A preliminary qualitative study of nurses’ and dietitians’ views on malnutrition management and oral nutritional supplementation prescription in the community

AbstractProtein-energy malnutrition, or undernutrition, arising from a deficiency of energy and protein intake, can occur in developed countries both in hospitalised patients and in the primary care/community setting. Oral nutritional supplements (ONS) are an effective method of managing malnutrition if prescribed for patients who are malnourished or at risk of malnutrition. Pooled data of older adults at risk of malnutrition indicate that ONS combined with dietary counselling is the most effective intervention. Previous Irish research has demonstrated that management of patients ‘at risk’ of malnutrition in the primary care/community setting is sub-optimal, with low awareness of the condition and its management among non-dietetic health care professionals. Therefore, the aim of this qualitative study is to explore community nurses’ and dietitians’ experiences and opinions on the management of malnutrition and the prescription of ONS in the primary care/community setting in Ireland. Three focus groups were conducted with primary care dietitians (n = 17) and one focus group with community nurses (n = 5), one of the nurses had prescribing rights. The focus groups explored the following domains; the term malnutrition and patient population presenting as malnourished or at risk of malnutrition, barriers and facilitators in the management of malnutrition, ONS prescribing in the primary care/community setting, and future directions in the management of malnutrition and ONS prescribing. Recorded focus groups were transcribed and analysed using inductive thematic analysis. Both professional groups showed similar perspectives, and three preliminary main themes were identified; i) Malnutrition is a misunderstood term, ii) Delayed treatment of malnutrition, iii) Challenges with ONS prescription in the primary care/community setting. Both dietitians and community nurses agreed that the term malnutrition had negative connotations for patients and preferred not to use it with them. Dietitians identified the need for a multidisciplinary approach to manage patients at risk of malnutrition in the community, and community nurses agreed on their pivotal role identifying the risk of malnutrition and providing first line advice to clients. However, community nurses expressed the urgent need for training to provide first line advice to patients to improve their nutritional status to prevent malnutrition. Both groups also agreed on the need for access to more dietitians in the community, and suggested that giving dietitians prescribing rights would improve appropriate ONS prescribing. Community nurses identified a gap in their knowledge of the different ONS products, and the need to receive independent generic education on nutritional supplements.

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A preliminary qualitative study of general practitioners’ views on malnutrition management and oral nutritional supplementation prescription in the community

Proceedings of The Nutrition Society ◽

10.1017/s0029665120002803 ◽

2020 ◽

Vol 79 (OCE2) ◽

Author(s):

Patricia Domínguez Castro ◽

Sharon Kennelly ◽

Barbara Clyne ◽

Gerard Bury ◽

Catriona Bradley ◽

...

Keyword(s):

Primary Care ◽

At Risk ◽

Qualitative Study ◽

General Practitioners ◽

Health Care Professionals ◽

Inappropriate Prescribing ◽

Community Setting ◽

Community Dwelling ◽

Care Community ◽

Oral Nutritional Supplements

AbstractMalnutrition, arising from a deficiency of energy and protein intake, occurs commonly among community-dwelling individuals. Oral nutritional supplements (ONS) are an effective method of managing malnutrition if prescribed for patients who are malnourished or at risk of malnutrition. However, previous research indicates that inappropriate prescribing of ONS occurs frequently in the community setting (30–70% prevalence). Moreover, it has been previously shown that the management of patients ‘at risk’ of malnutrition in the primary care/community setting in Ireland is sub-optimal, with low awareness of the condition and its management among non-dietetic health care professionals (HCPs). In Ireland, general practitioners (GPs) are the main prescribers of ONS in primary care. They are also on many occasions the first point of contact for individuals in the community who are malnourished or at risk of malnutrition. Therefore, exploring their experiences and perceptions can provide insight into the complexities of managing malnutrition and ONS prescribing in the community. The aim of this qualitative study was to explore GPs’ experiences and opinions on the management of malnutrition and the prescription of ONS in the primary care/community setting in Ireland. Semi-structured interviews were conducted with nine GPs. The interview explored among others the following domains; Barriers and facilitators in the management of malnutrition, ONS prescribing in the primary care/community setting, and future directions in the management of malnutrition and ONS prescribing. Recorded interviews were transcribed and analysed using inductive thematic analysis. Three main themes were identified; i) Malnutrition a secondary concern, encapsulating the idea that malnutrition is not something that GPs screen for in isolation ii) Resources and support for managing malnutrition are needed in the community iii) Reluctance to prescribe ONS. GPs reported not screening for malnutrition, but viewed it as a consequence of other conditions and social factors. According to the GPs, they should not have sole responsibility for malnutrition management and more dietitians and trained community nurses would be desirable to support them to deal with malnutrition in the community. A preference to avoid supplementation and implement dietary changes first was expressed by GPs. As main prescribers, GPs thought that they should receive further independent trainingon the different ONS available in the market as currently they did not feel confident prescribing a range of them. Awareness of ONS cost and its misuse by certain patients were reported as reasons that made GPs reluctant to prescribe them, potentially leading to under prescribing.

