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For peer review only

Implementing professional behaviour change in teams under pressure – results from phase one of a prospective

process evaluation of a new procedure for screening and treatment of malnutrition in community care for older

people (INSCCOPe).

Journal: BMJ Open

Manuscript ID bmjopen-2018-025966

Article Type: Research

Date Submitted by the Author: 14-Aug-2018

Complete List of Authors: Bracher, Mike; University of Portsmouth, School of Health Sciences and Social Work; Bournemouth University, Humans Sciences & Public Health, Faculty of Health & Social Sciences Steward, Katherine; Southern Health NHS Foundation Trust Wallis, Kathy; Wessex Academic Health Science Network (AHSN)

May, Carl; London School of Hygiene and Tropical Medicine Faculty of Epidemiology and Population Health Aburrow, Annemarie; Wessex Academic Health Science Network (AHSN) Murphy, Jane; Bournemouth University, Humans Sciences & Public Health

Keywords: screening, process evaluation, community care, malnutrition, normalization process theory, implementation

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Implementing professional behaviour change in teams under pressure – results from phase one of a prospective

process evaluation of a new procedure for screening and treatment of malnutrition in community care for older

people (INSCCOPe).

Mike Bracher (MB) ([email protected])12§

Katherine Steward (KS) ([email protected])3

Katherine Wallis (KW) ([email protected])4

Carl R. May (CRM) ([email protected])5

Annemarie Aburrow (AA) ([email protected])

Jane Murphy (JM) ([email protected])2

1. School of Health Sciences and Social Work (SHSSW), University of Portsmouth

2. Ageing and Dementia Research Centre (ADRC), Bournemouth University

3. Southern Health NHS Foundation Trust

4. Wessex Academic Health Science Network (AHSN)

5. Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine

§ Corresponding author

Mike Bracher, School of Health Sciences and Social Work (SHSSW), University of Portsmouth

Email: [email protected]; Tel: 07888706484

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Abstract

Objectives: To report findings of the implementation phase of a new procedure for screening and treatment of

malnutrition for older people in community settings.

Design: Prospective process evaluation using mixed methods with pre/post-implementation measures.

Setting and participants: Community teams (nursing and allied health professionals) within one area of a UK

National Health Service (NHS) Trust. 73 participants were recruited, of which 32 completed both pre and post-

implementation surveys.

Main outcome measures: NoMad survey for pre-post intervention measures; telephone interviews exploring

participant experiences and wider organisational/contextual processes.

Methods: Data prior to implementation of training, baseline (T0 – survey and telephone interview), and 2 months

following training (T1 – follow-up survey). Quantitative data described using frequency tables reporting team type,

healthcare provider (HCP) role group, and total study sample; analysis using Wilcoxon rank-sum (sub-group

comparison) and Wilcoxon signed-rank (within-group observation point comparison) tests. Qualitative interview

data (audio and transcription) analysed through directed content analysis using Normalization Process Theory (NPT).

Results: High levels of support were shown for nutrition screening and treatment activity among participants, as well

as areas of concern in relation to logistical and organisational support. Interviews indicated access to specialist

dietetic support as a concern. Results indicated a positive impact of training on knowledge of the new procedure;

however, most implementation measures saw no significant changes between time points or between sub-groups

(training participants vs. non-participants). Implementation barriers included: high levels of training non-completion;

vulnerability to attrition of trained staff; lack of monitoring of post-intervention compliance; lack of access to

specialist nutritional support.

Conclusion: Barriers to implementation were identified, and an amended implementation approach proposed.

Findings also contribute to the wider knowledge base on implementation and longer term embedding of new

procedures by supporting and extending observations of previous studies regarding the importance of Collective

Action and Reflexive Monitoring-type processes.

Strengths and Limitations

• Prospective investigation of factors promoting or inhibiting implementation of service development,

allowing for feedback to inform ongoing development of the programme.

• To our knowledge, this is the first time that a prospective process evaluation has been conducted specifically

on implementation of nutritional care in community settings process evaluations conducted on

implementation of nutritional care in community settings.

• Integrated use of mixed methods to provide reproducible measures at each observation point (quantitative,

survey), and explore processes underpinning them (qualitative, semi-structured telephone interviews).

• Lack of quota sample due to lack of data on workforce composition may mean that sample is

unrepresentative of the role/seniority profile of the target population.

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• Limitations of the study include: lack of observation of new procedures applied in situ, meaning that

processes relating to implementation can only be explored retrospectively through interviews, and therefore

recall and response bias may affect the data; lack of available data on composition of the target population

(i.e. the area of the organisation in which the intervention was implemented) limits reporting on

representativeness of the study sample.

Word Count = 5,168

Keywords: Nutrition, screening, process evaluation, community care, malnutrition, normalization process theory,

implementation

Background

Implementation of new procedures or technologies in healthcare settings involves complex processes, bringing

together individuals of different professional groups in varied kinds of work [1,2]. Process evaluation studies help us

to understand the success or failure of interventions, and illuminate the wide range of factors that shape

intervention outcomes [3]. The dynamics of practice implementation in open systems, like community health and

social care – is not well understood. Implementation conditions in community settings are different from those of

closed systems (secondary/hospital settings) because of the spatial distribution of service users and healthcare

providers and their focus on domiciliary screening and care. . and contextual factors such as funding, resource, and

staffing pressures, which may have consequences that differ from those found in hospitals [4,5].

Screening for malnutrition represents an important aspect of routine care for those working with older people in the

community [6–8]. However, malnutrition is often undiagnosed and frequently under-recognised in this area [9].

Previous studies in hospital and care home settings have indicated that contextual and organisational barriers can

impede introduction of new procedures for nutritional care [10,11]. To our knowledge, no published studies have

focused specifically and prospectively on implementation of nutrition screening in community settings. This paper

contributes to understanding implementation of professional behaviour change in community settings, by

presenting results from the implementation phase of a new procedure for screening and treatment of malnutrition

in community care for older people.

Prevalence, impact, and economic costs of malnutrition

Malnutrition is defined as ‘deficiencies, excesses or imbalances in a person’s intake of energy and/or nutrients’

covering ‘2 broad groups of conditions’: ‘undernutrition’, and ‘overweight, obesity and diet-related non

communicable diseases’ [12]. While the term can refer to people who are overweight, it is more often applied to

people who are underweight. In this paper, we use the term ‘malnutrition’ to refer to ‘undernutrition’ [13]. More

than 3 million individuals are estimated to be malnourished or at risk of malnutrition in the UK, the majority(93%)

living in the community [14,15]. Of these, over one million are over the age of 65 [16] while over 2 million people

aged over 75 years live alone and could be at increased risk [17]. Malnutrition has many negative consequences that

both affect the individual, and impose a strain on health-care resources through delayed recovery from illness,

increased need for health care provision at home, more frequent visits by nurses, and a greater number of hospital

admissions [13,18]. In 2015, Elia reported that the estimated cost of malnutrition in England was £19.6 billion, of

which spending on older adults over the age of 65, accounts for 52% [9]. A review of the impact of malnutrition in

older people indicated that malnutrition can be prevented through screening and early intervention, and that the

benefits of treating malnutrition far outweigh the costs [19]. However, it remains under-detected, under-treated and

under-resourced, and is often overlooked by those working with and for older people [19].

