthcare context that contributes to the functional approach to mealtimes, where meals are provided in a context of rules governing work and especially of time-constraint, rather than the domestic approach, where meals are provided to meet
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Sandra Ullrich, Helen McCutcheon and Barbara Parker
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The study This study was part of a larger research project that investigated nursing practice in nutritional care. A two-stage approach was required in which stage one was conducted in a residential aged care unit (Ullrich et al, 2011) and stage two was conducted in a tertiary healthcare setting. This paper will present stage two of the research project. Specifically, focus will be applied to the action research process and the long-term outcomes of the intervention to improve nursing practice in nutritional care.
Aims The aims of this study were: ■■ To assist participants in identifying the barriers and enablers to best practice in nutritional care ■■ To provide participants with the opportunity to identify and implement an intervention to improve nutritional care ■■ To assist participants in being critical and reflective as part of their decision-making process ■■ To evaluate the change that was made in relation to quality in action research.
Theoretical framework Reason and Bradbury define action research as a participatory, democratic process concerned with developing practical knowing in the pursuit of worthwhile human purposes. It seeks to bring together action and reflection, theory and practice, in participation with others, in the pursuit of practical solutions to issues of pressing concern to people, and more generally the flourishing of individual persons and their communities (Reason and Bradbury, 2006: 1). Action research was used because: it focuses on change and improvement; involves participants in the research process; looks at questions that arise from practice; involves a cyclical process of collecting information, feedback and reflection; and is an approach that generates knowledge (Stringer, 2013). The emancipatory and educational aims of action research resonate with the goals of nursing and, with its roots in the social and political sciences and organisational change, action research has the capacity to create sustainable change in the way healthcare organisations deliver patient care. Action research has the potential to foster an agenda for research among nurses by including them in research that is conducted alongside everyday practice (Stringer, 2013; Bellman, 2003; Manley and McCormack, 2004;Young, 2006). Action research is gaining recognition and acceptance within nursing practice as it demonstrates versatility in its application and capacity to catalyse change. This action research study followed the cyclic phases of: ‘Look’: building the picture; ‘Think’: interpreting and analysing; ‘Act’: planning and implementing solutions; and ‘Look’: reviewing progress and evaluating (Stringer, 2013). The principles of the ‘participatory world view’ governed the use of action research for this study. These principles involved incorporating collaboration and democracy in decisionmaking processes. Participants defined the issues and identified the solutions, making the whole process more meaningful for
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them. The participatory world view acknowledges that there are different forms of knowing and that the cyclic process of action research creates new knowledge such as new skills of inquiry and how to become co-researchers with one another. The participatory world view works towards practical and sustainable outcomes and recognises that the action research process develops over time (Reason and Bradbury, 2006).
Quality in action research There has been significant debate regarding the need for proof that the processes used in qualitative research are rigorous and credible (Mays and Pope, 2000; Bradbury and Reason, 2006). Some action research practitioners question whether we are trying to fit the qualities of action research into traditional discourse about validity, as they do not acknowledge its action-orientated outcomes (Bradbury and Reason, 2006). As a result, the term ‘quality’ has been offered as an alternative to ‘validity’ because of its wider connotations (Bradbury and Reason, 2006). Quality in action research considers the participative metaphor and the relationship between our participation in creating our world and our necessary actions, which leads us to consider how to judge the quality of our actions (Reason and Bradbury, 2006). This study addressed the issue of quality by relating the five interrelated dimensions of the participatory world view with eight choice-points and questions (Bradbury and Reason, 2006). These include: ‘quality as relational praxis; quality as reflexive-practical outcomes; quality as plurality of knowing; quality as engaging in significant work and emergent inquiry towards enduring consequences’ (Bradbury and Reason, 2006: 346–9).
Setting and participants This study was conducted in a metropolitan tertiary healthcare setting in Adelaide, South Australia—specifically, a 28-bed medical ward. This ward was chosen because patients required a high level of care provided by a team of approximately 75 registered nurses and 25 enrolled nurses. Eight registered nurses (RNs) and six enrolled nurses (ENs) participated in the first action research group discussion. However, participant numbers fluctuated with the addition of other clinical nurses, the nurse manager, RNs, ENs and nursing students. In total, 24 tertiary healthcare nurses regularly participated in the action research group discussions. Naturalistic recruitment was used whereby nurses who were interested in nutritional care were invited to attend an information session. Over time, these participants encouraged other nurses to participate in the study (Wadsworth, 2006). Ethics approval for the study was granted by the University of South Australia’s Human Research Ethics Committee and the tertiary healthcare organisation’s ethics committee.
Method A multi-method approach was used for this action research study.The strategies of data and between-method triangulation were chosen to assist in understanding the multidimensional issues associated with patient mealtimes and the provision of nutritional care (Farmer et al, 2006; Ullrich et al, 2011). Between-method triangulation allowed for the use of either
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principally social goals and personal needs, tastes and comforts (Bastone, 1983).
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CLINICAL FOCUS two or more methods, such as non-participant observation and action research group discussions to collect and interpret data. The use of action research group data complemented the non-participant observational data and enhanced the data’s confirmability (Denzin, 1989).
