Abstract
Purpose
To develop an intervention enhancing hospitalized older adults’ nutrition.
Methods
For the first time, a mixed-methods design with data triangulation was applied according to the six-step model of Corry et al. to elaborate on a complex nursing intervention in the form of a logic model. Patients who were aged ≥80 years and hospitalized for at least 5 days were included. Sample size for quantitative practice analysis was 135 older adults, whereas 22 older inpatients participated in interviews and observations for needs analysis and generated data for key principles.
Findings
The intervention “Eat Enough” encompasses nursing team culture and comprises six actionable targets to deliver needs-based support and reach required protein and energy intake for hospitalized older adults by sensitizing nurses and the interprofessional team. Facilitating nutritional intake would be supported by an advanced practice nurse who considers the medical and nursing care plan and therapy.
Conclusions
The intervention “Eat Enough” demonstrates that nurses play a key role in interprofessional teams to enhance older adults’ nutrition in hospital. The pipeline model displays how the actionable targets can be achieved, and how awareness raising can influence the context—leading to raised calories and protein requirement coverages and shorter length of stay.
Implications for clinical practice
By identifying risk factors of malnutrition and strengthening nurses’ responsibilities, the intervention “Eat Enough” could significantly enhance nutrition among hospitalized older adults. However, the logic model should be tested and implemented in future research.
Zweck
Entwicklung einer Intervention zur Verbesserung der Ernährung von älteren Menschen im Krankenhaus.
Methoden
Zum ersten Mal wurde ein Mixed-Methods-Design mit Datentriangulation nach dem Sechs-Schritte-Modell von Corry et al. angewandt, um eine komplexe Pflegeintervention in Form eines Logikmodells zu erarbeiten. Eingeschlossen wurden Patient*innen im Alter von ≥ 80 Jahren mit einem Krankenhausaufenthalt von mindestens fünf Tagen. Die Stichprobengröße für die quantitative Praxisanalyse betrug 135 ältere Erwachsene, während 22 ältere Erwachsene an Interviews und Beobachtungen für die Bedarfsanalyse teilnahmen und Daten für die Schlüsselprinzipien generierten.
Ergebnisse
Die Intervention “GENUG ESSEN” umfasst die Kultur des Pflegeteams und beinhaltet sechs Handlungsziele zur bedarfsgerechten Unterstützung und Erreichung der erforderlichen Protein- und Energiezufuhr für ältere Erwachsene im Krankenhaus durch Sensibilisierung des Pflegepersonals und des interprofessionellen Teams. Dazu gehört das Erfassen des Risiko für unausgewogene Protein-Energiezufuhr. Die Nahrungsaufnahme könnte von einer Advanced Practice Nurse unterstützt werden, welche den medizinischen Therapieplan und Pflegediagnosen mit kohärenten Massnahmen berücksichtigt.
Schlussfolgerungen
Die Intervention “GENUG ESSEN” zeigt, dass Pflegekräfte in interprofessionellen Teams eine Schlüsselrolle bei der Verbesserung der Ernährung älterer Erwachsener im Krankenhaus spielen. Das Pipeline-Modell stellt dar, wie die umsetzbaren Ziele erreicht werden können und wie die Bewusstseinsbildung den Kontext beeinflussen kann, was zu einer erhöhten Kalorien- und Proteinbedarfsdeckung und einer kürzeren Aufenthaltsdauer führt.
Implikationen für die Pflegepraxis
Durch die Identifizierung von Risikofaktoren für Mangelernährung und die Stärkung der Verantwortung des Pflegepersonals könnte die Intervention “GENUG ESSEN” die Ernährung von hospitalisierten älteren Erwachsenen deutlich verbessern. Das Logik Modell muss in zukünftigen Untersuchungen getestet und umgesetzt werden.
Schlüsselwörter
Pflegediagnose, Logikmodell, hospitalisierte ältere Erwachsene, Risiko für unausgewogene Protein-Energiezufuhr, interprofessionelles Team.
