Exploring hospital mealtime experiences of older inpatients, caregivers and staff using photovoice methods.

AIM: To gather and understand the experience of hospital mealtimes from the perspectives of those receiving and delivering mealtime care (older inpatients, caregivers and staff) using photovoice methods to identify touchpoints and themes to inform the co-design of new mealtime interventions. METHODS: This study was undertaken on acute care wards within a single metropolitan hospital in Brisbane, Australia in 2019. Photovoice methods involved a researcher accompanying 21 participants (10 older patients, 5 caregivers, 4 nurses and 2 food service officers) during a mealtime and documenting meaningful elements using photographs and field notes. Photo-elicitation interviews were then undertaken with participants to gain insight into their experience. Data were analysed using inductive thematic analysis, involving a multidisciplinary research team including a consumer. RESULTS: Themes were identified across the three touchpoints: (1) preparing for the meal (the juggle, the anticipation), (2) delivering/receiving the meal (the rush, the clutter and the wait) and (3) experiencing the meal (the ideal, pulled away and acceptance). Despite a shared understanding of the importance of meals and shared vision of 'the ideal' mealtime, generally this was a time of tension, missed cares and dissatisfaction for staff, patients and caregivers. There was stark contrast in some aspects of mealtime experience, with simultaneous experiences of 'the rush' (staff) and 'the wait' (patients and caregivers). There was an overwhelming sense of acceptance and lack of control over change from all. CONCLUSIONS: This study identified themes during hospital mealtimes which have largely gone unaddressed in the design of mealtime interventions to date. This research may provide a framework to inform the future co-design of mealtime interventions involving patients, caregivers and multidisciplinary staff, centred around these key touchpoints. PRACTICE IMPLICATIONS: Mealtimes are experienced differently by patients, caregivers, nurses and food service officers across three key touchpoints: preparing for, delivering/receiving and experiencing the meal. Improving mealtime experiences therefore necessitates a collaborative approach, with co-designed mealtime improvement programs that include specific interventions focusing each touchpoint. Our data suggest that improvements could focus on reducing clutter, clarifying mealtime roles and workflows and supporting caregiver involvement. IMPACT: What problem did the study address? Mealtimes are the central mechanism to meet patients' nutritional needs in hospital; however, research consistently shows that many patients do not eat enough to meet their nutritional requirements and that they often do not receive the mealtime assistance they require. Interventions to improve hospital mealtimes have, at best, shown only modest improvements in nutritional intake and mealtime care practices. Gaining deeper insight into the mealtime experience from multiple perspectives may identify new opportunities for improvement. What were the main findings? Patients, caregivers and staff have shared ideals of comfort, autonomy and conviviality at mealtimes, but challenges of complex teamwork and re-prioritisation of mealtimes in the face of prevailing power hierarchies make it difficult to achieve this ideal. There are three discrete touchpoints (preparing for, delivering/receiving and experiencing the meal) that require different approaches to improvement. Our data suggests a need to focus improvement on reducing clutter, clarifying mealtime roles and workflows and supporting caregivers. Where and on whom will the research have an impact? The research provides a framework for multidisciplinary teams to begin co-designing improvements to mealtime care to benefit patients, caregivers and staff, while also providing a method for researchers to understand other complex care situations in hospital. REPORTING METHOD: This manuscript is written in adherence with the Standards for Reporting Qualitative Research. PATIENT OR PUBLIC CONTRIBUTION: Patients and caregivers were involved in the conception and design of the study through their membership of the hospital mealtime reference group. A consumer researcher (GP) was involved in the team to advise on study conduct (i.e. recruitment methods and information), data analysis (i.e. coding transcripts), data interpretation (i.e. review and refinement of themes) and manuscript writing (i.e. review and approval of final manuscript).

Eat Walk Engage: Enabling acute care teams to deliver consistent fundamentals of care for older people.