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Phase 1—Look: building the picture The first phase of the action research cycle, ‘Look: building the picture’, assisted in gathering important information about the people and context in order to develop a detailed picture of nursing practice nutritional care within a tertiary healthcare environment (Stringer, 2013). Three weeks (including weekends) of non-participant observations were conducted of morning, midday and evening mealtimes, and snack periods. Non-participant observation allowed phenomena to be observed naturalistically and provided a contextualised understanding of patients’ experiences of mealtimes and factors that influenced and directed the efforts of nurses in this fundamental aspect of patient care (Bowling, 2002). Data collection and analysis were informed by aspects of the developmental research sequence, which consists of eight steps and assisted in understanding the culture of more complex social worlds, and facilitated action research group discussion (Spradley, 1980). These steps consisted of the identification of: social situations; clusters of situations and networks of situations in which nutritional care was provided (Spradley, 1980). A descriptive matrix guided the collection of data, and domain analysis allowed for the systematic examination of the recordings to determine its parts, the relationship among parts and the relationship to the whole (Spradley, 1980). A taxonomic analysis assisted in revealing the way phenomena were organised and the way they related to one another. Nonparticipant observation data collection involved a non-linear approach and as such there was continual movement along the developmental research sequence (Spradley, 1980). Following the non-participant observations, the first of four action research group discussions were held, which were taperecorded, transcribed verbatim (word for word) and with the researcher’s non-participant observational field notes provided qualitative data. The non-participant observations were presented to the participants with the aim of brainstorming the barriers and enablers to nursing practice in nutritional care.The action research group provided the context in which to stimulate discussion; pursue the topic in greater depth; gain and obtain different but complementary data on nursing practice in nutritional care—and thereby enhance the quality of the research (Bowling, 2002). Analysis of the action research group data was qualitative, using the interpretative inductive approach of the ‘analytic hierarchy’ (Spencer et al, 2003). The analytic hierarchy is described conceptually whereby the process of data management and analysis involves movement between nine ‘viewing platforms’, each of which involves different analytical tasks while providing an overview of the data (Spencer et al, 2003: 213). The analytic process was nonlinear; for this reason, the analytic hierarchy is shown with ladders linking the platforms, enabling movement both up and down the structure (Spencer et al, 2003). Data analysis involved immersion in the data by reading, identifying initial concepts and labelling the data by way of indexing. Data were
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sorted by concept so that materials with similar properties were located together and associatively analysed by noting the concepts that weaved in and out. The essence of the data was extracted as evidence for later representation. Descriptive analysis involved the exploration of data by detection, categorisation and classification, with the aim of presenting information that was authentic, meaningful and provided content that was illuminating (Ritchie et al, 2003).
Phase 2—Think: analysing and planning The second phase of the action research cycle, ‘Think: interpreting and analysing’, provided the momentum for the action research group to identify an intervention to improve nursing practice in nutritional care (Stringer, 2013). By using the information collected in phase one, participants collaboratively clarified with each other their understanding of patient mealtimes and nursing practice in nutritional care, identified priorities for action, and developed an action plan that led to a resolution of the problems (Stringer, 2013). Collaboratively, the nurses developed an intervention called Set Up Ready for Dining (SURFD), which was designed to assist nurses in initiating pre-meal preparation time and ensuring that patients and the environment were prepared. The activities included: ■■ Encouraging/assisting with toileting before meal delivery to minimise mealtime interruptions ■■ Positioning patients appropriately before meals (such as sit up in bed, sit out of bed) ■■ Ensuring the mealtime environment was uncluttered (such as clearing overbed table and moving overbed to within patient’s reach) ■■ Preparing for the mealtime approximately 30 minutes before expected meal delivery.
Phase 3—Act: solving problems and implementing solutions The third phase of the action research cycle, ‘Act: planning and implementing solutions’, involved the implementation of SURFD (Stringer, 2013). Implementation dates were set; flyers were strategically placed around the ward; and information sheets were placed in all staff pigeon holes, informing staff of the initiative. A 2-week trial period of SURFD was implemented.
Phase 4—Look: reviewing progress and evaluating The fourth phase of the action research cycle,‘Look: reviewing progress and evaluating’, involved making judgements, through the processes of reflection and critical thinking, about the effects of SURFD and to conclude whether or not it had been successful (Stringer, 2013). The non-participant observations of nursing practice during phase three were presented back to the action research group for collaborative evaluation.
SURFD’s long-term outcomes As is appropriate in an action research study, an evaluation of SURFD was made 4 months after its initial implementation (Stringer, 2013). Two weeks (including weekends) of nonparticipant observations were conducted of morning, midday
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Nursing practice Non-participant observation of the mealtime environment showed that some patients were inadequately positioned for mealtimes, either lying too flat or positioned too low in the bed or slouching to one side. Overbed tables were also positioned too high for some patients (ie. shoulder height or at nose level). Nurses were observed implementing SURFD by combining or ‘bundling’ it with other nursing care duties such as taking patient observations, blood sugar levels, administering medications, documenting, weighing patients, supervising student nurses, assisting other nurses with patient transfers and medication checks (Bowers et al, 2001). The implementation of SURFD was hindered when nurses were separated from patients owing to staff meal breaks and because nurses had to rectify problems associated with incorrect meal deliveries. SURFD was also hindered by factors that separated patients from the mealtime environment, such as having to attend ultrasound appointments. Visiting allied health professionals also separated patients from their meal by treating patients before and during mealtimes. Therefore, the successful implementation SURFD relied on an uninterrupted mealtime environment for patients and nurses and, importantly, keeping nurses and patients in the ward at mealtimes.
The mealtime environment Non-participant observations showed that clinical noise contributed to what appeared to be a chaotic atmosphere before and during patient mealtimes. Clinical noise included phone calls, patient call bells, ‘code blues’ (medical emergencies), monitors and cleaning equipment, loud visitors and the sound of foot traffic. The patient bays were observed, at times, to be less cluttered before and during mealtimes. However, nebuliser pumps, dressing packs, towels, gowns and patients’ personal items remained on some patients’ overbed tables during meal delivery.