A new procedure for screening and treatment of malnutrition (the intervention).

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There is good evidence to suggest that staff providing care and treatment within community settings (in both

physical and mental healthcare) who already review and manage older people, are well placed to perform routine

nutrition screening as part of practice (and in accordance with guidelines from the UK National Institute for Clinical

Excellence) (NICE) [8,20]. In the UK, local protocols concerning nutritional screening and assessment often exist

within National Health Service (NHS) hospital trusts, based on national protocols. However, previous service

development work around nutrition in the community indicates that it is often not considered a routine part of

interactions with older people [21].

This paper reports on the implementation phases of a new procedure for screening and treatment of malnutrition in

older people within an NHS Trust in England. It focuses on the work of community nursing and allied health

professionals (covering physical and mental health services respectively), mobilising this procedure in the

community (see Additional File 1).

Existing organisational policy within the Trust has established when a patient should be screened for malnutrition,

and the care that a patient should receive depending on their malnutrition risk (assessed by Malnutrition Universal

Screening Tool –‘MUST' screening) [6]. The new procedure introduced a number of updates to existing policy: firstly,

only patients at medium or high risk of malnutrition (those with a ‘MUST’ score of 1 or more) require monthly re-

screening and follow up (previously all patients were expected to receive monthly screening), while patients at low

risk are now re-screened annually, unless there is a significant change in their health status. Secondly, a nutritional

pathway including appropriate care planning actions to be taken depending on the risk level and each specific case,

which included provision of malnutrition information resource sheets to medium and high-risk patients as a

mandatory activity (previously these were not routinely provided to patients in these categories). New information

resources were produced as part of the project, and guidance for when to use existing resources was specified

within the new procedure. Thirdly, the electronic patient records system provides facility to store screening

information for malnutrition in one place (previously paper and electronic processes ran separately and in parallel).

Prior to implementation of this electronic system, concerns had been raised regarding the storage and availability of

screening information to inform treatment decisions as part of care planning. As part of the new procedure, a form

was generated within the electronic system to record screening results and enable care planning activity. Fourthly,

the new procedure emphasised that staff at all roles and grades who provide community care to older people have

responsibility for malnutrition screening and delivery of appropriate treatment. Introduction of the new procedure

was provided through staff training delivered by a registered dietitian. 12 sessions were offered to enable as many

staff as possible to attend a one-hour training session. Immediate effectiveness of training was assessed through

pre-and-post training knowledge check questionnaires.

The role of Normalisation Process Theory (NPT)

The current study is informed by Normalization Process Theory (NPT), which identifies, characterises and explains

the mechanisms that motivate and shape implementation processes [22]. NPT focuses on three aspects of

implementation processes: how the components of complex interventions confer particular capabilities on their

users; what the work of implementing, embedding and integrating these capabilities In everyday practice is, and how

intervening mechanisms (coherence, cognitive participation, collective action and reflexive monitoring), motivate

and shape implementation processes and explain their operation; and finally, how participants in implementation

processes mobilise structural and cognitive resources as they invest in them. NPT is now widely used to inform

process evaluation research, a recent systematic review shoes 130 reports of feasibility studies and process

evaluations of controlled and uncontrolled interventions in open and closed systems, most of these published in the

last five years.

In nutritional care, NPT has been used in two previous studies focused on: development the role of the nurse as a

link advisor for research and champion for nutrition in the neonatal intensive care unit [23]; and implementing

nutrition guidelines for older people in residential care homes [11]. However, the present study is the first to apply

this to implementation of procedures for screening and treatment of malnutrition in community settings. The theory

can be used prospectively (i.e. to identify potential areas of importance with respect to embedding and

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implementation within a given topic area) and retrospectively (i.e. to analyse existing processes, practices, and

technologies with respect to the social and organisational activities that relate to their implementation and

embedding) [24,25]. NPT does not provide a framework of causal prediction; rather, its intended use has been to

help anticipate the trajectory of a new practice, technology, or process, with respect to the success of its

implementation, and embedding in routine practice (that is, given attention to activities in areas identified in the

framework, whether implementation and embedding is more or less likely to be successful) [22].

Aims and objectives

The aim of the study was (i) to undertake a process evaluation of the implementation of the screening procedure

and its associated training, and (ii) identify factors that promote or inhibit embedding of nutritional screening as a

routine aspect of care. This paper focuses on the implementation phase of the work.

Methods

Exclusion and inclusion criteria

Eligible staff were community-based members of staff (e.g. Nurses, Occupational Therapists, Healthcare Support

Workers, Physiotherapists, and Associate Practitioners in physical or mental healthcare) involved in screening and/or

treatment activity relating to malnutrition, expected to be in post for the duration of the study (12 months) either

full or part time. Those not involved in nutrition screening and treatment activity (e.g. team administrators, other

support staff), and staff not expecting to be in post for the duration of the study were ineligible. The research team

sought to recruit the maximum number of willing participants of all roles and grades, due the lack of available

demographic data to support a quota sample.

Recruitment

Prior to an in-person invitation to participate in the study by the researcher (MB), potential participants (n=89) were

sent a Participant Information Sheet with contact details for the research team, circulated by team leads who

received it via email. Potential participants were then approached at a team meeting by the researcher (MB), at a

time agreed with the team lead, where the study was introduced, and participants’ questions answered.

Participants were informed of their right to withdraw at any stage without negative consequences, and without

giving a reason. Participants then completed an agreement form, a participant data form, and the T0 NoMad

instrument.

Study procedures

At T0, questionnaires were completed at the point of recruitment. At T1, questionnaires were circulated via team

leads. Data collection for phase one occurred at baseline (T0 – pre-implementation of procedure and training), and

approximately 2-3 months following completion of training (T1). Each point involved completion of a 23-item

questionnaire adapted from the NoMad instrument (a measure of normalization based on the NPT framework, see

Table 1) [24], and a follow-up semi-structured telephone interview (to be completed by a sub-sample of

participants). Rationale for the methods and study design are now described in accordance with Good Reporting of a

Mixed Methods Study (GRAMMS) criteria [26], and summarised in Figure 1.

[INSERT FIGURE 1]

Q1— When you screen and treat patients for malnutrition, how

familiar does it feel?

Q13—Screening and treatment for malnutrition disrupts working

relationships.

Q2— Do you feel that screening and treatment for malnutrition is

currently a normal part of your work?

Q14—I have confidence in other people’s ability to screen and pro-

vide treatment for malnutrition.

Q3— Do you feel that screening and treatment for malnutrition will

become a normal part of your work?

Q15—Work is assigned to those with skills appropriate to screening

and treatment for malnutrition.

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Q4—I can see how the new procedure for screening and treatment

of malnutrition differs from usual ways of working.

Q16—Sufficient training is provided to enable staff to implement

screening and treatment for mal-nutrition.

Q5—Staff in this organisation have a shared understanding of the

purpose of new procedure for screening and treatment of

malnutrition.

Q17—Sufficient resources are available to support screening and

treatment for malnutrition.