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Detection and Management of Malnutrition in Primary Care

Kompass Nutrition & Dietetics ◽

10.1159/000515778 ◽

2021 ◽

pp. 1-2

Author(s):

Trude Backer Mortensen

Keyword(s):

Primary Care ◽

Quality Care ◽

Community Setting ◽

Developed Countries ◽

Overweight And Obesity ◽

Community Dwelling ◽

Dietary Advice ◽

Structured Interviews ◽

Care Community ◽

Oral Nutritional Supplements

Background & aims: Malnutrition or undernutrition, arising from a deficiency of energy and protein intake, occurs commonly among community-dwelling individuals in developed countries. Once identified, malnutrition can be effectively treated in the majority of cases with dietary advice and the prescription of oral nutritional supplements (ONS) for patients who can eat and drink orally. However, previous research has reported inadequate screening and treatment of malnutrition in the community. The aim of this qualitative study was to explore general practitioners’ (GPs) experiences and opinions on the management of malnutrition and the prescription of ONS in the primary care/community setting in Ireland. Methods: Sixteen semi-structured interviews including chart stimulated recalls (CSR) were conducted with GPs. The interviews and CSRs explored, among others, the following domains; barriers and facilitators in the management of malnutrition, ONS prescribing in the primary care/community setting, and future directions in the management of malnutrition and ONS prescribing. Recorded interviews were transcribed and analysed following a generic qualitative approach with inductive thematic analysis using NVIVO 12 to facilitate data management. Results: Three main themes were identified. Theme 1: ‘Malnutrition is a secondary concern’, encapsulating the idea that the identification of malnutrition is usually secondary to other clinical issues or disease rather than an independent clinical outcome. This theme also includes the idea that obesity is viewed as a dominant nutritional issue for GPs. Theme 2: ‘Responsibility for malnutrition and ONS management in the community’, highlighting that GPs feel they do not know who is responsible for the management of malnutrition in the community setting and expressed their need for more support from other healthcare professionals (HCPs) to effectively monitor and treat malnutrition. Theme 3: ‘Reluctance to prescribe ONS’, emerging from the GPs reported lack of knowledge to prescribe the appropriate ONS, their concern that ONS will replace the patient’s meals and the costs associated with the prescription of ONS. Conclusions: GPs in Ireland do not routinely screen for malnutrition in their clinics as they feel unsupported in treating and managing malnutrition in the community due to limited or no dietetic service availability and time constraints. GPs also view malnutrition as a secondary concern to disease management and prioritise referral to dietetic services for patients with overweight and obesity. GPs reported that they have insufficient knowledge to change or discontinue ONS prescriptions. This study demonstrates that there is a clear need for primary care training in malnutrition identification, treatment and management and more community dietetic services are needed in order to support GPs and deliver high quality care to patients.

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Nurses’ perceptions towards the delivery and feasibility of a behaviour change intervention to enhance physical activity in patients at risk for cardiovascular disease in primary care: a qualitative study

BMC Family Practice ◽

10.1186/s12875-018-0888-1 ◽

2018 ◽

Vol 19 (1) ◽

Cited By ~ 2

Author(s):

Heleen Westland ◽

Yvonne Koop ◽

Carin D. Schröder ◽

Marieke J. Schuurmans ◽

P. Slabbers ◽

...

Keyword(s):

Physical Activity ◽

Cardiovascular Disease ◽

Primary Care ◽

At Risk ◽

Qualitative Study ◽

Behaviour Change ◽

Behaviour Change Intervention ◽

Patients At Risk ◽

Nurses Perceptions

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Perceived Facilitators and Barriers to Implementation of a Decision Support Tool for Adolescent Depression and Suicidality Screening: A Qualitative Study (Preprint)

10.2196/preprints.26035 ◽

2020 ◽

Author(s):

Ana Radovic ◽

Nathan Anderson ◽

Megan Hamm ◽

Brandie George-Milford ◽

Carrie Fascetti ◽

...