Technique within the healthcare context Action research group discussions provided insights into why nurses were unable to enact the activities of SURFD at patient mealtimes. In particular, technique within the healthcare context influenced how SURFD was implemented (Barnard and Sandelowski, 2001). The following statement highlights the emphasis of technique within this healthcare context and that ‘being flexible’ was very important to the operational efficiency of a busy medical ward:
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‘I don’t want it [SURFD] to be regimented … they [nurses] need to be bending, like a tree they need to blow with the wind. This week’s going to be flat out, they need to change their whole routines, as long as something’s systematically happening to keep them on track.’ (Nurse, 9 July 2009) Nurses stated that SURFD was a flexible approach to preparing patients and the environment for mealtimes. However, this flexibility also diminished nurses’ ability to implement SURFD because of the choices they made in terms of its priority: ‘I think another thing is that our focus here in the morning is to do observations and medication when you come out from handover; there isn’t a focus on meals.’ (Nurse, 17 November 2008) It appears that the implementation of SURFD was dependent not only on the nature of the ward during patient mealtimes, but also on the decisions made by nurses in terms of its prioritisation amid other nursing responsibilities. Nurses also stated that the interruptions of doctors and allied health care visits affected the implementation of SURFD and that the perfect mealtime environment was one that was free from these interruptions: ‘At lunch times, implementing SURFD still has issues—sort of allied health and doctors coming round.’ (Nurse, 6 July 2009) ‘To get the doctors and allied health off the ward at lunchtime would be perfect … when it [SURFD] gets done it’s been worthwhile.’ (Nurse, 6 July 2009)
Choices that nurses make However, despite these concerns, some nurses chose not to secure the time necessary for the implementation of SURFD. In particular, there were mixed perceptions around whether or not nurses could ask unnecessary visitors to the ward not to interrupt the preparation of patients and the environment for mealtimes as the following conversation shows: ‘I’ve had a go at doctors when they came round at lunchtime and I say, “Hey, this is a bit late, why are you doing it at this time? You’re coming in disturbing me with changing medications, you know, while I’m supposed to be concentrating on meals.” I have challenged the doctors sometimes.’ (Nurse 1) ‘I probably won’t challenge them.’ (Nurse 2) ‘Why not?’ (Facilitator) ‘I don’t know, I guess it’s my role as well, where I stand at the moment, I would tell someone, but I would tell my senior.’ (Nurse 1) ‘But you’re the patient advocate!’ (Nurse 2) (Conversation, 9 July 2009)
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and evening mealtimes and snack periods to determine whether SURFD was part of everyday nursing practice and to identify the barriers to, and enablers of, its sustainability. Two action research group discussions were held to provide participants with the opportunity to voice their opinions about SURFD and to discuss any continuing issues around nursing practice in nutritional care. The participants involved in the action research group discussions included past and new nursing participants.
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CLINICAL FOCUS Reconnecting to nutritional care Importantly, nurses spoke of how SURFD reconnected them back to their role in providing nutritional care: ‘I think for the patient–nurse relationship it’s identified that—hang on, I need to slow down here and actually make sure my patient’s eating, I want to eat, you need to eat as well. ’(Nurse, 9 July 2009) Returning to the fundamentals of nursing practice through the implementation of SURFD contributed to the delivery of better nursing care and better patient experiences at mealtimes: ‘I think it’s made us more aware … and honing in on that time to sit the patients up and to create that environment where they can actually sit up and eat, you know, and do for themselves.’ (Nurse, 6 July 2009) ‘I think that the patient enjoys being able to sit and eat their meal instead of lying there and waiting for somebody to get them ready, especially if they can see it and they can’t move to get it.’ (Nurse, 6 July 2009)
Limitations This project was undertaken in a tertiary healthcare setting and addressed specific issues in nutritional care. Therefore, care should be taken when extrapolating these findings to other settings (Bowling, 2002).
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Conclusion Action research facilitated change to nursing practice in nutritional care and enhanced nurses’ awareness of the importance of patient mealtimes (Stringer, 2013). Action research has previously been used to improve patient mealtimes within a tertiary setting, which led to positive outcomes such as staff reconnecting with, prioritising and participating in patient mealtimes (Dickinson et al, 2007). The common thread that unites the study by Dickinson et al (2007) and this study is the concept of reconnecting nurses to their role in providing fundamental patient care during mealtimes.This has some important implications for care outcomes, as evidence is accruing that the time nurses spend providing mealtime assistance is insufficient and not provided in a timely manner (Xia and McCutcheon, 2006; Tsang, 2008). However, to reconnect nurses back to nutritional care we need to understand that nursing practice is not only influenced by technique within the healthcare context but by the choices that nurses make in being the patient advocate during patient mealtimes. These choices often align with the functional approach to mealtimes where meals are provided in a context of rules governing work and especially of time constraint (Bastone, 1983). Nurses do this by managing patient mealtimes in order to maintain operational efficiency and by their perceived obligations toward medical and allied health professionals during this time. These decisions have contributed to the development of a healthcare culture in which medical staff and allied health professionals have
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KEY POINTS n Despite
being preventable and treatable, undernutrition remains a problem for many older patients within tertiary healthcare settings
n Nurses
are uniquely positioned to implement solutions that will lead to better nutritional care. But what is known about the management of undernutrition is not informing nursing practice
n Nursing
practice in nutritional care is influenced by technique within the healthcare context, which emphasises operational efficiency over a domestic approach whereby meals meet social and personal needs
n By
allowing interruptions to the provision of nutritional care, nurses have contributed to the culture of indifference within health care towards nurses’ role in nutritional care and the management of patients’ mealtimes in general
