Investigating the nutritional status and care of older (≥65 years) general surgical patients: a multiphase, action research study

Abstract

Background: Aligning care with best practicesuch as Enhanced Recovery After Surgery (ERAS) guidelinesmay improve patient outcomes. However, translating research into practice is challenging and implementation science literature emphasises the importance of understanding practice within the local context. This study aimed to explore staff perceptions about barriers and enablers to practice change aligning with nutrition-related recommendations from ERAS guidelines. Methods: A qualitative study using a maximum variation sampling method. Clinicians involved in care of patients admitted to two general surgical wards consented to participate in semi-structured interviews. Framework analysis was undertaken using the integrated Promoting Action on Research Implementation in Health Services framework to identify a priori and emergent themes. Results: From interviews with 13 clinicians (two surgical consultants, one registrar, one intern; one anaesthetist; two nurse unit managers, one surgical nurse coordinator, three nurses; two dietitians), three major themes were identified: a) complexity of the context (e.g. unpredictable theatre times, requirement for flexibility, and large, multidisciplinary workforce); b) strong decision making hierarchy, combined with lack of knowledge, confidence or authority of junior and nonsurgical staff to implement change; and c) poor communication and teamwork (within and between disciplines). These barriers culminate in practice where default behaviours are habit, and the view that achieving clinical consensus is challenging. Conclusions: This study highlights the necessity for a multifaceted implementation approach that simplifies the process, flattens the power differential and facilitates communication and teamwork. Other facilities may consider these findings when implementing similar practice change interventions.