Q6—I understand how new procedure for screening and treatment

of malnutrition affects the nature of my own work

Q18—Management adequately supports screening and treatment

for malnutrition.

Q7—I can see the potential value of new procedure for screening

and treatment of malnutrition for my work

Q19—I am aware of reports about the effects of screening and

treatment for malnutrition.

Q8—There are key people who drive screening and treatment for

malnutrition forward and get others involved.

Q20—The staff agree that screening and treatment for

malnutrition is worthwhile.

Q9—I believe that participating in screening and treatment for

malnutrition is a legitimate part of my role.

Q21—I value the effects that screening and treatment for mal-

nutrition has had on my work.

Q10—I’m open to working with colleagues in new ways to screen

and treat for malnutrition.

Q22—Feedback about screening and treatment for malnutrition

can be used to improve it in the future.

Q11—I will continue to support screening and treatment for

malnutrition.

Q23—I can modify how I work with tools and/or procedures for

screening and treatment for malnutrition.

Q12—I can easily integrate screening and treatment for malnutrition

into my existing work.

Table 1 - NoMad questions as statements for evaluation (Q1 response variables: Still feels very new, 0-10, Feels completely familiar. Q2 & Q3

response variables: Not at all, 0 – Somewhat, 5 – Completely, 10. Q4-23 response variables: Strongly agree, 1 – 5, Strongly disagree; Not

relevant to my role – 6; Not relevant at this stage – 7; Not relevant to screening and treatment for malnutrition – 8.) (Questions 4-7 mapped to

the construct ‘Coherence’ and were not included at T0; Questions 1-3 explore general feelings of familiarity and normalization, and are not

reported in this article).

NoMad questionnaire

Each participant was given an envelope containing a questionnaire, which was completed and sealed before

returning to the team lead (return envelopes did not contain identifiable information). At T0, participants completed

and returned these directly to the researcher (MB). At T1, participants were informed by email/text message that

the questionnaires were available for completion; two weeks thereafter a reminder email/text message was sent,

and completed questionnaires were then collected by a researcher (MB) after a further week (the three-week

interval accommodated staff annual leave).

Telephone interviews

Following T0 NoMad completion, a sub-sample of participants were invited to participate in a follow-up semi-

structured telephone interview. In addition to exploring NoMad responses for each of the NPT components,

qualitative interviews offered several benefits. Firstly, identification of factors not visible through the NoMad

instrument (e.g. how implementation may affect local contexts, for example, within different teams [27]), allowing

for iterative development of additional questions (to be added after the items adapted from NoMad) at future

observation points (interviews at T0 generated questions which were added to the questionnaire at T1, which are

reported in the findings section). Secondly, interviews offered opportunities to elaborate on responses to NoMad.

This was particularly useful for exploring congruence between beliefs and attitudes on the one hand, and actions and

experiences on the other. Given that NPT focuses primarily on individual and collective action (that is, the work that

people do as individuals and within collectives in order to enact and embed a new set of practices), semi-structured

interviewing offered an opportunity to ensure that this was explored effectively.

Data collection, management, and analysis

Data collection and storage.

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Questionnaire responses were collected via paper instruments, and audio data from interviews were collected using

digital dictaphones; both were stored electronically and securely on Bournemouth University (BU) servers, in

password protected folders to which only the project team had access. For transcription, files were sent using a

secure drop off-service, to a transcription service with which the study team had a confidentiality and nondisclosure

agreement.

Data Analysis

Results from NoMad instruments were analysed using descriptive and inferential (Wilcoxon rank-sum test for

between group differences in response, Wilcoxon signed-rank test for pre-post differences within groups) statistics

using SPSS v.23 (threshold for statistical significance was defined at the 0.05 level in this study). Qualitative data

were analysed through deductive thematic analysis informed by NPT, using a constant comparative approach,

performed with NVivo v11 software [28,29].

Study sample

Staff (n=89) were approached at T0, of which 73 consented to participate. The recruitment rate at T0 was 79%. The

recruited sample T0 comprised: 42 physical health (community) nurses, seven mental health nurses, 16 Healthcare

Support Workers, four Occupational Therapists, one Physiotherapist, and one other practitioner of Consultant-level1.

Further details of the study sample are given in table 2. A sub-sample of 16 participants also completed the semi-

structured telephone interview following completion of NoMad at T0 (see table 2; for a full description of the

approach process for interview, see Additional File 2). At T1, 32 participants completed the follow-up NoMad

questionnaire (attrition rate = 56%), 13 of which participated in the training while 19 did not. Of the 41 participants

who did not complete T1, 12 participants (16% of the T0 recruited sample) were identified as having left their teams,

including four team leads representing a third of those included in the study (n=12). Reasons for non-completion at

T1 by the remaining 29 participants were not given. NoMad results reported here reflect only those who completed

at both T0 and T1 (n=32 participants).

Role

NoMad T0

(n)

Interview

(T0)

NoMad T1

(n)

Mental Health Nurse (MHN) 7 2 1

Physical Health (Community) Nurse

(PHN) 42 13 22

Occupational Therapist (OT) 4 1 4

Healthcare Support Worker (HSW) 16 0 4

Physiotherapist (PT) 1 0 1

Associate Practitioner (AP) 2 0 0

Other (consultant-grade practitioner)

(Oth) 1 0 0

Total participants (all roles/bands) 73 16 32 Table 2 - Demographic characteristics of study sample.

Patient and public involvement

There was no patient or public involvement in the design or conduct of this study, which was a process evaluation of

practice change and involved only staff.

Results

Baseline (T0)

1 This participant’s specific role has been anonymised.

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Staff already support nutrition screening and treatment activity, see its value, and do not view it as disruptive to

other work.

T0 NoMad responses indicate strong support for, and value placed upon, nutrition screening and treatment activity.

94% (n=30) of total participants (n=32) strongly/agreed that staff see this activity as worthwhile (Q20, mean score =

2.0, see Table 3). 97% (n=31) strongly/agreed that screening and treatment of malnutrition was a legitimate part of

their role (Q9, mean score = 1.6, see table 4). 81% (n=26) strongly/agreed that they valued the effect that screening

and treatment for malnutrition has had on their work (Q21, mean score = 2.0, table 3). 97% (n=31) strongly/agreed

that they were open to working with colleagues in new ways to support this work (Q10, mean score = 1.4, Table 4).

97% (n=31) also strongly/agreed that they would continue to support this work (Q11, mean score = 1.4, Table 4).

This was reflected in responses of 14 participants to telephone interview (T1), all of which were compatible with

openness to introducing new ways of working, though three also raised concerns with respect to the time/resource

implications of implementation and embedding.

[T]he thing that does concern me is the time to imbed the new practice because there is so much to take in,

so much change, there’s so many boxes to tick sometimes; trying to imbed the practice is really challenging

when it’s moving so fast and the work load is going through the roof; I think taking the time with the patient

to be able to completely embed it is a challenge but I don’t think, I think as a team, I’ve only been here a

short while, but as a team they seem really keen to improve and implement anything that’s new and that’s

better. (P00905, PHN)

Existing arrangements for nutrition screening and treatment could easily be integrated into their overall body of

work, and were not seen to disrupt working relationships. 78% (n=25) of total respondents strongly/agreed that

existing nutrition screening and treatment activity could easily be integrated into their overall body of work (Q12,

mean score = 2.0, see table 5). 79% strongly/disagreed that screening and treatment of malnutrition disrupts

working relationships (Q13, mean score = 1.9, see table 5). Six respondents from interviews described discussion of

screening and treatment of malnutrition as a common feature of team meetings.

