Collecting pieces for the 'puzzle': Nurses' intraprofessional collaboration in the hospital-to-home transition of older patients.

BACKGROUND AND AIM: Communication is a key factor in intraprofessional collaboration between hospital nurses and homecare nurses in hospital-to-home transitions of older patients with complex care needs. Gaining knowledge of the nature of cross-sectoral communication is crucial for understanding how nurses collaborate to ensure a seamless patient trajectory. This study explores how cross-sectoral electronic health records communication influences collaboration between hospital nurses and homecare nurses when discharging older patients with complex care needs. METHOD: The study is based on qualitative group interviews with six hospital nurses and 14 homecare nurses working at different hospitals and municipalities across Denmark. Data were analysed using reflexive thematic analysis, as described by Braun and Clark. FINDINGS: The themes Collecting pieces for the 'puzzle': Losing the holistic picture of the patient; Working blindfolded: limited provision of and access to critical information; and Bypassing the 'invisible wall': dialogue supports cohesion illustrate the impact of organisational structures within electronic health records have on hospital nurses' and homecare nurses' intraprofessional collaboration across sectors. Challenges with predefined and word-limited elements in digital communication, and inadequate and limited access to significant medical information were identified. To compensate for the inadequacy of the electronic health records, direct contact and dialogue were emphasised as ways of fostering successful collaboration and overcoming the barriers created by electronic health records. CONCLUSION: Despite hospital nurses' and homecare nurses' desire to conduct holistic patient assessments, their ability to collaborate was hindered by failures in electronic health record communication resulting from restrictive organisational structures across sectors. Thus, it became necessary for hospital nurses and homecare nurses to bypass the electronic health record system and engage in dialogue to provide holistic care when discharging older patients with complex care needs. However, by hospital nurses and homecare nurses compensating for counter-productive organisational structures, problems brought about by the electronic health record system paradoxically remain invisible.

Coming home: older patients' and their relatives' experiences of well-being in the transition from hospital to home after early discharge.

BACKGROUND: This study aims to investigate the lived experience of well-being among older patients and their relatives in the transition from hospital to home after early discharge. Research has shown that the transition brings severe challenges to their everyday lives. However, to date, there has been a lack of research focusing on the lived experiences of well-being during this process. METHODS: The data collection and analysis followed the phenomenological approach of Reflective Lifeworld Research. Ten in-depth interviews with older patients and their relatives were conducted in Austria up to 2-5 days after hospital discharge. RESULTS: The essential meaning of the phenomenon of well-being in the transition from hospital to home is marked by security and confidence to face the challenges following the discharge. Four constituents emerged: being calm and in alignment with the homecoming, being in familiar surroundings at home-a sense of belonging, striving towards independence-continuity of life and having faith in the future. CONCLUSION: Our findings point to the importance of recognizing the vulnerability associated with the transition from hospital to home, as it impacts the existential aspects of space and time. Facilitating a sense of continuity and belonging can foster well-being during this critical period.

A comparative review of advanced practice nurse programmes in the Nordic and Baltic countries.

BACKGROUND: Advanced practice nurses (APNs) programs are career-development opportunities significant for nursing workforce retention as well as for the quality of patient care. Inconsistency regarding policy, education, titles, scope of practice, skills and competencies have been identified as major challenges in developing advanced practice nursing in Europe. APN roles and education are under development in the Nordic and Baltic countries. However, there is a lack of information on the current state in this region. OBJECTIVE: The purpose of this paper is to compare APN programs in the Nordic and Baltic countries to identify their commonalities and differences. DESIGN AND METHODS: This descriptive comparative study reviewed seven master's level APN programs in six Nordic and Baltic countries. Data was extracted from the programme by the expert teachers or leaders of the programmes (N = 9). Competencies recommended in the European Tuning Project (ETP) and the International Council of Nurses (ICN) guidelines on advanced practice nursing, were used to evaluate the programs. The same informants provided additional information on the current state of APN education in the country. RESULTS: The admission requirements were similar in the six countries but in two, clinical work experience is an entry requirement. There are two commonly identified APN roles: clinical nurse specialist (CNS) and nurse practitioner (NP). Most of the programs included all the EPT and ICN competencies. The main differences regarded prescribing competencies. All programmes included clinical training, but the methods on how it is implemented varies. CONCLUSION: The findings indicate that APN programs in the Nordic and Baltic countries correspond with the recommendations of the European Tuning Project and ICN guidelines. This is an important message for administrators, policymakers, and politicians, as well as the nursing community, on providing opportunities for APNs to practice to their full potential within each country as well as cross-country. TWEETABLE ABSTRACT: "APN programmes in the Nordic and Baltic countries correspond with international guidelines. Special attention is needed in future on the clinical training of APNs".