become aware of nurses’ flexibility during patient mealtimes and use it to their advantage. In turn, the choices made by nurses that make them unavailable when help is needed most can have a debilitating effect on the ill and frail, and reinforce the insignificance of mealtimes and diminish the role of the nurse in nutritional care within the wider healthcare context (Bowers et al, 2001). Technique within the healthcare context, which emphasises operational efficiency through nursing flexibility, contributes to the tension experienced by nurses as they endeavour to make their role in the delivery of nutritional care compatible with technique. However, this should not be viewed as the only reason for the difficulties nurses experience in providing effective nutritional care. Nurses must hold themselves and each other accountable for contributing to the indifference in wider health care around patient mealtimes by allowing certain interruptions to this fundamental and often complex component of patient care (Barnard and Sandelowski, 2001; Bowers et al, 2001; Pearson, 2003; Kitson, 2010). Given the recurring discussion in nursing literature of the prevalence of undernutrition and nurses’ roles in nutritional care, what is now required is evidence of implementing what is known about best practice in nutritional care into the practice setting. This includes not only disseminating research projects that have been successful, but also those that have not been successful (Morgan, 2006). By understanding the barriers and enablers to creating change, nursing and organisational researchers can begin to analyse the professional and organisational factors (both within the nursing profession and across disciplines) that facilitate sustainable change to the BJN way nutritional care is delivered to patients. Conflict of interest: this research was funded by the South Australian Government Department of Health. Banks M, Ash S, Bauer J, Gaskill D (2007) Prevalence of malnutrition in adults in Queensland public hospitals and residential aged care facilities. Nutrition and Dietetics 64(3): 172–8 Barnard A (1996) Technology and nursing: an anatomy of definition. Int J Nurs Stud 33(4): 433–41 Barnard A, Sandelowski M (2001) Technology and humane nursing care: (ir) reconcilable or invented difference? J Adv Nurs 34(3): 367–75 Bastone E (1983) The Hierarchy of Maintenance and the Maintenance of Hierarchy:
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Notes on Food and Industry, in The Sociology of Food and Eating. A Murcott, ed. Gower Publishing Company Limited, England Bellman L (2003) Nurse-led Change and Development in Clinical Practice. Whurr Publishers, Philadelphia Bowers BJ, Lauring C, Jacobson N (2001) How nurses manage time and work in long-term care. J Adv Nurs 33(4): 484–91 Bowling A (2002) Research Methods in Health: Investigating Health and Health Services. Open University Press, Buckingham Bradbury H, Reason P (2006) Broadening the bandwidth of validity: issues and choice-points for improving the quality of action research. In: Reason P, Bradbury H, eds. Handbook of Action Research. Sage Publications, London Canter D, Cooper A (1988) Design context and nursing roles. In: Wallis D, de Wolff CJ, eds. Stress and Organisational Problems in Hospitals: Implications for Management. Cambridge University Press Denzin NK (1989) The Research Act–A Theoretical Introduction to Sociological Methods. 3rd edn. Prentice Hall, New Jersey Dickinson A,Welch C, Ager L (2007) No longer hungry in hospital: improving the hospital mealtime experience for older people through action research. J Clin Nurs 17(11): 1492–502 Farmer R, Robinson K, Elliot SJ, Eyles J (2006) Developing and implementing a triangulation protocol for qualitative health research. Qualitative Health Research 16(3): 377–94 Kelly IE, Tessier S, Cahill A, et al (2000) Still hungry in hospital: identifying malnutrition in acute hospital admissions. QJM 93(2): 93–8 Kitson A (2010) Reclaiming nursing care. Collegian 17(1): 1–2 Kyle UG, Pirlich M, Lochs H, Schuetz T, Pichard C (2005) Increased length of hospital stay in underweight and overweight patients at hospital admission: a controlled population study. Clin Nutr 24(1): 133–42 Lazarus C, Hamlyn J (2005) Prevalence and documentation of malnutrition in hospitals: a case study in a large private hospital setting. Nutrition and Dietetics 62(1): 41–7 Manley K, McCormack B (2004) Practice development: purpose, methodology, facilitation and evaluation. In: McCormack B, Manley K, Garbett R, eds. Practice Development in Nursing. Blackwell Publishing, Oxford Mays N, Pope C (2000) Qualitative research in health care: assessing quality in qualitative research. BMJ 320: 50 Middleton MH, Nazarenko G, Nivison-Smith I, Smerdely P (2001) Prevalence of malnutrition and 12-month incidence of mortality in two Sydney teaching hospitals. Intern Med J 31(8): 455–61 Morgan G (2006) Images of Organization. Sage Publications, Thousand Oaks Pearson A (2003) Multidisciplinary nursing: re-thinking role boundaries. J Clin Nurs 12(5): 625–9 Productivity Commission Inquiry report (2011) Caring for Older Australians,
Report No. 53, Final Inquiry Report. Canberra, Australia Reason P, Bradbury H (2006) Introduction: inquiry and participation in search of a world worthy of human aspiration. In: Handbook of Action Research. Reason P, Bradbury H, eds. Sage Publications, London Ritchie J, Spencer L, O’Connor W (2003) Carrying out qualitative analysis. In: Qualitative Research Practice: A Guide for Social Students and Researchers. Ritchie J, Lewis J, eds. Sage Publications, London Spencer L, Ritchie J, O’Connor W (2003) Analysis: practices, principles and processes. In: Qualitative Research Practice–A Guide for Social Science Students and Researchers. Ritchie J, Lewis J, eds. Sage Publications, London Spradley JP (1980) Participant Observation. Holt, Rinehart and Winston Inc, Florida Stratton RJ, Green CJ, Elia M (2003) Disease-related Malnutrition: an Evidencebased Approach to Treatment. CABI Publishing, Oxfordshire Stringer E (2013) Action Research. 4th edn. Sage Publications, California Thomas JM, Isenring E, Kellett E (2007) Nutritional status and length of stay in patients admitted to an Acute Assessment Unit. J Hum Nutr Diet 20(4): 320–8 Tsang MF (2008) Is there adequate feeding assistance for the hospitalised elderly who are unable to feed themselves? Nutrition and Dietetics 65(3): 222–8 Ullrich S, McCutcheon H, Parker B (2011) Reclaiming time for nursing practice in nutritional care: outcomes of implementing Protected Mealtimes in a residential aged care setting. J Clin Nurs 20(9–10): 1339–48. doi: 10.1111/j.1365-2702.2010.03598.x Wadsworth Y (2006) The mirror, the magnifying glass, the compass and the map: facilitating participatory action research. In: Handbook of Action Research. Reason P, Bradbury H, eds. Sage Publications, London Weekes CE, Elia M, Emery PW (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). Clin Nutr 23(5): 1104–12 Xia C, McCutcheon H (2006) Mealtimes in hospital–who does what? J Clin Nurs 15(10): 1221–7 Young L (2006) Participatory action research (PAR): a research strategy for nursing? West J Nurs Res 28(5): 499–504
UROLOGY The British Journal of Nursing (BJN) Urology Supplement aims to promote evidence-based practice and the provision of high quality patient care. We welcome unsolicited articles including literature reviews, care studies and original research in all areas of urology. To contribute to the supplement or to enquire about how to become a peer reviewer in this area, contact us at [email protected] or 0207 501 6702.
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Despite being preventable and treatable, undernutrition remains a problem for many older people in tertiary healthcare settings. Nurses have a crucial role in assisting people who are unable to eat independently and are uniquely positioned to implement solutions that will lead to better nutritional care. However, what is known about the management of undernutrition is not informing nursing practice. This study used action research, underpinned by the ‘participatory world view’, to address the theory-practice gap. Data and between-method triangulation were used to collect and analyse qualitative non-participant observations and action research group data. Set Up Ready For Dining (SURFD) was developed and implemented by nurses to improve patient mealtimes. Findings show that nursing practice in nutritional care is influenced by technique within the healthcare context that emphasises operational efficiency, and by the choices that nurses made around being the patient advocate during mealtimes. Key words: Nutrition ■ Malnutrition ■ Older people ■ Nursing practice
T
he prevalence of undernutrition in older adults is reported to be a common occurrence in tertiary health care settings (Banks et al, 2007). The reasons for undernutrition are multifactorial and connected to: the history of nursing and the widening gap between nursing practice and the act of nourishing; current views around whose role it is to provide nutritional care; and technique within the healthcare context that ‘emphasise[s] a primacy of means, efficiency, and rational order’ (Barnard and Sandelowski, 2001: 372).