No it’s never disruptive and it’s never caused an issue for anyone, that’s why I disagreed, we are quite a

good stable team that get on well together and support each other when we are doing the work. (P00611,

PHN)

Concerns exist as to wider organisational support for nutrition screening and treatment by community teams, as well

as access to dietetic support.

Uncertainty or doubt was expressed by many participants regarding logistical and organisational support for

screening and treatment related activity. 59% of respondents were uncertain (44%) or strongly/disagreed (15%) with

the statement ‘[t]here are key people who drive screening and treatment for malnutrition forward and get others

involved’ (Q8, mean score = 2.9, see table 4). Of the 16 interview participants asked to about their response, 13

could not identify a key person. Of these 13, six highlighted absence of a ‘key’ or ‘link’ member of staff to provide

advice, support, and best practice updates (identified as being in place in other areas of practice, e.g. infection

control).

It would be a preference definitely to implement some kind of key worker strategy which I know they do try

and do but quite often falls you know dead on the ground so, I think yeah with regards to that yes it

definitely would be a more effective way of working if that was possible so that would be something good to

be implemented I guess. (P00614, PHN)

Sixteen interview participants were asked about dietetic referral in previous practice. Of these, two participants

confirmed that they had been able to refer to a dietitian, the remainder (n=13) had not referred in their current role.

Of the 13 who had not referred: three stated that this should be possible in principle through the GP; six further

participants were unsure if or how this would be possible. Of total (n=16) respondents, five stated explicitly that

access to dietetic services in the community needed improvement.

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I mean my only concern is, my understanding is there is not many community dietitians you know so it’s just

sort of getting advice, obviously we will refer to the GP but it’s not often we get input from dietitians

themselves. We’ve sort of got basic guidelines on how to go through, so to have some more input from

dietitians would be really good, really useful. (P00210, PHN)

56% (n=18) were uncertain or strongly/disagreed in relation to the statement ‘Work is assigned to those with skills

appropriate to screening and treatment for malnutrition’ (Q15, mean score = 2.8, see table 5). 62% (n=12)

strongly/disagreed with or were uncertain in relation to the statement ‘Sufficient training is provided to enable staff

to implement screening and treatment for malnutrition’ (Q16, mean score = 3.1, see table 5). 59% were uncertain

(40%) or strongly/disagreed (19%) that ‘Sufficient resources are available to support screening and treatment for

malnutrition’ (Q17, mean score = 2.9, table 5). 66% (n=21) were uncertain or strongly/disagreed that ‘Management

adequately supports screening and treatment for malnutrition’ (Q18, mean score = 2.5, table 5).

Construct Reflexive Monitoring

Component

Systematisation Communal

appraisal

Individual

appraisal Reconfiguration

Question /

observation

point

Q19-

T0

Q19-

T1

Q20-

T0

Q20-

T1

Q21-

T0

Q21-

T1

Q22-

T0

Q22-

T1

Q23-

T0

Q23-

T1

Training

Participants

(n=13)

Question /

component

mean

score 3.2 2.8 1.8 1.8 2.0 1.9 2.0 2.0 1.8 2.0

Non-

training

participants

(n=19)

Question /

component

mean

score 3.2 3.0 2.0 1.9 2.0 2.2 1.7 2.0 2.2 2.1

All

participants

(n=32)

Question /

component

mean

score 3.2 2.9 1.9 1.9 2.0 2.1 1.8 2.0 2.0 2.1

Table 3 - NoMad T0-T1 responses for 'Reflexive Monitoring' score colour intensity tends toward: blue (strongly agree – 1); white (neither agree

nor disagree – 3); yellow - strongly disagree – 5).

Construct Cognitive Participation

Component

Initiation Legitimation Enrolment Activation

Question /

observation

point

Q8-

T0

Q8-

T1

Q9-

T0

Q9-

T1

Q10-

T0

Q10-

T1

Q11-

T0 Q11-T1

Training

Participants

(n=13)

Question /

component

mean score 2.9 2.7 1.3 1.5 1.2 1.5 1.2 1.5

Non-training

participants

(n=19) Question /

component

mean score 2.9 2.7 1.7 1.7 1.5 1.6 1.5 1.6

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All

participants

(n=32)

Question /

component

mean score 2.9 2.7 1.6 1.7 1.4 1.6 1.4 1.6

Table 4 - NoMad T0-T1 scores for 'Cognitive Participation' score colour intensity tends toward: blue (strongly agree – 1); white (neither agree

nor disagree – 3); yellow - strongly disagree – 5).

Construct Collective Action

Component

Interactional

Workability Relational Integration Skill set Workability Contextual Integration

Question /

observation

point

Q12-

T0

Q12-

T1

Q13-

T0

Q13-

T1

Q14-

T0

Q14-

T1

Q15-

T0

Q15-

T1

Q16-

T0

Q16-

T1

Q17-

T0

Q17-

T1

Q18-

T0

Q18-

T1

Training

Participants

(n=13)

Question /

component

mean

score 1.9 1.8 1.8 2.1 2.6 2.5 2.8 2.9 2.9 2.7 2.9 2.9 2.6 2.4

Non-training

participants

(n=19)

Question /

component

mean

score 2.1 2.3 2.1 2.4 2.2 2.5 2.7 2.3 3.2 2.9 2.8 3.1 2.5 2.8

All

participants

(n=32)

Question /

component

mean

score

mean

score 2.0 2.1 1.9 2.3 2.4 2.5 2.8 2.6 3.1 2.8 2.9 3.0 2.5 2.6

Table 5 - NoMad T0-T1 responses for 'Collective Action' score colour intensity tends toward: blue (strongly agree – 1); white (neither agree nor

disagree – 3); yellow - strongly disagree – 5).

Training outcomes

126 staff members within the implementation area completed the training, representing 56% of full time staff

(n=223) at initiation of training (23% (n=30) of those completing were INSCCOPe participants). 40% (n=29) of

INSCCOPe participants (n=73) completed the training; 60% did not (see Additional File 3, tables 1 & 2). Pre-post

knowledge check scores indicated that the training had been effective in raising average knowledge check score for

all participants from 54% immediately prior to the training to 68% for immediately post-training (see Additional File

3, table 3). All role groups saw an increase in average scores, the largest (23%) being for Healthcare Support

Workers, while the smallest (7%) was for Occupational Therapists and Associate Practitioners (see Additional File 3,

table 3).

T1 Results

Results for NoMad responses within the ‘Coherence’ construct (Q4-7).