Being well? A meta-ethnography of older patients and their relatives' descriptions of suffering and well-being in the transition from hospital to home.

BACKGROUND: As the average length of hospital stay decreases, more and more older patients will need support during and after the hospital transition, which will mainly be provided by their relatives. Studies highlight the enormous effect such a transition has on the lives of older patients and their relatives. However, research is lacking regarding in-depth understanding of the complexities and the notions of suffering and well-being the older patients and their relatives describe in the transition from hospital to home. Therefore, this study aims to examine the description of suffering and well-being on a deeper, existential level by drawing on existing phenomenological research. METHODS: In order to synthesize and reinterpret primary findings, we used the seven-step method for meta-ethnography. Following specific inclusion criteria and focusing on empirical phenomenological studies about older patients and their relatives experiences of hospital to home transitions, a systematic literature search was conducted. Data from ten studies have been analyzed. RESULTS: Our analysis identified three intertwined themes: i) 'Being excluded vs. being included in the transition process', ii) 'Being a team: a call for support and a call to support' and iii) 'Riding an emotional rollercoaster'. The last theme was unfolded by the two subthemes 'Taking on the new role as a caregiver: oscillating between struggling and accepting' and 'Getting back to normal: oscillating between uncertainty and hope'. Within those themes, older patients and their relatives described rather similar than contradictory aspects. CONCLUSIONS: This study offers insights into the tension between existential suffering and well-being described by the older patients and their relatives during the transition from hospital to home. Especially, the description of well-being in all its nuances which, if achieved, enables older patients and their relatives to identify with the situation and to move forward, this process can then be supported by the health care professionals. However, there is still lack of knowledge with regards to a deeper understanding of existential well-being in this process. Given the increasing tendency towards early hospital discharges, the findings underpin the need to further investigate the experiences of well-being in this process.

What Makes Dependency on Homecare Bearable? A Phenomenological Study.

Becoming dependent on homecare in old age is a radical life change that requires complex adaption. The purpose of this study was to explore the existential dimension of being dependent on homecare with a particular focus on what makes dependency bearable. In total, 15 older people living in Denmark or Norway were interviewed using a phenomenological approach. The material was analyzed employing Max van Manen's meaning-giving approach coined "Phenomenology of practice." During the analysis, four themes emerged: pure acceptance of an inevitable situation, acting independently as much as possible, negotiating to receive good care, and gratitude toward caring caregivers. The results point to a need for respectful and individualized homecare leveling out the subordinate position in which dependency on homecare tends to place older people.

Who cares?-The unrecognised contribution of homecare nurses to care trajectories.

BACKGROUND: Organisation of patients' trajectories is a critical element of nursing practice. However, nursing practice is mainly expressed in terms of direct patient care, while the practices through which care is organised have received little attention, are poorly acknowledged and lack formal recognition. AIM: To examine the management of care trajectories as provided by homecare nurses. DESIGN: We conducted focus group interviews with 29 Danish homecare nurses. The analysis drew on the evidence based and theoretically informed framework care trajectory management. Care trajectory management is conceptualised as comprising of three organisational components: (1) Trajectory awareness, (2) Trajectory working knowledge and (3) Trajectory articulation. FINDINGS: The organising work of homecare nursing is both complex and unpredictable requiring advanced organisational, collaborative and clinical competences to secure concerted actions in alignment with the needs of the individual patient. Without having any formal obligation homecare nurses took on the responsibility for the coordination of the different activities of the professional actors, and for securing concerted actions. Care trajectory management as provided by homecare nurses reflected a high degree of commitment for patients and illustrated that this type of organising work was driven by the values of the humanistic ethos of nursing. CONCLUSION: The study highlights the strength of the invisible and ongoing organising work of homecare nurses. Care trajectory management in homecare reflects the moral foundation of nursing. Consequently, the professional logic of nursing reflected as direct patient care alone is too narrow. We need to acknowledge the organising work of patients' trajectories as a core task equal to direct patient care. Our study highlights the need for articulating the organising work of homecare nurses and for presenting problematic organisational structures to policymakers and managers. If not, the important organisational work of homecare nurses is at the risk of remaining invisible.