Background Australia’s population is set to change significantly over the next 50 years. According to the Productivity Commission Report (2011), the number of people aged 65 years and over is expected to more than double, from 2.7 million to 6.3 million, and will represent 24% of the total population in 30 years from now. Current evidence shows that older people Sandra Ullrich, Lecturer, School of Nursing and Midwifery, University of South Australia, Adelaide; Helen McCutcheon, Professor of Nursing, Florence Nightingale School of Nursing and Midwifery, King’s College London; Barbara Parker, Programme Director, School of Nursing and Midwifery, University of South Australia, Adelaide Accepted for publication: January 2015
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are the biggest users of tertiary healthcare facilities compared with their younger counterparts (Productivity Commission Report, 2011). Therefore, the ageing of Australia’s population and the health of Australia’s older population can be expected to affect both the demand for, and provision of, healthcare services. Consequently, healthcare organisations will face increasing pressures to provide better and more efficient health care. Internationally, the prevalence of undernutrition in older patients ranges from 12% to 84% (Stratton et al, 2003) with a study into medical records showing that up to 70% of cases go undiagnosed (Kelly et al, 2000). Australian studies show that the prevalence of undernutrition in tertiary healthcare settings ranges between 12% and 53% (Middleton et al, 2001; Lazarus and Hamlyn, 2005; Thomas et al, 2007). These findings indicate a real need for recognising patients at nutritional risk and implementing effective management strategies to optimise clinical outcomes (Kelly et al, 2000; Middleton et al, 2001; Weekes et al, 2004; Kyle et al, 2005). Although there is no single reason for poor nutritional intake, it appears that the act of including machinery and equipment (i.e. technology) in nursing practice introduces patterns of technological activity that, by their very nature, change or modify nursing behaviour (Barnard, 1996). Some authors suggest that changes in the design and layout of hospitals, geared to the functional and technological, convey mixed social and psychological messages to both nurses and patients (Canter and Cooper, 1988). On the one hand, healthcare organisations symbolise warmth and caring as the foundation for treatment; on the other, they have come to symbolise the curative power of technology. It is this paradox that may cause nurses to distance themselves from patients as a way of resolving this conflict (Canter and Cooper, 1988; Bowers et al, 2001). By contrast, Barnard and Sandelowski (2001) argue that it is technique within the healthcare context that has increasingly structured collective behaviour and professional perspectives. Technique within the healthcare context—with its emphasis on a primacy of means, efficiency and rational order— influences the choices that are made, and these choices do not necessarily attend to such phenomena as the human and cultural differences, feelings and meanings associated with mealtimes (Bastone, 1983; Barnard and Sandelowski, 2001; Kitson, 2010). Therefore, it is technique within the healthcare context that contributes to the functional approach to mealtimes, where meals are provided in a context of rules governing work and especially of time-constraint, rather than the domestic approach, where meals are provided to meet
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Sandra Ullrich, Helen McCutcheon and Barbara Parker
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The study This study was part of a larger research project that investigated nursing practice in nutritional care. A two-stage approach was required in which stage one was conducted in a residential aged care unit (Ullrich et al, 2011) and stage two was conducted in a tertiary healthcare setting. This paper will present stage two of the research project. Specifically, focus will be applied to the action research process and the long-term outcomes of the intervention to improve nursing practice in nutritional care.
Aims The aims of this study were: ■■ To assist participants in identifying the barriers and enablers to best practice in nutritional care ■■ To provide participants with the opportunity to identify and implement an intervention to improve nutritional care ■■ To assist participants in being critical and reflective as part of their decision-making process ■■ To evaluate the change that was made in relation to quality in action research.
Theoretical framework Reason and Bradbury define action research as a participatory, democratic process concerned with developing practical knowing in the pursuit of worthwhile human purposes. It seeks to bring together action and reflection, theory and practice, in participation with others, in the pursuit of practical solutions to issues of pressing concern to people, and more generally the flourishing of individual persons and their communities (Reason and Bradbury, 2006: 1). Action research was used because: it focuses on change and improvement; involves participants in the research process; looks at questions that arise from practice; involves a cyclical process of collecting information, feedback and reflection; and is an approach that generates knowledge (Stringer, 2013). The emancipatory and educational aims of action research resonate with the goals of nursing and, with its roots in the social and political sciences and organisational change, action research has the capacity to create sustainable change in the way healthcare organisations deliver patient care. Action research has the potential to foster an agenda for research among nurses by including them in research that is conducted alongside everyday practice (Stringer, 2013; Bellman, 2003; Manley and McCormack, 2004;Young, 2006). Action research is gaining recognition and acceptance within nursing practice as it demonstrates versatility in its application and capacity to catalyse change. This action research study followed the cyclic phases of: ‘Look’: building the picture; ‘Think’: interpreting and analysing; ‘Act’: planning and implementing solutions; and ‘Look’: reviewing progress and evaluating (Stringer, 2013). The principles of the ‘participatory world view’ governed the use of action research for this study. These principles involved incorporating collaboration and democracy in decisionmaking processes. Participants defined the issues and identified the solutions, making the whole process more meaningful for
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them. The participatory world view acknowledges that there are different forms of knowing and that the cyclic process of action research creates new knowledge such as new skills of inquiry and how to become co-researchers with one another. The participatory world view works towards practical and sustainable outcomes and recognises that the action research process develops over time (Reason and Bradbury, 2006).
Quality in action research There has been significant debate regarding the need for proof that the processes used in qualitative research are rigorous and credible (Mays and Pope, 2000; Bradbury and Reason, 2006). Some action research practitioners question whether we are trying to fit the qualities of action research into traditional discourse about validity, as they do not acknowledge its action-orientated outcomes (Bradbury and Reason, 2006). As a result, the term ‘quality’ has been offered as an alternative to ‘validity’ because of its wider connotations (Bradbury and Reason, 2006). Quality in action research considers the participative metaphor and the relationship between our participation in creating our world and our necessary actions, which leads us to consider how to judge the quality of our actions (Reason and Bradbury, 2006). This study addressed the issue of quality by relating the five interrelated dimensions of the participatory world view with eight choice-points and questions (Bradbury and Reason, 2006). These include: ‘quality as relational praxis; quality as reflexive-practical outcomes; quality as plurality of knowing; quality as engaging in significant work and emergent inquiry towards enduring consequences’ (Bradbury and Reason, 2006: 346–9).