Four questions (Q4-7) mapping to the NPT domain of ‘Coherence’ and its components were added to NoMad

instrument at T1 (between agreement and uncertain, see table 6). For all participants completing T1, 46% (n=15)

disagreed or were uncertain in response to the statement (Q4): ‘I can see how the new procedure for screening and

treatment of malnutrition differs from usual ways of working’ (mean score = 2.7, see table 6). The same responses

represented 38% (n=5) of training participants (mean score = 2.5), and 52% (n=10) of non-training participants

(mean score = 2.7, see table 6). This indicates that for those who both did and did not complete the training,

differentiation of the new procedure introduced through training for existing practice requires further attention.

In the all T1 participant group, 41% (n=13) disagreed or were uncertain regarding the statement (Q5): ‘Staff in this

organisation have a shared understanding of the purpose of new procedure for screening and treatment of

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malnutrition’ (mean score = 2.7, see table 6). Responses of this type represented 38% (n=5) in the training

participant group (mean score = 2.5, and 42% (n=9) of the training non-training group (mean score = 2.9, see table

6). Results indicate a large proportion in both sub-groups for whom shared understanding (Communal Specification)

of the procedure remains vague.

25% (n=8) of the all participant group disagreed or were uncertain in relation to the statement (Q6): ‘I understand

how the new procedure for screening and treatment of malnutrition affects the nature of my own work’ (mean

score = 2.4, see table 6). Respondents providing such answers represented only one response in the training

participant subgroup (mean score = 2.0), with the seven remaining respondents of this type representing 37% of

training non-training group (mean score = 2.7, see table 6). Here, results indicate a difference in how well

participants in respective sub-groups understood the new procedure in terms of their own practice (Individual

Specification), and the difference between groups approached significance (p=0.06, see Additional File 4, table 4).

Comparing this with results from Q5, results indicate a greater effect of training on understanding implications for

individual working compared with team working.

75% (n=24) of all participants strongly/agreed with the statement (Q7): ‘I can see the potential value of the new

procedure for screening and treatment of malnutrition for my work’ (mean score = 2.2, see table 6). 92% (n=12) of

the training participant group (mean score = 1.7), and 37% (n=7) of the non-training participant group (mean score =

2.6, see table 6), gave responses of this type. This difference between sub-groups was significant (p=0.01, see

Additional File 4, table 6), and indicates a potential impact of training on value placed on the new procedure.

Construct Coherence

Component

Differentiation Communal

specification

Individual

specification Internalisation

Question /

observation

point Q4 Q5 Q6 Q7

Training

Participants

(n=13)

Question /

component

mean score 2.5 2.5 2.0 1.7

Non-training

participants

(n=19) Question /

component

mean score 2.7 2.9 2.7 2.6

All

participants

(n=32)

Question /

component

mean score 2.6 2.7 2.4 2.2

Table 6 - NoMad T1 mean scores for 'Coherence' (score colour intensity tends toward: blue (strongly agree – 1); white (neither agree nor

disagree – 3); yellow - strongly disagree – 5).

Changes in NoMad response (T0-T1)

Wilcoxon signed-rank tests were used to investigate differences between responses to Q8-23 for all participants

(n=32), training participants (n=13), and non-training participants (n=19) respectively. For all participants, only Q13

saw a significant change from T0 (mean score = 1.9) to T1 (mean score – 2.3, see table 5), which involved a shift

towards uncertainty or disagreement with the statement ‘Screening and treatment for malnutrition disrupts working

relationships’ (T = 32.00, r = -0.29, p = 0.02; see Additional File 4, table 2). This indicates small-to-moderate effect on

responses during the period in which the training took place. Changes in Q13 responses for non-training participants

(2.1 (T0) – 2.4 (T1)) also approached significance (T = 8.00, r = -0.29, p = 0.07; p=0.01, see Additional File 4, table 2).

No other significant changes were observed (see Additional File 4, tables 1-3).

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Differences between sub-group responses (T0 & T1)

A significant difference was observed for Q7-T1 (W = 124, r = -0.43, p = 0.01), while Q6-T1 approached statistical

significance (W = 156.5, r = -0.33, p = 0.06 – see Additional File 4, table 4). No significant differences were found for

any other questions at either of the time points (see Additional File 4, tables 4-7).

Dietetic questions

Interview responses at T0 indicated that access to dietetic services was a significant concern for many participants.

Additional questions regarding availability and adequacy of dietetic services were appended to the questionnaire at

T1. Overall, results show that 30-90% of all participants had concerns about or were uncertain in relation to, all

aspects of dietetic service explored by the question statements (see table 7). Proportions of responses were similar

for both training and non-training participants in most areas (A1-2, A4-6), and Wilcoxon rank-sum test results

between sub-group response to each question showed no statistically significant differences (see Additional File 4,

table 8). These results echo those indicated by the telephone interview, that many participants appear to have

doubts regarding current adequacy of dietetic services in relation to procedure, support, and resource allocation.

Training group % strongly/agree

% strongly/disagree or

uncertain

A1 - I know where to get specialist support and

advice on treatment for malnutrition if I need it

Non-training

participants (n=19) 0.47 0.47

Training Participants

(n=13) 0.54 0.38

All (n=32) 0.50 0.44

A2 - I have sufficient access to patient information

resources relating to malnutrition

Non-training



(n=13) 0.69 0.31

All (n=32) 0.56 0.41

A3 - Patient information resources relating to

malnutrition are useful and effective

Non-training



(n=13) 0.69 0.31

All (n=32) 0.47 0.50

A4 - My team has access to a dietician if a patient

requires it

Non-training



(n=13) 0.38 0.54

All (n=32) 0.34 0.59

A5 - I know the procedure for referring a patient to

a dietician if required

Non-training



(n=13) 0.46 0.54

All (n=32) 0.44 0.53

A6 - Availability of dieticians is sufficient to meet

the needs of our patients

Non-training



(n=13) 0.23 0.77

All (n=32) 0.13 0.84

A7 - Current state of malnutrition screening is

sufficient to meet the needs of our patients

Non-training



(n=13) 0.38 0.54

All (n=32) 0.50 0.44

A8 - Current arrangements for treatment of

malnutrition are sufficient to meet the needs of

our patients

Non-training



(n=13) 0.54 0.38

All (n=32) 0.34 0.59

Table 7 – Results as percentages for responses to additional dietetic questions at T1.

Discussion

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Study findings indicate that staff support and value nutrition screening and treatment activity, and that the training

provided is effective in improving knowledge of the new procedure. However, significant barriers to successful

implementation remain. Implications of these barriers and recommendations for addressing them are discussed, in

addition to wider implications for implementation of service developments in community settings.

Results indicate several challenges to the current implementation design: firstly, non-completion of training (44% of

total staff (n=223) did not complete); secondly, staff attrition (12 participants left post between T0-T1, of which four

were team leads); thirdly, lack of monitoring (while pre-post knowledge checks were taken, no procedures for

monitoring ongoing compliance currently exist); fourthly, concerns about institutional support for nutrition

screening and treatment activity (as indicated through interviews and responses to dietetic survey questions) which

persisted after introduction of the procedure through training.