Keywords
INTRODUCTION
As the population ages (Kelley et al., 2018), the number of older adults in hospitals also increases (Bakerjian, 2022), accompanied by higher rates of patients with multimorbidity and malnutrition (Volkert, Beck, Cederholm, Cruz-Jentoft, et al., 2019; Volkert et al., 2020). Older people with acute or chronic health conditions require comprehensive care and medical treatment (i.e., geriatric medicine). Complex health and medical conditions that need such comprehensive care often occur in people aged 80 years or older (UEMS, 2021). The consequences of malnutrition in older patients include the increased risks of wound infections, acute confusion, and falls, as well as higher mortality rates in people who are malnourished than in those who meet the nutritional requirements (Volkert, Beck, Cederholm, Cruz-Jentoft, et al., 2019). Eating and nutrition contribute to health and recovery. Moreover, individualized nutrition-related interventions can reduce hospital length of stay, readmission, and healthcare costs (Fitall et al., 2019; Schuetz et al., 2019). Several guidelines and intervention studies suggest improving hospitalized older adults’ nutrition (Brunner et al., 2022; Volkert, Beck, Cederholm, Cereda, et al., 2019). However, the specific ways of addressing this, such as weighing patients and conducting risk assessments, are often lacking (Arensberg et al., 2022). The preliminary results of an interprofessional nurse-led project demonstrated that older adults’ nutrition in hospitals was influenced by interactions among patients, nurses, and various interprofessional team members (Grob et al., 2018). The results of the nurse-led project indicated that nutrition of older adults in hospitals is a complex issue, underscored by the fact that the risk of malnutrition is influenced by reduced oral protein and calorie intake or increased protein and calorie requirements, whereas both factors are again affected by environmental and organizational context as well as personal reasons (Volkert, Beck, Cederholm, Cruz-Jentoft, et al., 2019). Additional indicators of complex nursing interventions include flexibility in delivering interventions and the number of outcome-based targets (Schutte, 2021; Skivington et al., 2021).
Theoretical background
Professional nurses care about, assess, and diagnose people's reactions to their health situations and plan and deliver interventions accordingly (Herdman et al., 2021). These multilayered tasks and responsibilities are integrated into standardized nursing languages, such as the NANDA-International Nursing Diagnoses (Herdman et al., 2021), the Nursing Intervention Classification (NIC) (Wagner et al., 2022), and the Nursing Outcome Classification (NOC) (Moorhead et al., 2023). The concept of the Advanced Nursing Process represents an evidence-based reflection on the body of nursing knowledge and is a new, valid version of the nursing process (Leoni-Scheiber et al., 2020). Several guidelines and intervention studies suggested improving older adults’ nutrition in hospitals; however, a risk diagnosis and a nursing intervention had not existed at that time (Brunner et al., 2022). Research about interventions to improve nutrition in older people has been presented recently (Volkert et al., 2020). Yet, a focus on how to implement these interventions into practice, how to support nurses in nutrition-related care, and which nursing interventions would be effective in hospitalized older adults was missing (Brunner et al., 2022). Using a program theory approach for intervention development could respond to the above-mentioned issues (O'Cathain et al., 2019; Wallner et al., 2023). In general, a program theory offers a way to unravel the processes leading to changed behavior and, further on, to positive effects of nursing interventions by explaining their mechanisms of action and demonstrating how they contribute to positive health outcomes (Wallner et al., 2023). Behavior change occurs in five stages: “precontemplation, contemplation, preparation, action, and maintenance” (Michie et al., 2014, p. 445ff; Prochaska & Velicer, 1997; Velicer et al., 1998). A theory of change is the baseline of the current research methodology (De Silva et al., 2014; Eldredge et al., 2016; Michie et al., 2014). Program theory development is an iterative process that can be reviewed, refined, and adapted at each stage of intervention development (Skivington et al., 2021). It was assumed that a program theory describing how to change the attitude of an interprofessional team was necessary to enhance hospitalized older adults’ nutrition and provide a way to evaluate the intervention program's effect.
Interprofessional care is defined as the collaboration and coordination among personnel from various health professions with patients and their families to enhance care quality and reduce healthcare costs (Hintenach & Howe, 2020; Labrague et al., 2022). Empirical evidence suggests that structured, systematic interprofessional collaboration reduces complications and enhances patient-related outcomes, especially for hospitalized older adults (Hintenach & Howe, 2020; Olotu et al., 2019).
Purpose
The study aimed to develop a program theory in the form of a logic model to describe a complex intervention enhancing older hospitalized adults’ nutrition by describing how to change the attitude of a nursing team.