AIMS: Fundamentals of care are particularly important for older people in acute inpatient settings, who are at increased risk of serious hospital-associated complications like delirium and functional decline. These complications occur due to interactions between clinical complexity and the complex processes and context of hospital care and can be reduced by consistent attention to the fundamentals of care. This paper aims to illustrate of how multi-level nursing leadership of fundamentals of care can be supported to emerge within complex multidisciplinary delivery systems in acute care. DESIGN: Discussion paper informed by clinical and organizational experience of a multidisciplinary leadership team and complexity leadership theory. DATA SOURCES: We provide a series of vignettes as practical illustrations of a successful multidisciplinary improvement program called Eat Walk Engage which supports the delivery of better care for older inpatients, significantly reducing delirium. We argue that taking a broader complexity-based approach including collaborative multidisciplinary engagement, iterative and integrated interventions and appropriate knowledge translation frameworks can enable emergent leadership by nurses at all levels. IMPLICATIONS FOR NURSING: This promising approach to improving care for older patients requires organizational support for facilitation and reflective practice, and for meaningful data to support change. Our discussion challenges nursing leaders to support the time, agency and connections their nursing staff need in order to emerge as local leaders in fundamental care. CONCLUSION: The debate around scope and responsibilities for fundamentals of care in hospital care has important practical implications for conceptualizing leadership and accountability for improvement. IMPACT: Our discussion illustrates how a structured multidisciplinary approach that acknowledges and navigates complexity can empower nurses to lead and improve outcomes of older patients in acute care.

Using a general theory of implementation to plan the introduction of delirium prevention for older people in hospital.

AIM: To develop an implementation plan for delirium prevention. BACKGROUND: The use of non-pharmacological interventions to prevent hospital-acquired delirium is well established but their implementation has been notoriously difficult to achieve. Systematic analysis of context as part of implementation planning is critical. METHODS: Ethnographic study was conducted in a 24-bed general medical ward. Eleven patients and family members and 15 health service staff participated through observations, individual interviews and document review. Inductive analysis was used to generate themes that described enablers and barriers. RESULTS: Enablers included a ward culture that embraced safety and placing the person at the centre of care. Barriers were in tension with the enablers and included limited staff knowledge, specialist forms exclusive to the nursing discipline, inflexible ward routines and frequent disruptions. CONCLUSIONS: In addition to standard implementation strategies such as individual education and leadership, implementing delirium prevention requires consideration of team practices, review of policy document design and identification of outcomes data than can support collaborative reflexive practice. IMPLICATIONS FOR NURSING MANAGEMENT: The use of a theory-informed ethnographic approach exposed tensions that may be otherwise invisible. Understanding the tensions increases the likelihood of implementation success. Using a systematic assessment approach can create a comprehensive implementation plan.

Cognitive impairment in older hospital inpatients: prevalence, care needs and carer perceptions.

Objectives The aim of this study was to describe the prevalence of cognitive impairment in hospital inpatients, the associated need for assistance with activities of daily living (ADL) and carer perceptions of hospital care. Methods A prospective cross-sectional observational study was conducted in a large metropolitan teaching hospital in Brisbane, Australia. Participants were inpatients aged ≥65 years and their carers. Cognitive impairment was measured by clinician auditors using the validated 4 'A's test (4AT), with a score >0 indicating cognitive impairment (1-3, probable dementia; >3, probable delirium). The need for supervision and/or assistance with ADL was recorded from daily nursing documentation. Carers were invited to complete a brief questionnaire. Results In all, 92 of 216 older inpatients (43%) had cognitive impairment, including 52 (24%) with probable delirium. The need for supervision and/or assistance with ADL increased significantly with 4AT score. Fifty-two carers of patients with cognitive impairment reported feeling welcome and that care was safe. They identified opportunities for better information, greater support and more inclusion of carers. Conclusions Cognitive impairment is common in older inpatients and is associated with increased care needs. Workforce planning and health professional training need to acknowledge the needs of patients with cognitive impairment. There are opportunities for greater support and more involvement of carers. What is known about the topic? Cognitive impairment due to delirium and dementia increases with age, and is common in older medical and surgical inpatients. However, cognitive impairment remains under-recognised by healthcare staff. Australian guidelines now recommend routine screening using valid tools, and including carers, when appropriate, when assessing, caring for and communicating with people with cognitive impairment. What does this paper add? This cross-sectional study using the validated 4AT showed 43% of hospital inpatients aged ≥65 years had cognitive impairment. Participants with cognitive impairment had higher care needs and much longer hospitalisations. Carers of people with cognitive impairment reported unmet information needs in hospital and had limited involvement in assessment and care. What are the implications for practitioners? Cognitive impairment is common in older inpatients. Hospitals and healthcare professionals must be prepared and equipped to recognise cognitive impairment, and address the accompanying patient and carer needs.