In response, we propose two main changes to the implementation design. Firstly, appointment of a key person for

the new procedure, with specialist nutritional expertise and remit to: monitor training completion rates and

procedure compliance; disseminate practice updates; provide advice and support for nutrition screening and

treatment. This addresses a suggestion by several interview participants, who cited the benefits of this role in other

areas such as wound care, as well as a gap indicated by uncertain survey responses (NoMad Q8 – see table 4). The

value of such a role in implementing new nutritional care procedures has also been demonstrated in secondary care

settings [10,27]. Updates on compliance, training, and resource needs would be provided to senior managers at

regular intervals, moving from a single-point intervention at the level of HCPs through training, to one that links the

work of monitoring and resource allocation directly to those with responsibility to ensure successful implementation

of the new procedure (thus creating an organisational feedback loop to promote sustainability and embedding in

management practice). Secondly, training design needs to be adaptable to cope with the changeable working

patterns, organisational and resource support challenges, and staff turnover that restricted training participation and

left those who did complete the training vulnerable to attrition. We therefore recommend that training is delivered

through the existing organisational e-learning portal, rather than in person. Combined with improvements in

monitoring, support, and flexibility, this will help to promote successful implementation, and support resilience to

organisational turbulence.

Implications

While the barriers here identified relate to specific processes within the study field, they point to processes relevant

to implementation in general, which map to components of NPT; enabling participation (enrolment); responding to

workforce turbulence (communal appraisal; reconfiguration); monitoring of compliance (systemisation); ensuring

adequate provision of resource (contextual integration). These components fall within the ‘Collective Action’ and

‘Reflexive Monitoring’ domains of NPT, indicating importance these domains for successful implementation. The

findings also echo those of Johnson & May’s (2015) theory-led overview of systematic reviews of interventions to

promote professional practice change, insofar as positive attitudes of staff were outweighed by lack of engagement

with collective action [30]. The present study points to the importance of key people as ‘pumps’ to drive and sustain

organisational behaviour loops, adding to the extant literature emphasising the importance of individuals with the

resource, authority, and legitimacy (both personal and institutional) to drive forward new developments in

healthcare [10,23,27,31,32]. In addition, it indicates the importance of designing intervention objects that are

resilient to organisational turbulence. Many healthcare interventions take place in complex settings wherein

emergent and contextual factors can modify the conditions of implementation. Providing organisational ‘closure’

through monitoring and support of a key person is important in mitigating these effects; however, the objects of

interventions (e.g. procedures, training seminars, technologies etc.) are important in this process. In the INSCCOPe

study, the proposed move from in-person to online delivery of the training was an example of how an intervention

object may be redesigned in response to turbulence encountered within the field of implementation.

These findings are interdependent; appropriate design choices for objects can only be expected to have effects if

participants are directed to use them in some way, which typically involves the organisational work of key people. In

their evaluation of an intervention to support carers of stroke survivors, Clarke et al. (2013) observed that

participants unable to attend training did not make use of replacement resources (a DVD) because they were not

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directed to do so [27]. The observations from the present study add to the body of literature indicating the

importance of contextual factors (i.e. turbulence) as well as creating practical (rather than simply attitudinal)

conditions for professional behaviour change, as key determinants in the success (or failure) of service development

initiatives.

Practical issues in the INSCCOPe study – work necessary to secure and maintain participation.

Considerable work was necessary to recruit and conduct interviews with participants (see Additional File 2), and to

obtain NoMad responses at T1 (where questionnaires were left with team leads for circulation and completion,

instead of completing in the presence of a researcher as occurred during recruitment at T0). 116 telephone calls

were made in order to secure 16 interviews, with seven participants requiring one or more rearrangements of their

scheduled time, and four cancelling after initial agreement. In almost all cases where contact was made, inability to

participate or need for rescheduling was attributed to volume and changeability of workload. We recommend that

future studies involving community teams should be aware of this as a necessary condition of participation in this

area of work and look to accommodate this. We would also recommend that questionnaire instruments are

completed during in-person visits by a researcher where possible, to minimise participant attrition.

Conclusion

We have presented a prospective process evaluation, exploring initial implementation of a new procedure for

screening and treatment of malnutrition in community settings. Guided by NPT, we have explored aspects of

implementation and embedding, as well as areas of ongoing need in relation to organisational, specialist, and

resource support for nutrition screening and treatment. In so doing, we have highlighted some generic aspects of

implementation relevant to service development in community settings and proposed two specific areas of attention

for those designing such interventions. These findings add to the wider knowledge base on implementation and

embedding by supporting and extending observations regarding the importance of Collective Action and Reflexive

Monitoring mechanisms.

Declarations

Ethics approval and consent to participate

Ethical approval for the study has been granted through institutional ethical review (Bournemouth University); NHS

Heath Research Authority approval (IRAS ID – 223214) was granted on 05/04/2017. NHS Research Ethics committee

approval was not required for this study, as it involves only staff.

Consent for publication

Not applicable.

Data sharing statement

No additional unpublished data are available from this study.

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Funding

The project is funded by The Burdett Trust for Nursing.

Author contributions

JM, KW, and KS devised the project (for which CRM and AA also provided advice). JM obtained funding at the host

institution, Bournemouth University. JM managed the study as chief investigator. MB was primarily responsible for

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study design, protocol, data collection and analysis with input from JM, KW, KS, AA and CRM. All authors

contributed significant revisions to drafts of the manuscript, and have read and approved the final manuscript.

Acknowledgements

The study team would like to acknowledge the support of the Burdett Trust for Nursing, and of staff within Southern

Health NHS Foundation Trust for their help and support in the development of this study.

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Figure legends

Figure 1 - Relationship between ICT/OPMH participant questionnaire and semi-structured telephone interview data.

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Change Record

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Additional File 1

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Additional File 1

CONTENTS

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Additional File 1

1 Assessment of risk of malnutrition in a community setting

1.1 Incidence of malnutrition

A person can become malnourished through under nutrition or excess (obesity). This

procedure sets out the approach and best practice for assessing and treating under

nutrition in a community setting.

Malnutrition is defined as ‘a state of nutrition in which there is a deficiency (or

excess) of energy, protein and other nutrients which causes adverse effects on body

form, function and clinical outcome’. As such it is essential that professionals

working in integrated community team are equipped and able to identify and

appropriately treat or direct patients to appropriate care.

Whilst the emphasis over recent years has been on addressing issues of under

nutrition in hospitals the fact remains that studies show that 1 in 10 people over 65

living in the community are malnourished or at risk of malnutrition (Bapen 2006).

Children, the elderly, socially isolated and those with chronic disease are most at

risk.

The costs of treating the consequences of malnutrition are in excess of £13 billion

(Elia 2009) and half of this was spent on older adults. From a report released in

2003 (Elia 2003), it is evident that malnutrition is under-recognised and undertreated

across care settings. It is documented that someone who suffers from malnutrition

has more visits to their GP, more visits to hospital and longer hospital stays (where

death more likely). They also have trouble with wound healing, infections (due to

poorer immune system), reduced mobility and falls.

1.2 Best practice guidelines

Providing best practice nutrition and hydration care involves five key principles, which incorporate NICE’s Nutrition support in adults quality standard (QS24) and clinical guidance (CG32). These are 1) raising awareness to prevent and treat malnutrition, 2) working together within and across organisations, 3) identifying malnutrition risk

early using screening tools, 4) developing individualized care plans, and 5) monitoring and evaluating the impact of care on an individual’s outcome.(Malnutrition Taskforce 2013).