METHODS
A convergent parallel mixed-methods design with method and data triangulation was applied according to Corry et al.’s (2013) model of developing complex interventions. This complex intervention will lead to the development of a logic model, displayed with a pipeline model.
Design
The six-step model of Corry et al. (2013) provides the methodological framework for a comprehensible, structured procedure. This study addressed steps (1)–(5): (1) problem identification; (2) identify overall objective; (3) identify key principles to guide the intervention; (4) build the intervention and plan delivery of the intervention; and (5) model the intervention, seek expert review, and develop the intervention (Figure 1).
Intervention development according to the model by Corry et al. (2013).
Setting
The setting for data collection of the problem identification that included needs analysis, practice analysis, and policy strategy analysis was an urban acute care hospital with 200 beds. About 70% of all patients in this hospital were admitted via the emergency department, with an average length of stay of 6.9 days and a mean age of 68 years (Stadtspital Zürich Waid, 2018). The proportion of patients aged >80 years was 38% (Hauri, 2021). Sub-settings for data collection were one perioperative, one internal medicine, and one acute geriatric ward for generally insured patients.
Problem identification
Sampling: Patients who were aged ≥80 years and hospitalized for at least 5 days were included in the purposive convenience sample. Older adults were chosen because of their demographically known risk for multimorbidity and malnutrition (Volkert, Beck, Cederholm, Cruz-Jentoft, et al., 2019). Patients with enteral tube feeding or parenteral nutrition and terminally ill persons (determined from medical and/or nursing reports) were excluded. The number of participants was based on feasibility to get a similar number of participants per sub-setting.
Practice analysis
Data collection: The practice analysis corresponded to the investigation of nutritional status and food intake, from which nutrition-related needs were derived by experts in the field. Food-intake protocols of 45 patients per sub-setting were collected from September 2018 to June 2019 during 5 days with three mealtimes per patient. Based on 2025 food-intake protocols, a “protein or calorie requirement—coverage ratio” was synthesized. The following two formulas were used: calories intake related to calories requirement—(1) 30 kcal/kg of body weight per day (Volkert, Beck, Cederholm, Cruz-Jentoft, et al., 2019) and (2) protein intake related to protein requirement: 1 g of protein per kilogram of body weight per day (Volkert, Beck, Cederholm, Cruz-Jentoft, et al., 2019)—with a targeted 100% coverage of calories and protein requirements (Rosenberger et al., 2019). Clusters were sought, linking cases with similar calorie and protein requirement coverage rates and seeking for correlations of these nutritional variables to other patient characteristics such as the number of nursing diagnoses or medical diagnoses, length of hospital stay, and body mass index.
Policy analysis
Data collection: The policy analysis was conducted with an umbrella review (Aromataris et al., 2017) and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement (Page et al., 2021), summarizing interventions to optimize nutrition in hospitalized older adults. A systematic search was conducted in CINAHL, PubMed, and the Cochrane Database. Included were studies reporting nutrition interventions that involved nurses or the interprofessional team in optimizing older hospitalized people's nutrition.
Needs analysis
Data collection: The needs assessment primarily addressed the implicitly and explicitly stated nutrition-related needs of the older adult inpatients. Semi-structured observations that lasted 8.4 h and one semi-structured interview about nutrition in the hospital were conducted with 22 older adult inpatients (Supporting Information 1: observation guide, Supporting Information 2: interview guide). Observations included preparation and assistance for meals and conversations with older adults such as physicians’ ward rounds and nurses’ shift-handovers. For content validation, a focus group discussion (Supporting Information 3: Focus group interview guide) took place to further define patients’ nutrition-related needs with eight experts with professional experience (Table 1). The interviews and the focus group discussion were transcribed verbatim and analyzed independently using thematic analysis (2015).
Focus group characteristics.
Abbreviation: APN, advanced practice nurse.
Data analysis: The thematic content analysis of observations was deductively conducted along the observation guide and according to Mayring (2015). Interviews were coded inductively. Nutrition-related processes occurring daily in the hospital were investigated and interpreted. The researcher's stance was that perception based on experience and knowledge was subjective and that the phenomenon under investigation was context-bound, as elaborated by the sociologists Berger and Luckmann (2011).