Setting and participants This study was conducted in a metropolitan tertiary healthcare setting in Adelaide, South Australia—specifically, a 28-bed medical ward. This ward was chosen because patients required a high level of care provided by a team of approximately 75 registered nurses and 25 enrolled nurses. Eight registered nurses (RNs) and six enrolled nurses (ENs) participated in the first action research group discussion. However, participant numbers fluctuated with the addition of other clinical nurses, the nurse manager, RNs, ENs and nursing students. In total, 24 tertiary healthcare nurses regularly participated in the action research group discussions. Naturalistic recruitment was used whereby nurses who were interested in nutritional care were invited to attend an information session. Over time, these participants encouraged other nurses to participate in the study (Wadsworth, 2006). Ethics approval for the study was granted by the University of South Australia’s Human Research Ethics Committee and the tertiary healthcare organisation’s ethics committee.
Method A multi-method approach was used for this action research study.The strategies of data and between-method triangulation were chosen to assist in understanding the multidimensional issues associated with patient mealtimes and the provision of nutritional care (Farmer et al, 2006; Ullrich et al, 2011). Between-method triangulation allowed for the use of either
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principally social goals and personal needs, tastes and comforts (Bastone, 1983).
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CLINICAL FOCUS two or more methods, such as non-participant observation and action research group discussions to collect and interpret data. The use of action research group data complemented the non-participant observational data and enhanced the data’s confirmability (Denzin, 1989).
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Phase 1—Look: building the picture The first phase of the action research cycle, ‘Look: building the picture’, assisted in gathering important information about the people and context in order to develop a detailed picture of nursing practice nutritional care within a tertiary healthcare environment (Stringer, 2013). Three weeks (including weekends) of non-participant observations were conducted of morning, midday and evening mealtimes, and snack periods. Non-participant observation allowed phenomena to be observed naturalistically and provided a contextualised understanding of patients’ experiences of mealtimes and factors that influenced and directed the efforts of nurses in this fundamental aspect of patient care (Bowling, 2002). Data collection and analysis were informed by aspects of the developmental research sequence, which consists of eight steps and assisted in understanding the culture of more complex social worlds, and facilitated action research group discussion (Spradley, 1980). These steps consisted of the identification of: social situations; clusters of situations and networks of situations in which nutritional care was provided (Spradley, 1980). A descriptive matrix guided the collection of data, and domain analysis allowed for the systematic examination of the recordings to determine its parts, the relationship among parts and the relationship to the whole (Spradley, 1980). A taxonomic analysis assisted in revealing the way phenomena were organised and the way they related to one another. Nonparticipant observation data collection involved a non-linear approach and as such there was continual movement along the developmental research sequence (Spradley, 1980). Following the non-participant observations, the first of four action research group discussions were held, which were taperecorded, transcribed verbatim (word for word) and with the researcher’s non-participant observational field notes provided qualitative data. The non-participant observations were presented to the participants with the aim of brainstorming the barriers and enablers to nursing practice in nutritional care.The action research group provided the context in which to stimulate discussion; pursue the topic in greater depth; gain and obtain different but complementary data on nursing practice in nutritional care—and thereby enhance the quality of the research (Bowling, 2002). Analysis of the action research group data was qualitative, using the interpretative inductive approach of the ‘analytic hierarchy’ (Spencer et al, 2003). The analytic hierarchy is described conceptually whereby the process of data management and analysis involves movement between nine ‘viewing platforms’, each of which involves different analytical tasks while providing an overview of the data (Spencer et al, 2003: 213). The analytic process was nonlinear; for this reason, the analytic hierarchy is shown with ladders linking the platforms, enabling movement both up and down the structure (Spencer et al, 2003). Data analysis involved immersion in the data by reading, identifying initial concepts and labelling the data by way of indexing. Data were
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sorted by concept so that materials with similar properties were located together and associatively analysed by noting the concepts that weaved in and out. The essence of the data was extracted as evidence for later representation. Descriptive analysis involved the exploration of data by detection, categorisation and classification, with the aim of presenting information that was authentic, meaningful and provided content that was illuminating (Ritchie et al, 2003).
Phase 2—Think: analysing and planning The second phase of the action research cycle, ‘Think: interpreting and analysing’, provided the momentum for the action research group to identify an intervention to improve nursing practice in nutritional care (Stringer, 2013). By using the information collected in phase one, participants collaboratively clarified with each other their understanding of patient mealtimes and nursing practice in nutritional care, identified priorities for action, and developed an action plan that led to a resolution of the problems (Stringer, 2013). Collaboratively, the nurses developed an intervention called Set Up Ready for Dining (SURFD), which was designed to assist nurses in initiating pre-meal preparation time and ensuring that patients and the environment were prepared. The activities included: ■■ Encouraging/assisting with toileting before meal delivery to minimise mealtime interruptions ■■ Positioning patients appropriately before meals (such as sit up in bed, sit out of bed) ■■ Ensuring the mealtime environment was uncluttered (such as clearing overbed table and moving overbed to within patient’s reach) ■■ Preparing for the mealtime approximately 30 minutes before expected meal delivery.
Phase 3—Act: solving problems and implementing solutions The third phase of the action research cycle, ‘Act: planning and implementing solutions’, involved the implementation of SURFD (Stringer, 2013). Implementation dates were set; flyers were strategically placed around the ward; and information sheets were placed in all staff pigeon holes, informing staff of the initiative. A 2-week trial period of SURFD was implemented.
Phase 4—Look: reviewing progress and evaluating The fourth phase of the action research cycle,‘Look: reviewing progress and evaluating’, involved making judgements, through the processes of reflection and critical thinking, about the effects of SURFD and to conclude whether or not it had been successful (Stringer, 2013). The non-participant observations of nursing practice during phase three were presented back to the action research group for collaborative evaluation.