Keyword(s):

Mental Health ◽

Primary Care ◽

Qualitative Study ◽

Focus Groups ◽

Decision Support Tool ◽

Depression Screening ◽

Self Disclosure ◽

Support Tool ◽

Adolescent Parent ◽

Barriers To Implementation

BACKGROUND Screening Wizard (SW) is a technology-based decision support tool aimed at guiding primary care providers (PCPs) to respond to depression and suicidality screens in adolescents. Separate screens assess adolescents’ and parents’ reports on mental health symptoms, treatment preferences, and potential treatment barriers. A detailed summary is provided to PCPs, also identifying adolescent-parent discrepancies. The goal of SW is to enhance decision making to increase utilization of evidence-based treatments. OBJECTIVE We describe a multi-stakeholder qualitative study with adolescents, parents, and providers to understand potential barriers to implementation of SW. METHODS We interviewed 11 parents and 11 adolescents, and conducted 2 focus groups with 17 healthcare providers (PCPs, nurses, therapists, staff) across 2 pediatric practices. Participants described previous experiences with screening for depression and were shown a mock-up of SW and asked for feedback. Interviews and focus groups were transcribed verbatim, and codebooks inductively developed based on content. Transcripts were double-coded, and disagreements adjudicated to full agreement. Completed coding was used to produce thematic analyses of interviews and focus groups. RESULTS We identified five main themes across the interviews and focus groups: (1) parents, adolescents, and pediatric PCPs agree that depression screening should occur in pediatric primary care; (2) there is concern that accurate self-disclosure does not always occur during depression screening; (3) Screening Wizard is viewed as a tool that could facilitate depression screening, and which might encourage more honesty in screening responses; (4) parents, adolescents and providers do not want Screening Wizard to replace mental health discussions with providers; and (5) providers want to maintain autonomy in treatment decisions. CONCLUSIONS We identified that providers, parents, and adolescents all have concerns with current screening practices, mainly regarding inaccurate self-disclosure. They recognized value in SW as a computerized tool that may elicit more honest responses and identify adolescent-parent discrepancies. Surprisingly, providers did not want the SW report to include treatment recommendations, and all groups did not want the SW report to replace conversations with the PCP about depression. While SW was originally developed as a treatment decision algorithm, this qualitative study has led us to remove this component, and instead focus on aspects identified as most useful by all groups. We hope that this initial qualitative work will improve future implementation of SW.

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Primary care teams’ experiences of delivering mental health care during the COVID-19 pandemic: a qualitative study

BMC Family Practice ◽

10.1186/s12875-021-01496-8 ◽

2021 ◽

Vol 22 (1) ◽

Author(s):

Rachelle Ashcroft ◽

Catherine Donnelly ◽

Maya Dancey ◽

Sandeep Gill ◽

Simon Lam ◽

...

Keyword(s):

Mental Health ◽

Primary Care ◽

Health Care ◽

Qualitative Study ◽

Mental Health Care ◽

Focus Groups ◽

Care Delivery ◽

Virtual Care ◽

Primary Care Teams ◽

The Impact

Abstract Background Integrated primary care teams are ideally positioned to support the mental health care needs arising during the COVID-19 pandemic. Understanding how COVID-19 has affected mental health care delivery within primary care settings will be critical to inform future policy and practice decisions during the later phases of the pandemic and beyond. The objective of our study was to describe the impact of the COVID-19 pandemic on primary care teams’ delivery of mental health care. Methods A qualitative study using focus groups conducted with primary care teams in Ontario, Canada. Focus group data was analysed using thematic analysis. Results We conducted 11 focus groups with 10 primary care teams and a total of 48 participants. With respect to the impact of the COVID-19 pandemic on mental health care in primary care teams, we identified three key themes: i) the high demand for mental health care, ii) the rapid transformation to virtual care, and iii) the impact on providers. Conclusions From the outset of the COVID-19 pandemic, primary care quickly responded to the rising mental health care demands of their patients. Despite the numerous challenges they faced with the rapid transition to virtual care, primary care teams have persevered. It is essential that policy and decision-makers take note of the toll that these demands have placed on providers. There is an immediate need to enhance primary care’s capacity for mental health care for the duration of the pandemic and beyond.

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What role for oral nutritional supplements in primary care?

Drug and Therapeutics Bulletin ◽

10.1136/dtb.2018.8.0657 ◽

2018 ◽

Vol 56 (8) ◽

pp. 90-93 ◽

Cited By ~ 2

Keyword(s):