Identify overall objective
Six actionable targets were elaborated (Brunner, Mayer, Hopbach, et al., 2021; Brunner, Nardi, et al., 2021): At least 80% of older adults in hospitals take their meals at the table. All older adults in hospitals receive needs-based support for food intake. Nutritional status and deviations are discussed in at least 80% of the team visits, including appetite; weight changes; and problems with swallowing, digestion, or excretion. Structured reporting from nursing staff to service staff via electronic health records (EHRs) is available for at least 80% of the older adults in hospitals. The treatment goal regarding nutrition is defined for each older adult's inpatient situation. Protein and calorie requirements are met at an average of 80% or higher.
Identify key principles
As the risk for malnutrition in hospitalized older adults was often underreported (Volkert et al., 2020) and a nutrition-related risk nursing diagnosis was missing (Herdman et al., 2021), the research group identified a definition and risk factors and consequently developed a risk nursing diagnosis according to the quality standards of standardized nursing language (Herdman et al., 2021; Rabelo-Silva et al., 2021). A literature review led to risk factors, validated by 22 hospitalized older people's perspectives and observations, including their nursing EHRs. EHR were revised for accuracy, consistency, and patient outcomes using a validated instrument: the Quality of Diagnoses, Interventions and Outcomes (Q-DIO; Table 2) (Müller-Staub et al., 2010; Müller-Staub et al., 2009), as suggested by the concept of the Advanced Nursing Process (Leoni-Scheiber et al., 2020). Data from the literature review, observations, and interviews as well as patients’ EHRs were synthesized, focusing on risk factors for malnutrition.
Quantitative data of nursing electronic health records (EHRs).
Build the intervention
Quantitative variables (Table 3) and the qualitative analysis of patients’ subjective feelings were triangulated as equivalent data (Figure 1). The practice analysis revealed interrelationships between sub-setting and protein and energy intake (Table 3).
Cluster analysis according to calories and protein requirement coverage rate.
Note: Red-framed data, together with observations, interviews, and focus group discussions, led to the hypothesis that acute geriatric ward with a sound nutritional care path resulted in high protein and calorie coverage rates.
Abbreviations: BMI, body mass index; NRS-2002, Nutrition Risk Score 2002 according to Kondrup.
Significant differences between groups.
As an example, Ms J., an 80-year-old multimorbid patient suffering from malnutrition and dementia and other co-morbidities, treated with 13 pharmaceutical agents, stayed at the acute geriatric ward during 10 days. Her EHR displayed a Nutrition Risk Score of 4, and a nutrition-related nursing diagnosis with a Q-DIO value of 1.13 (Table 2). Qualitative data analysis brought to light that Ms J. received a second coffee with milk in the morning as requested, and she got motivating eating assistance from a licensed nursing assistant at lunch with time to have soup and dessert while sitting at the table. Furthermore, the room was well prepared for eating (light, fresh air). During doctors’ ward round, Ms J. was checked for pain as an appetite-influencing factor, and optimal nutrition and food consistency were reviewed at nurses’ report. Thus, a positive effect of interprofessional cooperation and systematic recording of the risk of malnutrition, as implemented in the sub-setting acute geriatric ward, might be concluded, as stated in an earlier publication (Brunner, Mayer, Dietrich, et al., 2021).
Surveillance of nutritional status and supporting food intake were essential duties in nursing, as shown within the policy analysis—an umbrella review summarizing 13 reviews (Brunner et al., 2022). Components of interventions were patients’ assistance, patients’ instruction, food service, the meal environment, and nutrient-dense snacks (Brunner et al., 2022). The needs analysis—a qualitative content analysis of 22 patient observations and 22 semi-structured interviews—led to the following themes: the need to assess and address older patients’ attitudes toward life, the need for nutrition-related education, and the need for food-intake support (Brunner et al., 2023). The key principles of this study were elaborated according to the coherence and accuracy of EHRs and data from interviews and observations, leading to a risk nursing diagnosis with the following risk factors (Brunner, Mayer, Breidert, et al., 2021): healthcare workers’ attitude and culture—missing staff's awareness for nutrition, inappropriate mealtime environment, impaired oral cavity status, impaired swallowing, polypharmacy and multimorbidity, appetite loss, and care dependency (Brunner, Mayer, Breidert, et al., 2021). A new nursing diagnosis was thus developed: risk for imbalanced protein-energy nutritional intake (Brunner, Mayer, Dietrich, et al., 2021).