Walking a tightrope - as a next-of-kin to an adolescent or young adult with cancer facing eating difficulties.

PURPOSE: Eating difficulties cause reduced food intake and poor quality of life among adolescents and young adults (AYAs) with cancer. Therefore, next-of-kin eating support is crucial. The purpose of this study was to explore the lived experiences of being close to AYAs with cancer in the context of eating when they are at home between high-emetogenic chemotherapy (HEC) sessions. METHOD: In-depth interviews were conducted with 12 next-of-kin to AYAs (15-29 years old) with oncological or haematological diseases, treated with HEC. Van Manen's hermeneutic-phenomenological approach guided the design. RESULTS: The essential meaning of the next-of-kin experiences is reflected in the overarching theme "Utilizing meals as an action-opportunity" consisting of two subthemes: 'Being on constant alert' and "Walking a tightrope to maintain usual everyday life." CONCLUSIONS: Findings revealed that utilizing meals as an action-opportunity towards AYAs' food intake involved existential feelings including fear of losing their loved ones. Next-of-kin experienced that providing support through and with food was their only avenue of action. However, this sparked feelings of frustration and powerlessness.

Comparison of video and in-hospital consultations during early in-home care for premature infants and their families: A randomised trial.

INTRODUCTION: Early in-home care is increasingly being used in Scandinavian countries for clinically stable premature infants. Due to challenges with travel and hospital resources, alternative ways to support parents during early in-home care are being considered. The aim of this study was to test whether the proportion of mothers exclusively breastfeeding, parental confidence and mother-infant interaction increased after early in-home care with premature infants, and to compare the outcomes of in-home care involving the use of video communication and a mobile application with those of in-home care involving in-hospital consultations. METHODS: This study was conducted in four neonatal wards offering premature infant in-home care in Denmark. Premature infants were randomised using 1:1 block randomisation. During early in-home care, families had planned consultations two to three times a week, during which they received support from nurses: the intervention group had video consultations, while the control group had in-hospital consultations. RESULTS: The proportion of exclusively breastfeeding mothers at discharge was 66.7% in the intervention group vs 66% in the control group and decreased to 49.4% vs 55%, respectively, 1 month after discharge. No significant improvements were found in the intervention group compared with the control group. In the intervention group, some video consultations were changed to telephone consultations due to problems with the video function, or to in-hospital consultations due to infants' requirement for medical services. No significant differences in secondary outcomes were observed. DISCUSSION: The study showed similar breastfeeding proportions at discharge. No unfavourable effects of video consultation compared with in-hospital consultation were found, indicating that video consultation could be a viable option and an important supplement during early in-home care. TRIAL REGISTRATION: ClinicalTrials.gov ID: NCT02581800.

Struggling to Eat to Survive Cancer-Lived Experiences of Eating Among Adolescents and Young Adults Undergoing High-Emetogenic Chemotherapy.

Purpose: The purpose of this study was to provide in-depth understanding of adolescents' and young adults' (AYAs') lived experiences of eating when they are at home between high-emetogenic chemotherapy sessions. Methods: The study was guided by van Manen's hermeneutic-phenomenological methodology. Eligible AYAs were 15-29 years old, diagnosed with either oncological or hematological cancer, treated with high-emetogenic chemotherapy, and Danish speaking. AYAs were recruited from three university hospital departments. Data were collected using semi-structured in-depth interviews. Results: Thirteen AYAs, aged 17-29 years, participated in the interviews via telephone or face-to-face in their homes. The essential meaning of the phenomenon of eating can be characterized by the overarching theme "Struggling to eat to survive" and unfolded through the following three themes: "Cooperating with a deceiving body", "Capturing moments of eating opportunities", and "Being loved and cared for at home". Conclusions: Struggling to eat was essential for survival and a fundamental existential challenge that required reflection and consciousness. AYAs experienced their deceiving bodies as a major concern, which challenged their ability to eat and forced them to develop strategies to capture moments of eating opportunities. AYAs kept hold of doing "something" themselves to maintain the slightest control of their own lives and thereby assist clinical outcomes and cure. However, AYAs had to struggle with food and start viewing food as a friend, not an enemy.