Primary Care ◽

Healthcare Professionals ◽

Nutritional Supplements ◽

Nutritional Intake ◽

Nutrition Support ◽

Dietary Advice ◽

Treatment Goals ◽

Fortified Food ◽

Oral Nutritional Supplements ◽

Regular Review

Malnutrition, a deficiency of energy, protein and other nutrients, is a cause of health problems and adverse clinical outcomes.1,2 It has been estimated that a significant number of people have, or are at risk of, malnutrition and the National Institute for Heaxlth and Care Excellence (NICE) has recognised the need to improve healthcare professionals’ knowledge of the causes, effects and treatment of malnutrition.3,4 However, NICE acknowledged that “there is no clear evidence available as to whether screening is really beneficial or how it should be carried out”.4 One of the key elements to improve or maintain nutritional intake for people with malnutrition is the provision of nutrition support, including dietary advice, the use of fortified food and additional snacks. Although for some people oral nutritional supplements (ONS) may be needed, their use can be limited by poor compliance due to low palatability or unwanted effects such as nausea and diarrhoea.5 Without appropriate assessment, treatment goals and regular review processes, the provision of ONS products may be ineffective and waste NHS resources. Here, we discuss the place of nutritional supplements in the management of malnutrition.

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What are the opportunities for cancer care and related research in primary care? A qualitative study of the views of patients, carers, and practice staff

British Journal of General Practice ◽

10.3399/bjgp19x703505 ◽

2019 ◽

Vol 69 (suppl 1) ◽

pp. bjgp19X703505

Author(s):

Joseph Clark ◽

Elvis Amoakwa ◽

John Blenkinsopp ◽

Florence Reedy ◽

Miriam Johnson

Keyword(s):

Primary Care ◽

Palliative Care ◽

Qualitative Study ◽

Focus Groups ◽

Cancer Care ◽

Information Needs ◽

Controlled Trial ◽

Unmet Need ◽

Care Staff ◽

Trial Participation

BackgroundResearch to identify the role of primary care in cancer care is important. However, trials in primary care are difficult.AimTo understand how patients, families, and primary care clinicians view their role in cancer care and identify opportunities for cancer primary care research.MethodQualitative study embedded within a feasibility cluster randomised controlled trial of a primary care based needs assessment intervention. The Supportive Cancer Needs Survey (SCNS) was the main outcome. In-depth interviews with patients/carers and focus groups with primary care staff explored views on cancer care and trial participation. Data were recorded, transcribed verbatim, and analysed thematically by three independent researchers.ResultsFifteen cancer patients and three carers were interviewed and four focus groups (n = 11) were conducted. Three themes were generated satisfaction with current care; key time-points for improved cancer care; and information and research. Satisfaction with current care among patients was high in spite of 72% reporting at least one moderate-high unmet need at baseline. Most patients undergoing cancer treatment were unsure when to access primary care. Patients and carers highly valued proactive contact from their practice following diagnosis though this was uncommon. Post-oncology discharge was a key time-point for information needs and support for patients. Patients were reluctant to consider palliative care in spite of palliative care needs. Some felt therapeutic benefit from completing study measures.ConclusionPatients are satisfied with cancer primary care despite unmet needs. Palliative care is poorly understood by many who may benefit. Research participation may benefit some patients.

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Using the electronic health record to build a culture of practice safety: evaluating the implementation of trigger tools in one general practice

British Journal of General Practice ◽

10.3399/bjgp18x695489 ◽

2018 ◽

Vol 68 (669) ◽

pp. e279-e285 ◽

Cited By ~ 2

Author(s):

Tom Margham ◽

Natalie Symes ◽

Sally A Hull

Keyword(s):

Primary Care ◽

At Risk ◽

General Practice ◽

Patient Safety ◽

Ease Of Use ◽

High Yield ◽

Case Review ◽

Patients At Risk ◽

Barriers To Implementation ◽

Narrative Evaluation

BackgroundIdentifying patients at risk of harm in general practice is challenging for busy clinicians. In UK primary care, trigger tools and case note reviews are mainly used to identify rates of harm in sample populations.AimThis study explores how adaptions to existing trigger tool methodology can identify patient safety events and engage clinicians in ongoing reflective work around safety.Design and settingMixed-method quantitative and narrative evaluation using thematic analysis in a single East London training practice.MethodThe project team developed and tested five trigger searches, supported by Excel worksheets to guide the case review process. Project evaluation included summary statistics of completed worksheets and a qualitative review focused on ease of use, barriers to implementation, and perception of value to clinicians.ResultsTrigger searches identified 204 patients for GP review. Overall, 117 (57%) of cases were reviewed and 62 (53%) of these cases had patient safety events identified. These were usually incidents of omission, including failure to monitor or review. Key themes from interviews with practice members included the fact that GPs’ work is generally reactive and GPs welcomed an approach that identified patients who were ‘under the radar’ of safety. All GPs expressed concern that the tool might identify too many patients at risk of harm, placing further demands on their time.ConclusionElectronic trigger tools can identify patients for review in domains of clinical risk for primary care. The high yield of safety events engaged clinicians and provided validation of the need for routine safety checks.

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