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Developing and evaluating interventions that are applicable and relevant to inpatients and those who care for them; a multiphase, pragmatic action research approach.

Bell JJ, Rossi T, Bauer JD, Capra S - BMC Med Res Methodol (2014)

Bottom Line: This study demonstrates substantially different findings to those previously reported, and is the first to demonstrate that multidisciplinary, multimodal nutrition care reduces intake barriers, delivers a higher proportional increase in protein and energy intake compared with baseline than other published intervention studies, and improves patient outcomes when compared with individualised nutrition care.The findings are considered highly relevant to clinical practice and have high translation validity.The authors strongly encourage the development of similar study designs to investigate complex health problems in elderly, multi-morbid patient populations as a way to evaluate and change clinical practice.

View Article: PubMed Central - HTML - PubMed

Affiliation: Department of Nutrition and Dietetics, The Prince Charles Hospital, Rode Road, Chermside, Brisbane 4035, Australia. Jack.Bell@health.qld.gov.au.

ABSTRACT

Background: Randomised controlled trials may be of limited use to evaluate the multidisciplinary and multimodal interventions required to effectively treat complex patients in routine clinical practice; pragmatic action research approaches may provide a suitable alternative.

Methods: A multiphase, pragmatic, action research based approach was developed to identify and overcome barriers to nutritional care in patients admitted to a metropolitan hospital hip-fracture unit.

Results: Four sequential action research cycles built upon baseline data including 614 acute hip-fracture inpatients and 30 purposefully sampled clinicians. Reports from Phase I identified barriers to nutrition screening and assessment. Phase II reported post-fracture protein-energy intakes and intake barriers. Phase III built on earlier results; an explanatory mixed-methods study expanded and explored additional barriers and facilitators to nutritional care. Subsequent changes to routine clinical practice were developed and implemented by the treating team between Phase III and IV. These were implemented as a new multidisciplinary, multimodal nutritional model of care. A quasi-experimental controlled, 'before-and-after' study was then used to compare the new model of care with an individualised nutritional care model. Engagement of the multidisciplinary team in a multiphase, pragmatic action research intervention doubled energy and protein intakes, tripled return home discharge rates, and effected a 75% reduction in nutritional deterioration during admission in a reflective cohort of hip-fracture inpatients.

Conclusions: This approach allowed research to be conducted as part of routine clinical practice, captured a more representative patient cohort than previously reported studies, and facilitated exploration of barriers and engagement of the multidisciplinary healthcare workers to identify and implement practical solutions. This study demonstrates substantially different findings to those previously reported, and is the first to demonstrate that multidisciplinary, multimodal nutrition care reduces intake barriers, delivers a higher proportional increase in protein and energy intake compared with baseline than other published intervention studies, and improves patient outcomes when compared with individualised nutrition care. The findings are considered highly relevant to clinical practice and have high translation validity. The authors strongly encourage the development of similar study designs to investigate complex health problems in elderly, multi-morbid patient populations as a way to evaluate and change clinical practice.

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Related in: MedlinePlus

Identifying and overcoming barriers to nutritional care in patients with acute hip fracture. Figure 1 demonstrates the multiple phases of this action research approach. Action research cycles are based on those presented by McNiff & Whitehead [37]. Baseline evaluation to phase III represent the observational phase of an action research cycle and also provide baseline data for a before-and-after prospective interventional trial. The implementation of key changes to routine clinical practice (the ‘intervention’) are then evaluated in phase IV.
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Figure 1: Identifying and overcoming barriers to nutritional care in patients with acute hip fracture. Figure 1 demonstrates the multiple phases of this action research approach. Action research cycles are based on those presented by McNiff & Whitehead [37]. Baseline evaluation to phase III represent the observational phase of an action research cycle and also provide baseline data for a before-and-after prospective interventional trial. The implementation of key changes to routine clinical practice (the ‘intervention’) are then evaluated in phase IV.

Mentions: A multiphase, pragmatic, AR project with four sequential AR cycles building on baseline data was developed to identify and overcome barriers to nutrition care in hip fracture between November 2010 and September 2012 (see Figure 1). Six hundred and forty one acute hip fracture inpatients were included across all phases and 30 purposively sampled multidisciplinary clinicians actively working in the care unit were included in focus groups stratified by clinical experience as defined by positional accountability. Methods for each phase are clearly described elsewhere[28-31]; ethics approvals were obtained from the Prince Charles Hospital (HREC/11/QPCH/90; HREC12/QPCH/83) and The University of Queensland (HMS11/0607; HMS12/0904) human ethics committees. The phases can be presented according to an AR cycle as follows:


Developing and evaluating interventions that are applicable and relevant to inpatients and those who care for them; a multiphase, pragmatic action research approach.