Model the intervention, seek expert review, and develop the intervention
Data were triangulated according to steps (1)–(4) in Corry et al. without prioritizing any data sources. In a second focus group discussion, codes resulting from triangulation were adapted, summarized, and reformulated for clarity and distinctiveness. Next, the intervention components were developed and declared valid, realistic, and measurable by a second focus group.
Subsequently, the components of the intervention were synthesized into the main elements: context, actionable targets, and the pipeline model with input, processes, output, outcomes, and impact (Funnell & Rogers, 2011).
Ethical considerations
The Good Clinical Practice Guidelines (ICH, 2016) were followed with the knowledge that acutely ill older patients are particularly vulnerable persons (Schweizerische Eidgenossenschaft, 2023). Trustworthiness and authenticity (Creswell & Plano Clark, 2018) were sought through alignment with the “Criteria for Reporting the Development and Evaluation of Complex Interventions in healthcare: revised guideline” (Möhler et al., 2015), and content validation of a logic model by a research colloquium at University of Vienna.
RESULTS
The intervention “Eat Enough,” which is shown in a logic model contains three main elements—context, actionable targets, and a pipeline model (Figure 2). These main interdependent elements influence each other as indicated by arrows and explained in the following paragraphs.
Intervention “Eat Enough”—logic model.
Context
The context describing the factors influencing older adult inpatients’ nutrition and food intake is incorporated in every step of the logic model (Figure 2, blue arrows). The elements of the context are explained as follows. Older adults’ attitude toward life and food impacts appetite and amount of food intake; for example, whether the older adult is willing for rehabilitation including protein-rich food or a hospitalized older adult is focused on staying slim and not eating or drinking protein- or energy-enriched soups.
In addition, the nursing team culture has an essential impact on whether nurses conduct a thorough assessment to recognize nutritional problems and whether nurses are present and deliver support during mealtimes or serve between-meal snacks in the afternoon or evening.
Linked with the nursing team culture is the attitude of the nursing leadership toward a nutrition enhancing complex intervention. If a nurse leader recognizes nutrition as part of the therapy and advocates this stance to medical and nursing staff, actionable targets can be achieved. Human resources, for example, the nurse-to-patient ratio per shift, affect the care and priorities of nurses and the interprofessional team.
Documentation system, infrastructure of the ordering system/kitchen, and menu/catering options impact the kind and variety of meals ordered by service staff and the suggestions of the registered dieticians as well as the proportions of protein and calories per meal.
Actionable targets
The actionable targets are described in Figure 2 and step (2) of Corry's Model and serve to raise awareness and to educate nurses and the interprofessional healthcare team to enhance older adults’ nutrition and foster measurable outputs.
Pipeline model
The pipeline model with the five components—input, processes, output, outcome, and impact—is the third element of the intervention “Eat Enough.”
Input
Inputs correspond to raising awareness and conducting educational activities at the beginning of the implementation of “Eat Enough” by an advanced practice nurse (APN). A situation analysis is recommended as the first step in implementing a complex intervention (Funnell & Rogers, 2011), which involves determining strengths, weaknesses, opportunities, and threats (SWOT analysis) (Helms & Nixon, 2010). A joint debate based on the claims–concerns–issues process (Guba & Lincoln, 2001; McCormack et al., 2009) is also used to explore the attitudes of a group or care team. Each participant reflects on what works well, what are the difficulties in assessing nutritional status, and what questions arise from the identified difficulties. Further input from APNs could come via information within the interprofessional healthcare team about the risk factors for malnutrition, nursing diagnoses, and consequent nursing interventions. These inputs lead to the processes for behavioral changes among nurses and the interprofessional team.
Processes
The described processes include staff training, case analysis, and mini-audits of nursing assessments to provide an appetizing environment and need-based support before, during, and after meals. The training by APNs and dieticians comprises annual workshops sensitizing on nutrition-related topics, such as the risk of malnutrition, oral health, and the scope of nursing responsibility of the interprofessional healthcare team. Nurses’ main competencies are to select an individually appropriate nursing diagnosis that entails recognizing the risk of malnutrition with linkages to outcome criteria and interventions (Brunner, Mayer, Breidert, et al., 2021).
Another activity within the process of change is ensuring the flow of information within the interprofessional healthcare team, which is accomplished through weekly updates of nutritional status and nutrition-related treatment goals at interprofessional meetings.