Despite NICE guidelines there is currently there is a lack of:

• Screening for malnutrition

• Documentation of nutritional status

• Use of appropriate equipment and care plans

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Additional File 1 • Monitoring and review

• Implementation of nutrition support

A good Nutritional Care Pathway looks like this

performed by the Integrated Community Team.

NICE recommends using ‘MUST’ across care settings as it is valid, reliable and easy

to use, however, clinicians may use their clinical skills to employ other

nonstandardised nutritional screening tools to assess patient risk and progress. (see

key questions 1.4). The MUST tool can be accessed via this link

http://www.bapen.org.uk/screening-and-must/must-calculator

The first step is to identify the risk with a screening tool. Screening score e ffects treatment, and the effect of treatment is monitored and reviewed. This step is often missed. Nutritional support can be maximised in two ways – food first and oral nutritional supplements but without the initial steps and a review , clinical benefits are not seen.

1.3 Screening for risk using MUST ( Malnutrition Universal Screening Tool ) Assessment of nutritional status should take place within the initial assessment

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Additional File 1 Weighing Scales

To measure weight within the community setting it is acceptable to use the patient’s

own scales but class 3 scales should be available in all teams. Scales for weighing

patients using hoists can be accessed via the Hampshire Integrated Equipment

Store.

Nutrition screening frequency guidelines

Nutrition assessment takes place on initial assessment using MUST wherever

possible.

Low risk – repeat MUST in one year or where new clinical concerns Medium

and High Risk – repeat MUST in monthly intervals.

1.4 Key questions for assessing undernutrition.

Whilst the recommended tool for nutritional risk assessment is MUST it is

recognised that qualified clinicians may use their clinical skills to employ other

nonstandardised nutritional screening tools to assess patient risk and progress.

The following questions could be used where a clinician cannot complete a MUST

score due to patient condition and to ascertain clinical concerns and need to repeat

MUST. It is best practice to employ both the MUST and the clinical questions.

• Does the patient appear thin or very thin with loose fitting clothes/jewellery or

dentures? Is this new for the patient?

• Has the patient lost weight (unplanned) in the last 3-6 months?

• Has the patient had new changes in appetite or swallowing difficulties?

• Does the patient now need assistance with feeding?

• Is the patient or carer reporting a reduction in dietary intake compared to

normal?

• Does the patient require help with shopping or food preparation?

For intentional rounding these questions can be simplified to

• Any unplanned weight loss in the last 3-6 months. ?

• Why have you lost weight?

The warning signs of undernutrition/malnutrition that clinicians should be aware of

include, fragile skin, poor wound healing, apathy, wasted muscles, poor appetite,

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Additional File 1 altered taste sensation, impaired swallowing, altered bowel habit, loose fitting

clothing, being unable to keep warm and poor concentration.

2 Care Pathway

2.1 Description of care pathway – the following care pathway was developed as

part of the Older Persons Essential Nutrition (OPEN) project in Eastleigh. It sets out

nutritional care according to risk as assessed using the MUST tool. It can also be

used where risk is established using nutritional assessment questions.

2.2 Low risk (MUST score of 0)

For low risk patients review of MUST is done yearly if the patient remains on the

Integrated Care Team caseload. On each visit intentional rounding should be

completed and include the intentional rounding questions from 1.4

Where new concerns emerge the MUST would be repeated before the next review

date.

Clinician should also consider giving the patient healthy eating advice especially if

concerns are identified regarding obesity or if the patient has a wound – specific

nutrition for wound healing advice.. Further help for patients identified as obese can

be obtained from their GP.

2.3 Medium and High risk (MUST score of 1,2,3)

Discuss and agree nutrition goals with patient using a food first approach. Record

this in a care plan shared with the patient. This care plan should include

• Food fortification goals

• And consider referral to community services e.g. lunch clubs or social services

where access to food or assistance with meals required.

The patient should be provided with the malnutrition leaflet (appendix 1) and other

relevant advice sheets (determined by clinician). All patients with a wound should be

given the ‘Healthy eating for healthy healing advice sheet’.

The following advice sheets are available in appendix 2

• Poor appetite

• Food fortification tips

• Eating well and dementia

If other medical concerns are identified for example nausea, vomiting constipation or

diarrhoea a referral to GP should be made.

If difficulty swallowing identified (dysphagia) is identified a referral to Speech and

Language Therapy should be discussed with the patient’s GP.

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Additional File 1

A review of the patient’s weight should take place in one month. If there is

improvement in the weight and/or MUST then follow the guidelines for that score.

If there is deterioration in the MUST score to 2 or above or no improvement in a

score of 2 or above oral nutritional supplements should be considered in

collaboration with the patient and request for a prescription made to the GP.

Sample packs of supplements can be obtained directly from the company for patients to try. See http://www.westhampshireccg.nhs.uk/downloads/1138-guide-toprescribing-ons-formularies-full-june-2016/file

• The patient should be provided with the ‘Tips for taking you supplements’

sheet.

• Appointments should be made to monitor weight monthly and the care plan

updated with any actions recorded in the progress notes.

• If no improvement or further deterioration in weight or MUST the patient

should be referred to their GP for a review. Staff should also consider referral

to rapid access geriatrician led clinics where they exist.

2.5 Palliative care/end of life care considerations

All patients being admitted onto the Integrated Community Team caseload require

an assessment of nutritional status using MUST whenever possible. Where the

patient is receiving palliative care it is necessary to modify the approach as a loss of

appetite and desire for food plus weight loss is part of the disease and deterioration

progress. Emphasis should be on alleviation of suffering such as treatment of dry

mouth, nausea and vomiting and a holistic, supportive approach. Repeating the

MUST and nutritional assessment would be based on clinical judgement and patient

need.

2.6 Wound care and nutrition

Good nutrition is linked with good outcomes for wound healing. Specific advice

regarding eating for wound healing should be given to all patients with wounds.

If wound healing is static or deteriorating then nutrition should be considered and

MUST repeated, and a care plan addressing nutrition established as this will have

significant benefits in healing and the patient’s quality of life

3 Oral Nutritional Supplements

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http://www.westhampshireccg.nhs.uk/downloads/1138-guide-to-prescribing-ons-formularies-full-june-2016/file




















Additional File 1 3.1 Formulary

A formulary exists to direct the appropriate prescribing of ONS. The most up-to-date

formulary can be found on the West Hampshire CCG website –

http://www.westhampshireccg.nhs.uk/downloads/1138-guide-to-prescribing-onsformularies-full-june-2016/file A form to request prescriptions for ONS is contained in the formulary and should be

used for all requests.

Direct to patient free samples can be obtained for each of the products on the

formulary. It is recommended that a patient samples products to improve

compliance.

4 Specialist Support

4.1 Dietician referral

Dietician support can be obtained via referral to the acute hospitals dietetic

team via the patient’s GP. A list of contact details for the hospital dietetic team is

available on the Southern Health Intranet.