Love, joy and necessity - A phenomenological study of food and meals in adolescents and young adults with cancer receiving high-emetogenic chemotherapy.

PURPOSE: This study explored how the phenomenon of meals appeared in the interrelationship between adolescents and young adults (AYAs) receiving high-emetogenic chemotherapy, their next of kin and health professionals in the clinical setting. METHOD: Data were collected by 140 h of participant observation conducted to gain insights into the nature of how meals appeared in the interrelationship between 12 AYAs (age 15-29 years), their next-of-kin and health professionals. The AYAs were patients with oncological and haematological diseases recruited from three university hospital departments. Data analysis was guided by van Manen's hermeneutic-phenomenological approach. RESULTS: The essential meaning of the phenomenon may be characterized by the overarching theme; 'Seeking the joy of meals in the shadow of treatment' and the following three themes: 'Meals as a necessary evil' (AYAs); 'Meals as a matter of love' (next-of-kin); and 'Meals in the shadow of medical treatment' (health professionals). CONCLUSIONS: Meals is a multi-facetted and complex phenomenon that has different meanings to AYAs, next-of-kin and health professionals. To the AYAs, meals emerged as a necessary evil in connection with which urges to eat occurred as glimpses of desire. Prominent feelings of powerlessness and food as love were highlighted by the next-of-kin, whereas food and meals appeared secondary to treatment for health professionals, reflecting the traditional biomedical paradigm. The findings revealed that adopting a holistic approach to AYAs concerning meals can have the potential to increase their food intake.

Knowledge of mothers and fathers' experiences of the early in-home care of premature infants supported by video consultations with a neonatal nurse.

AIM: To gain in-depth knowledge of mothers' and fathers' experiences of the whole trajectory of an early in-home care programme supported by video consultations with a neonatal nurse. DESIGN: A qualitative interview study. METHODS: Data were collected through dyadic semi-structured interviews with mothers and fathers participating in virtual early in-home care programmes and were subjected to inductive content analysis. FINDINGS: The mothers and fathers were anxious about mastering the care of their premature infants at the start of the early in-home care phase but gradually developed confidence by the completion of the early in-home care programme. Being at home during the early in-home care programme gave the mothers and fathers an opportunity to test their decision making concerning the care of the infant while having the ability to obtain support from nurses when needed. CONCLUSION: Our findings indicate that the trajectory of early in-home care programmes combined with video consultations contributes to parents' increased confidence as mothers and fathers. TRIAL REGISTRATION: Clinical trial registration: REG-113-2014 and SJ-431 .

Video consultation as nursing practice during early in-home care for premature infants and families viewed from the families' homes'.

AIM: This study examined how communication between nurses and families in video consultations in a neonatal early in-home care program unfolded in the context of parents' homes. DESIGN: A qualitative study based on focused observations supported by audio-recorded video consultations. METHODS: The data were collected through nine video consultations between nurses and families in an early in-home care program. The transcribed material was examined using inductive content analysis. FINDINGS: The analyses revealed the following themes: "Setting the scene," "Weight as a point of reference" and "The pros and cons of technology." The video consultations unfolded in a relaxed atmosphere, but also as one-way communication dominated by nurses, with the infant's weight as the focus. The study finds that a focus on training in video communication is needed to take full advantage of video consultations' potential.

Living in limbo while one's identity is changing: Patients' existential experiences 6 months after a kidney transplantation with a living donor.

AIM: To investigate patients' existential experiences in everyday life after a kidney transplantation with a living donor. DESIGN: A qualitative study anchored in a hermeneutic-phenomenological approach inspired by Ricoeur's theory of narrative and interpretation. METHOD: Eleven patient interviews were conducted approximately 6 months after a kidney transplantation with a living donor. The interviews were conducted between August 2017-May 2019. Analysis and interpretation are based on Ricoeur's theory of interpretation. RESULTS: Four themes were identified: Experiencing bodily vulnerability while getting back to life; Feeling guilt while experiencing gratitude; Living in limbo while one's identity is changing; and Facing the future with hope while having reservations. CONCLUSION: This study reveals that patients experience multifaceted existential challenges in their everyday lives during the transition of the kidney transplantation process. Post-surgery complications for donors lead to feelings of guilt in patients; plus, they must adapt to a new existence, including a new identity. The patients feel they are in limbo, as they experience their existence as uncertain and their identity as unknown. IMPACT: The study highlights a need for developing a rehabilitation programme to address the individual and various existential challenges faced by patients who need to undergo a kidney transplantation.