Output
Facilitating a nutrition-improving culture through the abovementioned inputs and processes of change could lead to measurable outputs, including the risk of recorded malnutrition screenings, the accuracy and coherence of nutritional assessment, nursing diagnosis, interventions, and nurses’ evaluations in EHRs. The efficient division of tasks and secure information flow among distinct groups of professionals (service staff, nurses, physicians, and registered dieticians) can be observed and measured using nurses’ EHRs.
Outcomes
The outputs lead to increased knowledge and improved adherence to service standards in the interprofessional team. The degree of achievement of the actionable targets should be reviewed annually to measure effects and assure the sustainability of this logic model. The following short-term outcomes can be measured to promote patients’ nutritional support by the interprofessional care team: applying knowledge tests or questionnaires to evaluate the knowledge of nurses and the adherence to nutrition-related guidelines by reviewing the Advanced Nursing Process in EHRs.
Impact
According to this logic model, the complex nursing intervention “Eat Enough” will result in changed behavior and nutrition-enhancing attitudes among nurses and the interprofessional healthcare team. Among other changes in action, the nursing staff will take primary responsibility for older adults’ nutrition in hospitals. The nursing-sensitive impact will be the protein and calorie requirement coverage of older adults in hospitals. Consequently, older adults’ self-care abilities could be improved or at least maintained, and the duration of hospital stays could be reduced. Further, such an intervention could increase cost recovery through billable medical diagnoses (malnutrition and dysphagia) with interprofessional therapy and reduced complication rates (lower prevalence of falls, pressure ulcers, and delirium). The impact will also be seen in lower readmission rates owing to sustained changes in dietary habits.
DISCUSSION
“Eat Enough” is a comprehensive intervention that seeks to enhance nutrition in older hospitalized adults. The relevance of nurses’ attitudes has been acknowledged within this logic model as well as in other contexts related to the Advanced Nursing Process (Leoni-Scheiber et al., 2021) and older adults’ nutrition (Hestevik et al., 2020).
The intervention “Eat Enough” responds to the importance of interprofessional care, including patient perspectives, as also emphasized by Hintenach and Howe (2020) and Labrague et al. (2022). A consensus study described the lack of knowledge about most effective interventions and the need for measuring patient-relevant outcomes (Volkert, Beck, Cederholm, Cereda, et al., 2019). The herein-presented intervention fills the gap on how to enhance the nutrition of hospitalized older adults. Therefore, older adults’ nutritional needs will be addressed, and risk factors for malnutrition might be reduced. The “Input” and “Processes” of the pipeline model encompass elements of the behavior change processes according to the transtheoretical model, such as consciousness raising, dramatic relief, and self-reevaluation (Michie et al., 2014, p. 445ff; Prochaska & Velicer, 1997; Velicer et al., 1998).
Goodwin et al. (2019) concluded their analysis of “intervention development and treatment success […]” with the insight that investing in the development of an intervention is worthwhile, as comprehensively developed interventions are more effective. Subsequently, scientifically sound, and patient-needs-related care plans with aims and interventions can be realized based on a complex nursing intervention such as “Eat Enough” (Mayer, 2023; Moore et al., 2019; Wallner et al., 2023). Similarly to “Eat Enough,” the findings from a multicenter qualitative study were “needs and expectations for patient participation”; elements for a complex intervention, such as [interprofessional] “collaboration,” “screening,” “mealtime assistance,” or “monitoring” (Van Den Berg et al., 2023).
Intervention programs were developed and tested such as a care pathway focusing on adult medical patients as described in the EFFORT study (Schuetz et al., 2019). A broad guideline to assess and treat nutrition and hydration in geriatrics has been published (Volkert, Beck, Cederholm, Cruz-Jentoft, et al., 2019). In addition, The Joint Action Malnutrition in the Elderly Knowledge Hub investigated the prevalence, risk factors, and general fields of action to address malnutrition in older people (Volkert et al., 2020). Still, the latter is general and did not propose setting- and nursing-specific actionable targets.
Strengths
The uniqueness of “Eat Enough” is that patients aged ≥80 years, regardless of their cognitive status or medical department, were actively involved. This is the first time that data from patient statements, observations, nursing EHRs, nutrition counseling, and nutrition experts (focus group discussions) have been synthesized, which led to a complex nursing intervention. “Eat Enough” includes a theory-based perspective that fosters an understanding concerning how and under what circumstances this complex nursing intervention might change attitudes, practice, and consequently enhance hospitalized older adults’ nutrition.