Bell JJ, Rossi T, Bauer JD, Capra S - BMC Med Res Methodol (2014)

Identifying and overcoming barriers to nutritional care in patients with acute hip fracture. Figure 1 demonstrates the multiple phases of this action research approach. Action research cycles are based on those presented by McNiff & Whitehead [37]. Baseline evaluation to phase III represent the observational phase of an action research cycle and also provide baseline data for a before-and-after prospective interventional trial. The implementation of key changes to routine clinical practice (the ‘intervention’) are then evaluated in phase IV.
© Copyright Policy - open-access
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC4150929&req=5

Figure 1: Identifying and overcoming barriers to nutritional care in patients with acute hip fracture. Figure 1 demonstrates the multiple phases of this action research approach. Action research cycles are based on those presented by McNiff & Whitehead [37]. Baseline evaluation to phase III represent the observational phase of an action research cycle and also provide baseline data for a before-and-after prospective interventional trial. The implementation of key changes to routine clinical practice (the ‘intervention’) are then evaluated in phase IV.
Mentions: A multiphase, pragmatic, AR project with four sequential AR cycles building on baseline data was developed to identify and overcome barriers to nutrition care in hip fracture between November 2010 and September 2012 (see Figure 1). Six hundred and forty one acute hip fracture inpatients were included across all phases and 30 purposively sampled multidisciplinary clinicians actively working in the care unit were included in focus groups stratified by clinical experience as defined by positional accountability. Methods for each phase are clearly described elsewhere[28-31]; ethics approvals were obtained from the Prince Charles Hospital (HREC/11/QPCH/90; HREC12/QPCH/83) and The University of Queensland (HMS11/0607; HMS12/0904) human ethics committees. The phases can be presented according to an AR cycle as follows:

Bottom Line: This study demonstrates substantially different findings to those previously reported, and is the first to demonstrate that multidisciplinary, multimodal nutrition care reduces intake barriers, delivers a higher proportional increase in protein and energy intake compared with baseline than other published intervention studies, and improves patient outcomes when compared with individualised nutrition care.The findings are considered highly relevant to clinical practice and have high translation validity.The authors strongly encourage the development of similar study designs to investigate complex health problems in elderly, multi-morbid patient populations as a way to evaluate and change clinical practice.

View Article: PubMed Central - HTML - PubMed

Affiliation: Department of Nutrition and Dietetics, The Prince Charles Hospital, Rode Road, Chermside, Brisbane 4035, Australia. Jack.Bell@health.qld.gov.au.

ABSTRACT

Background: Randomised controlled trials may be of limited use to evaluate the multidisciplinary and multimodal interventions required to effectively treat complex patients in routine clinical practice; pragmatic action research approaches may provide a suitable alternative.

Methods: A multiphase, pragmatic, action research based approach was developed to identify and overcome barriers to nutritional care in patients admitted to a metropolitan hospital hip-fracture unit.

Results: Four sequential action research cycles built upon baseline data including 614 acute hip-fracture inpatients and 30 purposefully sampled clinicians. Reports from Phase I identified barriers to nutrition screening and assessment. Phase II reported post-fracture protein-energy intakes and intake barriers. Phase III built on earlier results; an explanatory mixed-methods study expanded and explored additional barriers and facilitators to nutritional care. Subsequent changes to routine clinical practice were developed and implemented by the treating team between Phase III and IV. These were implemented as a new multidisciplinary, multimodal nutritional model of care. A quasi-experimental controlled, 'before-and-after' study was then used to compare the new model of care with an individualised nutritional care model. Engagement of the multidisciplinary team in a multiphase, pragmatic action research intervention doubled energy and protein intakes, tripled return home discharge rates, and effected a 75% reduction in nutritional deterioration during admission in a reflective cohort of hip-fracture inpatients.

Conclusions: This approach allowed research to be conducted as part of routine clinical practice, captured a more representative patient cohort than previously reported studies, and facilitated exploration of barriers and engagement of the multidisciplinary healthcare workers to identify and implement practical solutions. This study demonstrates substantially different findings to those previously reported, and is the first to demonstrate that multidisciplinary, multimodal nutrition care reduces intake barriers, delivers a higher proportional increase in protein and energy intake compared with baseline than other published intervention studies, and improves patient outcomes when compared with individualised nutrition care. The findings are considered highly relevant to clinical practice and have high translation validity. The authors strongly encourage the development of similar study designs to investigate complex health problems in elderly, multi-morbid patient populations as a way to evaluate and change clinical practice.

Show MeSH
Related in: MedlinePlus