A mixed methods evaluation of an individualised yoga therapy intervention for rheumatoid arthritis: Pilot study.

OBJECTIVES: to explore patients' experiences of an individualised yoga therapy intervention for rheumatoid arthritis (RA), specifically in terms of its acceptability and impact on patient-reported outcomes. DESIGN: Ten patients took part in a 16 week yoga therapy intervention in a hospital setting, consisting of 10 one-to-one consultations with a yoga therapist followed by two group review sessions. Changes in health (EQ-5D, HADS) were assessed pre- and post-intervention and at 12-month follow-up. In-depth interviews were conducted post-intervention and analysed using thematic analysis. RESULTS: Attendance of the 1-to-1 sessions was high (98 %) and all participants reported strong commitment to their personalised home practice. There were significant improvements in measures of depression, anxiety, pain, quality of life and general health at post-intervention and 12-months (p < 0.05). In interviews, all but one participant reported positive changes to their symptoms and several reported reductions in their medication and broader benefits such as improved sleep, mood and energy, enabling re-engagement with life. The personally tailored nature of the practice and perceived benefits were key motivational factors. Particular value was placed on the therapeutic function of the consultation and provision of tools to manage stress and build resilience. CONCLUSION: This yoga therapy intervention was positively received by patients with RA, with high levels of adherence to both the treatments and tailored home practice. The findings suggest that yoga therapy has potential as an adjunct therapy to improve RA symptoms, increase self-care behaviours and manage stress and negative affect such as anxiety. A larger multi-centre study is therefore warranted.

Voluntary exercise or systemic propranolol ameliorates stress-related maladaptive behaviors in female rats.

Many people will experience at least one traumatic event in their lifetime, with up to 20% developing Post-Traumatic Stress Disorder (PTSD) or PTSD-like symptoms. In addition, the likelihood that females will develop PTSD after trauma is more than twice that of males. Despite its prevalence, current treatment strategies for trauma victims are limited and substantial portions of affected individuals remain resistant to treatment, suggesting that additional interventions are necessary. Using an animal model of traumatic stress, the present studies tested the hypothesis that either voluntary exercise and/or administration of the adrenergic beta-receptor antagonist propranolol, would ameliorate stress-related maladaptive behaviors. In Study 1 four groups of female rats were exposed to a sequence of stressors that included anesthesia, restraint, forced swim, exposure to predator scent and fear conditioning. Rats then underwent re-exposure sessions in which stress-related conditioned stimuli were presented. In addition to re-exposure, stressed rats were treated with propranolol (10 mg/kg) and/or given the opportunity to engage in voluntary wheel running intermittently for 4 weeks. Stress-associated maladaptive behavior was assessed using the elevated plus and open field mazes and fear memory tests. Cognitive ability was assessed using a novel odor recognition task. A main effect of exercise on behaviors related to anxiety and resilience was observed, but neither a main effect of propranolol nor a synergistic effect of propranolol and exercise were observed. Neither stress induction nor treatment influenced recognition memory. In contrast, in Study 2 in which the timing and dosage of propranolol (0.25-2.0 mg/kg), and the number and timing of re-exposure sessions were adjusted, propranolol produced both a reduction in anxiety-like behaviors as well as resilience to a subsequent stressor. These results are consistent with the notion that combining re-exposure therapy with additional interventions is beneficial for female trauma victims. Furthermore, the findings support the view that in pre-clinical models, voluntary exercise, which bolsters hippocampal function and propranolol, which affects amygdala-dependent memory reconsolidation and peripheral noradrenergic signaling, can ameliorate stress-related symptoms.