SURFD’s long-term outcomes As is appropriate in an action research study, an evaluation of SURFD was made 4 months after its initial implementation (Stringer, 2013). Two weeks (including weekends) of nonparticipant observations were conducted of morning, midday
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Nursing practice Non-participant observation of the mealtime environment showed that some patients were inadequately positioned for mealtimes, either lying too flat or positioned too low in the bed or slouching to one side. Overbed tables were also positioned too high for some patients (ie. shoulder height or at nose level). Nurses were observed implementing SURFD by combining or ‘bundling’ it with other nursing care duties such as taking patient observations, blood sugar levels, administering medications, documenting, weighing patients, supervising student nurses, assisting other nurses with patient transfers and medication checks (Bowers et al, 2001). The implementation of SURFD was hindered when nurses were separated from patients owing to staff meal breaks and because nurses had to rectify problems associated with incorrect meal deliveries. SURFD was also hindered by factors that separated patients from the mealtime environment, such as having to attend ultrasound appointments. Visiting allied health professionals also separated patients from their meal by treating patients before and during mealtimes. Therefore, the successful implementation SURFD relied on an uninterrupted mealtime environment for patients and nurses and, importantly, keeping nurses and patients in the ward at mealtimes.
The mealtime environment Non-participant observations showed that clinical noise contributed to what appeared to be a chaotic atmosphere before and during patient mealtimes. Clinical noise included phone calls, patient call bells, ‘code blues’ (medical emergencies), monitors and cleaning equipment, loud visitors and the sound of foot traffic. The patient bays were observed, at times, to be less cluttered before and during mealtimes. However, nebuliser pumps, dressing packs, towels, gowns and patients’ personal items remained on some patients’ overbed tables during meal delivery.
Technique within the healthcare context Action research group discussions provided insights into why nurses were unable to enact the activities of SURFD at patient mealtimes. In particular, technique within the healthcare context influenced how SURFD was implemented (Barnard and Sandelowski, 2001). The following statement highlights the emphasis of technique within this healthcare context and that ‘being flexible’ was very important to the operational efficiency of a busy medical ward:
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‘I don’t want it [SURFD] to be regimented … they [nurses] need to be bending, like a tree they need to blow with the wind. This week’s going to be flat out, they need to change their whole routines, as long as something’s systematically happening to keep them on track.’ (Nurse, 9 July 2009) Nurses stated that SURFD was a flexible approach to preparing patients and the environment for mealtimes. However, this flexibility also diminished nurses’ ability to implement SURFD because of the choices they made in terms of its priority: ‘I think another thing is that our focus here in the morning is to do observations and medication when you come out from handover; there isn’t a focus on meals.’ (Nurse, 17 November 2008) It appears that the implementation of SURFD was dependent not only on the nature of the ward during patient mealtimes, but also on the decisions made by nurses in terms of its prioritisation amid other nursing responsibilities. Nurses also stated that the interruptions of doctors and allied health care visits affected the implementation of SURFD and that the perfect mealtime environment was one that was free from these interruptions: ‘At lunch times, implementing SURFD still has issues—sort of allied health and doctors coming round.’ (Nurse, 6 July 2009) ‘To get the doctors and allied health off the ward at lunchtime would be perfect … when it [SURFD] gets done it’s been worthwhile.’ (Nurse, 6 July 2009)
Choices that nurses make However, despite these concerns, some nurses chose not to secure the time necessary for the implementation of SURFD. In particular, there were mixed perceptions around whether or not nurses could ask unnecessary visitors to the ward not to interrupt the preparation of patients and the environment for mealtimes as the following conversation shows: ‘I’ve had a go at doctors when they came round at lunchtime and I say, “Hey, this is a bit late, why are you doing it at this time? You’re coming in disturbing me with changing medications, you know, while I’m supposed to be concentrating on meals.” I have challenged the doctors sometimes.’ (Nurse 1) ‘I probably won’t challenge them.’ (Nurse 2) ‘Why not?’ (Facilitator) ‘I don’t know, I guess it’s my role as well, where I stand at the moment, I would tell someone, but I would tell my senior.’ (Nurse 1) ‘But you’re the patient advocate!’ (Nurse 2) (Conversation, 9 July 2009)
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and evening mealtimes and snack periods to determine whether SURFD was part of everyday nursing practice and to identify the barriers to, and enablers of, its sustainability. Two action research group discussions were held to provide participants with the opportunity to voice their opinions about SURFD and to discuss any continuing issues around nursing practice in nutritional care. The participants involved in the action research group discussions included past and new nursing participants.
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CLINICAL FOCUS Reconnecting to nutritional care Importantly, nurses spoke of how SURFD reconnected them back to their role in providing nutritional care: ‘I think for the patient–nurse relationship it’s identified that—hang on, I need to slow down here and actually make sure my patient’s eating, I want to eat, you need to eat as well. ’(Nurse, 9 July 2009) Returning to the fundamentals of nursing practice through the implementation of SURFD contributed to the delivery of better nursing care and better patient experiences at mealtimes: ‘I think it’s made us more aware … and honing in on that time to sit the patients up and to create that environment where they can actually sit up and eat, you know, and do for themselves.’ (Nurse, 6 July 2009) ‘I think that the patient enjoys being able to sit and eat their meal instead of lying there and waiting for somebody to get them ready, especially if they can see it and they can’t move to get it.’ (Nurse, 6 July 2009)
Limitations This project was undertaken in a tertiary healthcare setting and addressed specific issues in nutritional care. Therefore, care should be taken when extrapolating these findings to other settings (Bowling, 2002).