Existential Contradictions in Living With End-Stage Renal Disease: A Qualitative Metasynthesis.

A qualitative metasynthesis following Sandelowski and Barroso's method was conducted to explore what characterizes the existential experiences of individuals living with end-stage renal disease. The findings show that patients with end-stage renal disease live with several existential contradictions characterized by the following: perception of the body-oscillating between connection and separation, maintaining life-oscillating between freedom and captivity, uncertainty-oscillating between hope and despair, and enduring technology-oscillating between being perceived as an object and subject. Consequently, living with end-stage renal disease is challenging for patients; hence, the support of nurses is important to alleviate patients' vulnerability.

Sharing our story individualized and triadic nurse meetings support couples adjustment to living with deep brain stimulation for Parkinson's disease.

Treatment with deep brain stimulation for Parkinson's disease, leads to a rapid improvement in mobility, which may challenge patients and spouses when adjusting to everyday life. An intervention, developed to support the adjustment to everyday life with DBS, demonstrated that individualized meetings with a specialized nurse was experienced as important and fruitful by both patient and spouses. Purpose: The aim was to gain a deeper understanding of how the meetings contributed to the adjustment process. Method: 38 audio-recorded meetings and six written summaries from eight couples participating in the intervention, were analyzed in a hermeneutic process. Results: The analysis revealed four themes: A relational triad of co-creating personal knowing. Sharing and listening in an atmosphere of trust and openness. Unveiling the couple's everyday life, coping strategies and expectations. Supporting adjustment through knowing their personal story. Conclusion: The triadic dynamics in the meetings were quite particular. The main focus was the patients' and spouses' stories, individually and as a couple. The DBS nurse pursues solutions based on professional and specialized knowledge of Parkinson's disease and the couple's everyday life. Thus, the intervention meetings offered tailored, individualized and specialized care in supporting adjustment to DBS for PD both individually and as couples.

Do the carers care? A phenomenological study of providing care for patients suffering from alcohol use disorders.

Excessive alcohol consumption can have adverse effects on health, and patients who suffer from alcohol use disorders are subject to much stigmatization. Nurses are often the first point of contact when patients enter the acute medical unit, and it is pivotal that this contact establishes the basis for future collaboration. The aim of this study is to elucidate nurses' lived experience of providing care to patients suffering from alcohol use disorders. This present study has a qualitative research design, anchored in phenomenological and hermeneutical methodology as described in reflective lifeworld research. Ten in-depth, open-ended interviews with nurses working in an acute medical unit were conducted. The analysis showed that providing care to patients suffering from alcohol use disorders was a highly complex task to accomplish. This required the nurse to engage with the patient in a sensitive cooperation in order to be dealing with the intricacy of the patient's life situation and balancing care between standardized procedures and the complexity of the patients. Further, a two-sided feeling of responsibility emerged: a professional responsibility and a personal responsibility causing the provision of care as being caught between feelings of despondency and resignation. Nurses lack opportunities for being creative in determining how to provide care; instead, patients' perspectives of well-being should be taken into account and should guide the provision of a meaningful care. Nurses must call for opportunities to deviate from the firmly established procedures restraining the care of this population.

Nurses experiences of ethical dilemmas: A review.