Limitations
As needs and practice analyses were conducted in one hospital setting, the program theory is not generalizable for other hospitals or other care institutions. As the “Eat Enough” complex intervention has not been implemented yet, it remains unknown how to convince hospital leaders and policymakers about the importance of this nurse-guided logic model. Nevertheless, it is assumed that nursing leaders’ attitudes toward a complex nutritional intervention will be associated with nutrition-enhancing activities, culture, nurses’ attitudes, and the better nutritional status of patients (Laur et al., 2017).
IMPLICATIONS
Implications for clinical practice
This logic model demonstrates the importance of nurses as the main personnel responsible for the nutrition of older hospitalized adults in an interprofessional healthcare team. Inputs from APNs and interprofessional collaboration are necessary to assess older adults’ nutritional status in hospitals and to set individual goals linked to an appropriate risk nursing diagnosis. The nursing staff are primarily responsible for the nutrition process and need to be systematically guided; thus, interprofessional collaboration is both an opportunity and a necessity for nursing practice, especially in the context of hospitalized older adults (Argenta et al., 2022; van Leendert et al., 2021).
Implications for nursing research
In future research, the logic model needs validation in clinical practice. Investigation of the effectiveness of the intervention through implementation research, which involves the participation of key personnel and requires a randomized selection of departments based on a purposive sample of institutions, is suggested. Future implementation projects should test its feasibility and consider the economic impact as well as uncertainties before and after the implementation of “Eat Enough.” Finally, the complex intervention and its inputs and processes can be utilized to validate the nursing intervention “Nutrition management” of the NIC (Wagner et al., 2022).
Implications for teaching
The development of the complex intervention “Eat Enough” could be applied in teaching materials, especially regarding the risk of malnutrition and evidence-based nursing interventions in hospitalized older adults.
Implications for politics and society
Reduced complication rates and decreased length of stay minimize healthcare costs. Strengthening nurses’ areas of responsibility by focusing on core nursing issues, such as eating and nutrition, might increase nurses’ job satisfaction (Michie et al., 2014; Specchia et al., 2021).
CONCLUSION
The intervention “Eat Enough” might lead to both behavioral and attitudinal changes of interprofessional teams. By identifying risk factors and stating the respective nursing diagnosis as well as by strengthening nurses’ responsibilities, the logic model with evidence-based interventions might positively impact nutrition and other nurse-sensitive outcomes of hospitalized older adults.
AUTHOR CONTRIBUTIONS
The authors declare that they agree to be accountable for all aspects of the study entitled “Eat Enough”—A nurse-led intervention to enhance hospitalized older adults’ protein and energy nutrition that aims to be published in the International Journal of Nursing Knowledge.
The authors ensure that questions related to any part of the work's accuracy or integrity are appropriately investigated and resolved. Each author has participated sufficiently in data collection and analysis and critically reviewed the manuscript to take public responsibility for appropriate portions of the content. Finally, they confirm to have given final approval of the version to be published.
Silvia Brunner, project leader, was involved in data collection, analysis, and prepared the manuscript; Maria Müller-Staub, strategic and clinical support and supervisor of the project, was involved in the entire research process, including the review of data analysis and manuscript.
Hanna Mayer, strategic and methodological supervisor of this intervention development, was involved in the entire research process and reviewing the manuscript.
CONFLICT OF INTEREST STATEMENT
The authors declare no conflicts of interest.
FUNDING INFORMATION
All authors declare that there was no funding for this study.
Footnotes
ACKNOWLEDGMENTS AND ETHICS STATEMENT
Many thanks are expressed to the City Hospital Zurich, for the working contract supporting this study. Prof. Dr M. Müller Staub and Univ.-Prof. Dr H. Mayer are heartfully thanked for supervision and feedback during the writing process. In addition, the members of the Soundingboard discussed the project progress and thus the draft of the nursing intervention “Eating Enough.” Soundingboard members were PD Dr. med. M. Breidert, PD Dr. med. M. Dietrich, S. Frei, K. Hopbach, Dr. med. M. Nardi, M. Rechsteiner. The local ethics committee examined the research project and provided a “Declaration of No Objection” (Req-2016-00670).