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Conclusion Action research facilitated change to nursing practice in nutritional care and enhanced nurses’ awareness of the importance of patient mealtimes (Stringer, 2013). Action research has previously been used to improve patient mealtimes within a tertiary setting, which led to positive outcomes such as staff reconnecting with, prioritising and participating in patient mealtimes (Dickinson et al, 2007). The common thread that unites the study by Dickinson et al (2007) and this study is the concept of reconnecting nurses to their role in providing fundamental patient care during mealtimes.This has some important implications for care outcomes, as evidence is accruing that the time nurses spend providing mealtime assistance is insufficient and not provided in a timely manner (Xia and McCutcheon, 2006; Tsang, 2008). However, to reconnect nurses back to nutritional care we need to understand that nursing practice is not only influenced by technique within the healthcare context but by the choices that nurses make in being the patient advocate during patient mealtimes. These choices often align with the functional approach to mealtimes where meals are provided in a context of rules governing work and especially of time constraint (Bastone, 1983). Nurses do this by managing patient mealtimes in order to maintain operational efficiency and by their perceived obligations toward medical and allied health professionals during this time. These decisions have contributed to the development of a healthcare culture in which medical staff and allied health professionals have
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KEY POINTS n Despite
being preventable and treatable, undernutrition remains a problem for many older patients within tertiary healthcare settings
n Nurses
are uniquely positioned to implement solutions that will lead to better nutritional care. But what is known about the management of undernutrition is not informing nursing practice
n Nursing
practice in nutritional care is influenced by technique within the healthcare context, which emphasises operational efficiency over a domestic approach whereby meals meet social and personal needs
n By
allowing interruptions to the provision of nutritional care, nurses have contributed to the culture of indifference within health care towards nurses’ role in nutritional care and the management of patients’ mealtimes in general
become aware of nurses’ flexibility during patient mealtimes and use it to their advantage. In turn, the choices made by nurses that make them unavailable when help is needed most can have a debilitating effect on the ill and frail, and reinforce the insignificance of mealtimes and diminish the role of the nurse in nutritional care within the wider healthcare context (Bowers et al, 2001). Technique within the healthcare context, which emphasises operational efficiency through nursing flexibility, contributes to the tension experienced by nurses as they endeavour to make their role in the delivery of nutritional care compatible with technique. However, this should not be viewed as the only reason for the difficulties nurses experience in providing effective nutritional care. Nurses must hold themselves and each other accountable for contributing to the indifference in wider health care around patient mealtimes by allowing certain interruptions to this fundamental and often complex component of patient care (Barnard and Sandelowski, 2001; Bowers et al, 2001; Pearson, 2003; Kitson, 2010). Given the recurring discussion in nursing literature of the prevalence of undernutrition and nurses’ roles in nutritional care, what is now required is evidence of implementing what is known about best practice in nutritional care into the practice setting. This includes not only disseminating research projects that have been successful, but also those that have not been successful (Morgan, 2006). By understanding the barriers and enablers to creating change, nursing and organisational researchers can begin to analyse the professional and organisational factors (both within the nursing profession and across disciplines) that facilitate sustainable change to the BJN way nutritional care is delivered to patients. Conflict of interest: this research was funded by the South Australian Government Department of Health. Banks M, Ash S, Bauer J, Gaskill D (2007) Prevalence of malnutrition in adults in Queensland public hospitals and residential aged care facilities. Nutrition and Dietetics 64(3): 172–8 Barnard A (1996) Technology and nursing: an anatomy of definition. Int J Nurs Stud 33(4): 433–41 Barnard A, Sandelowski M (2001) Technology and humane nursing care: (ir) reconcilable or invented difference? J Adv Nurs 34(3): 367–75 Bastone E (1983) The Hierarchy of Maintenance and the Maintenance of Hierarchy:
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Notes on Food and Industry, in The Sociology of Food and Eating. A Murcott, ed. Gower Publishing Company Limited, England Bellman L (2003) Nurse-led Change and Development in Clinical Practice. Whurr Publishers, Philadelphia Bowers BJ, Lauring C, Jacobson N (2001) How nurses manage time and work in long-term care. J Adv Nurs 33(4): 484–91 Bowling A (2002) Research Methods in Health: Investigating Health and Health Services. Open University Press, Buckingham Bradbury H, Reason P (2006) Broadening the bandwidth of validity: issues and choice-points for improving the quality of action research. In: Reason P, Bradbury H, eds. Handbook of Action Research. Sage Publications, London Canter D, Cooper A (1988) Design context and nursing roles. In: Wallis D, de Wolff CJ, eds. Stress and Organisational Problems in Hospitals: Implications for Management. Cambridge University Press Denzin NK (1989) The Research Act–A Theoretical Introduction to Sociological Methods. 3rd edn. Prentice Hall, New Jersey Dickinson A,Welch C, Ager L (2007) No longer hungry in hospital: improving the hospital mealtime experience for older people through action research. J Clin Nurs 17(11): 1492–502 Farmer R, Robinson K, Elliot SJ, Eyles J (2006) Developing and implementing a triangulation protocol for qualitative health research. Qualitative Health Research 16(3): 377–94 Kelly IE, Tessier S, Cahill A, et al (2000) Still hungry in hospital: identifying malnutrition in acute hospital admissions. QJM 93(2): 93–8 Kitson A (2010) Reclaiming nursing care. Collegian 17(1): 1–2 Kyle UG, Pirlich M, Lochs H, Schuetz T, Pichard C (2005) Increased length of hospital stay in underweight and overweight patients at hospital admission: a controlled population study. Clin Nutr 24(1): 133–42 Lazarus C, Hamlyn J (2005) Prevalence and documentation of malnutrition in hospitals: a case study in a large private hospital setting. Nutrition and Dietetics 62(1): 41–7 Manley K, McCormack B (2004) Practice development: purpose, methodology, facilitation and evaluation. In: McCormack B, Manley K, Garbett R, eds. Practice Development in Nursing. Blackwell Publishing, Oxford Mays N, Pope C (2000) Qualitative research in health care: assessing quality in qualitative research. BMJ 320: 50 Middleton MH, Nazarenko G, Nivison-Smith I, Smerdely P (2001) Prevalence of malnutrition and 12-month incidence of mortality in two Sydney teaching hospitals. Intern Med J 31(8): 455–61 Morgan G (2006) Images of Organization. Sage Publications, Thousand Oaks Pearson A (2003) Multidisciplinary nursing: re-thinking role boundaries. J Clin Nurs 12(5): 625–9 Productivity Commission Inquiry report (2011) Caring for Older Australians,
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UROLOGY The British Journal of Nursing (BJN) Urology Supplement aims to promote evidence-based practice and the provision of high quality patient care. We welcome unsolicited articles including literature reviews, care studies and original research in all areas of urology. To contribute to the supplement or to enquire about how to become a peer reviewer in this area, contact us at [email protected] or 0207 501 6702.
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Supplement published twice a year covering all aspects of urology nursing from infection prevention to uro-oncology and long-term conditions
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