BACKGROUND: Nursing care is rapidly evolving due to the advanced technological and medical development, and also due to an increased focus on standardization and the logic of production, permeating today's hospital cultures. Nursing is rooted in a holistic approach with an ethical obligation to maintain and respect the individual's dignity and integrity. However, working within time limits and heavy workload leads to burnout and ethical insensitivity among nurses, and may challenge nurses' options to act on the basis of ethical and moral grounds in the individual care situation. AIM: The aim of this study is to describe and discuss ethical dilemmas described and experienced by nurses in clinical practice today. METHOD: The study was performed as a literature review following the matrix method allowing to synthesize literature across methodological approaches. A literature search was performed, including relevant studies published between 2011 and 2016. A total of 15 articles were included and analyzed focusing on their description of ethical dilemmas. ETHICAL CONSIDERATION: We have considered and respected ethical conduct when performing a literature review, respecting authorship and referencing sources. RESULTS: The analysis revealed three themes, relating to important aspects of nursing practice, such as the nurse-patient relationship, organizational structures, and collaboration with colleagues. The findings are summarized in the following three themes: (1) balancing harm and care, (2) work overload affecting quality, and (3) navigating in disagreement. Ethically difficult situations are evident across settings and in very diverse environments from neonatal care to caring for the older people. Organizational structures and being caught in-between professional values, standardization, and busyness was evident, revealing the complexity of nursing practice and the diversity of ethical dilemmas, concerns, and distress experienced by clinical nurses. CONCLUSION: Nursing practice is challenged by organizational structures and the development of the health care system, inhibiting nurses' professional decision-making and forcing them to compromise basic nursing values.

Living in one's own world, while life goes on: Patients' experiences prior to a kidney transplantation with a living donor.

AIMS AND OBJECTIVES: To investigate patients' existential experiences in everyday life prior to a kidney transplantation with a living donor. BACKGROUND: Kidney transplantation is a well-established treatment for patients with end-stage kidney disease. The prevalence of patients living with end-stage renal disease is increasing. Simultaneously, kidney transplantations with a living donor are increasing. However, patients experience challenging existential aspects concerning kidney transplantation. DESIGN: A qualitative study with a hermeneutic-phenomenological approach inspired by Ricoeur was chosen. METHODS: Fourteen interviews with patients living with end-stage kidney disease were conducted 7-14 days before a planned kidney transplantation with a living donor. Analysis and interpretation were based on Ricoeur's theory of interpretation. We applied the Criteria for Reporting Qualitative Research (see Appendix S1). RESULTS: Four themes were identified: living with subjective feelings of illness while objectifying the body; living in one's own world while the world outside goes on; feeling grateful while being concerned for the donor; and hoping for the best, while preparing for the worst. CONCLUSION: Patients' existential challenges are multifaceted. Patients articulate their kidney function in numeric terms, trying to make the invisible visible for themselves and others. Sustaining normality becomes important for patients, and the waiting time from donor evaluation to transplantation triggers excitement, hope and frustration. RELEVANCE TO CLINICAL PRACTICE: The results increase insights into individuals' existential experiences in their everyday lives. Hereby, the results articulate the need for support from health professionals prior to a kidney transplantation.

Struggles with infrastructures of information concerning hospital-to-home transitions.

Homecare nurses play a unique role in providing care during the follow-up after hospital discharge and in preventing readmission. The aim of this study was to explore the key challenges faced by homecare nurses in relation to caring for discharged patients. Data were collected through five focus group interviews with 29 Danish homecare nurses and subjected to inductive content analyses. The key challenges faced by homecare nurses fell into three themes: struggling to see the bigger picture, caring for patients from a distance, and compromising on professionalism. The findings demonstrated a paradox between the need for information and the struggle to access this information due to complicated infrastructures of information-sharing. Homecare nurses took on a substantial responsibility in providing the best possible care despite having limited information. Ironically, by taking on this responsibility, they implicitly contribute to covering up the problems of organisational and professional information flow.

Infants' transition from milk to solid foods - the lived experiences of first-time parents.

Purpose: During the transition from ingesting milk to ingesting solid food, infants substantiate their eating habits. The present study focuses on this transition. Specifically, it aimed to explore first-time parents' lived experiences of their infants' transition from milk to solid foods.Method: The study is based on the descriptive phenomenological approach Reflective Lifeworld Research (RLR). Ten mothers and ten fathers were interviewed twice; when the infants were aged four to five months and again at seven to eight months of age. Data were analysed according to RLR principles.Results: The findings show that the transition from milk to solid food is a demanding in-between phase. The physically intimate feeding situation is replaced by unfamiliar situations in which parents and infant are physically separated and new types of food are introduced. The process of feeding requires parents' full attention and sensitivity towards the infant's reactions.Conclusion: The study highlights how shared parental experiences were reflected in frames for how a meal should normally proceed, including parents' desire to create healthy eating habits and uphold harmony duringfamily mealsWe suggest for health professionals to present parents with a wider frame of normality, especially as concerns the concept of what constitutes "normal" eating patterns.