4.3 Dementia

People living with dementia may find eating and drinking difficult or refuse food or

drink for a number of reasons:

• Problems expressing hunger/thirst, or dislike of a particular food or drink

• Low mood or lack of interest in food

• Confusion in recognising food and remembering how to eat

• Poor concentration making it difficult to sit down and finish a meal

• Other challenges associated with dementia include:

• Reduced thirst sensation

• Limited recognition of hunger

• Paranoia surrounding food

• Difficulties chewing and swallowing

Advice for those caring for someone with dementia can be found in the leaflet

‘Eating and Drinking Well – Supporting People Living with Dementia.’

5. Hydration

5.1 Many older people prefer drinking tea or coffee to water and it can be difficult to

persuade people to drink enough water. Furthermore, older people should not be

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Additional File 1 expected to change their drinking habits just because they are receiving care

services.

5.2 Hot drinks are good for hydration and only likely to act as a diuretic (making the

body produce more urine) if they are high in caffeine and consumed in excessive

amounts. Decaffeinated teas and coffees and herbal teas should be encouraged if

this is a concern.

5.3 Based on the available information and the importance of good hydration in older

people it would seem appropriate to encourage fluid intake generally, and to offer a

selection of hot and cold drinks throughout the day and whenever people request

them.

5.4There should only be cause for concern if an individual’s overall liquid intake is

inadequate, or their intake of caffeinated and or sugary drinks is excessive. Medical

advice should be sought if an individual has particular health problems that affect the

maintenance of good hydration, which may require fluid restriction and close

monitoring.

6. Training

6.1 Nutrition training pathway

All staff will receive training on nutritional care and management and

assessment of their competences to ensure they have the appropriate skills

needed to ensure that patients’ nutritional needs are met.

It is recommended that all staff should undertake both NHLP 5 Planning and

delivering Nutritional Care and NHLP Course 6 E-learning Malnutrition

Universal Screening Tool (MUST)

References 1. ENHA, BAPEN, ILC-UK – ‘Malnutrition among older people in the community: policy Recommendations for

Change’ (2006)

2. Elia M, Russell CA. Combating malnutrition: Recommendations for action. : The British Association for Parenteral and Enteral Nutrition; 2009.

3. Malnutrition Task Force: “Malnutrition in later life: Prevention and Early Intervention” (2013)

4. Elia M. The 'MUST' report.Nutritional screening for adults: a multidisciplinary responsibility.Development and use of the 'Malnutrition Universal Screening Tool' ('MUST') for adults. : A report by the Malnutrition Advisory Group of the British Association for Parenteral and Enteral Nutrition; 2003.

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Additional File 1

Appendix A Care pathway

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Additional File 1

MUST>1 Score 1 or more

Medium and High Risk Investigate & take action

Discuss and agree nutrition goals with patient. This should be a food first approach. Record this in a care plan shared with the patient/carers/GP.

This should include a plan on how to increase calorie/protein intake as well as fluid intake

Provide malnutrition leaflet and other relevant adv ice sheets

Arrange review in one month. Repeat MUST and/or assessment

MUST Score 0

Low Risk

Provide healthy eating advice sheet

Review MUST score if signs of deterioration noted through

intentional rounding otherwise repeat yearly.

If risk remains stable or improvement noted (e.g. weight stabilised, weight gain, pressure sores healing, goals fully or par tially met, or MUST Score

decreased ) Continue and/or update plan. Document progress, and document further

actions as appropriate

If risk deemed to worsen ( ) e.g. weight decreasing further, goals not met… Discuss oral nutritional supplements with the patient and request prescription

from GP using prescription request form Provide ONS information sheet.

Arrange follow up appointment in one month

If further weight loss or no improvement, refer to GP or diet itian if available. Update care plan and record actions in progress notes

End of life care guidelines override this pathway

Establish the cause of malnutrition

When cause identified, take action, e.g. referral to community services e.g. lunch clubs or social services where access to food or assistance with meals required

If other medical concerns e.g. nausea, vomiting constipation or diarrhoea, refer to GP. If difficulty swallowing identified (dysphagia) refer to speech and language therapy

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Participants eligible for interview

approach = 73

Participants excluded prior to initial email

= 10 (n=4 did not provide contact details,

n=6 reached cut-off prior to date of

eligibility for email approach)

Participants sent initial email asking

them to take part in an interview = 63

Participants responding to

initial email = 9

Agreed initial

date for

interview = 4

No response to further

email (passed to

telephone approach) = 4

Declined

interview

participation = 1

Email address

invalid (passed

to telephone

approach) = 12

No reply to

initial email

(passed to

telephone

approach) =

42

Stage 1 T0

interview

approach (email)

Stage 2 T0 interview

approach (telephone call) Participants passed to telephone

approach = 58

Reached cut-off prior to date of

eligibility for telephone approach) =

16

Missing or invalid telephone

number provided = 6

Stage 3 T0 interview approach

(completion/follow-up on

un/successful interviews)

Participants approached

by telephone = 36

Participants agreed initial

date for interview = 16

Participants declined interview

= 3

No response from participant =

16 (n=3 reached call limit, n=14

reached cut-off)



Completed on date

initially agreed = 13

Followed up after

uncontactable for initial

interview = 7

Follow up unsuccessful = 4

(n=2 uncontactable, n=2

declined rescheduled

interview)

Interview

rearranged and

completed = 3 Total ICT/OPMH interviews

completed = 16

Additional File 2 - Flow diagram of T0 interview approach process (114 calls were made to participants at stage 2. Mean number of follow-up calls at stage 3 before interview completion = 2.3, range = 2-4; Mean number of follow-up

calls before reaching training implementation = 3.8, range = 1-6; Mean number of calls before reaching point of training implementation = 3.6, range = 1-7; Mean number of calls before contact leading to agreement at stage 2 =

2.2; range = 1-6)

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Additional File 3 – pre-post training knowledge and current screening practice check

tables.

Role

Total training participants (n)

INSCCOPe total participants (n)

INSCCOPe participants completed training (n)

INSCCOPe participants completed training as % of total training participants (n=126)

INSCCOPe participants completed training as % of INSCCOPe participants (n=73)

% of INSCCOPe participants not completing training

Mental Health Nurse 14 7 4 0.29 0.57 0.43

Physical Health Nurse 32 42 15 0.47 0.36 0.64

Occupational Therapist 13 4 2 0.15 0.50 0.50

Healthcare Support Worker 27 16 7 0.26 0.44 0.56

Physiotherapist 13 1 0 0.00 0.00 1.00

Associate Practitioner 6 2 1 0.17 0.50 0.50

Unspecified 15 1 0 0.00 0.00 1.00

Students (INELIGIBLE FOR INSCCOPe) 6 0 0 0.00 0.00 0.00

Total 126 73 29 0.23 0.40 0.60 Table 1 - Numbers and percentages of participants completing training by role (total and INSCCOPe-specific) (response

values are row percentages – percentages represent responses within ranges given in column labels - greater intensity of green indicates closer to 100%)

Category Team


INSCCOPe participants completed training as % of total participants completed training

INSCCOPe participants not completing training (n)


Urban ICT (n=28)

1 (n=4) 4 1.00 0 0.00

4 (n=5) 5 1.00 0 0.00

6 (n=4) 3 0.75 1 0.25

8 (n=4) 0 0.00 4 1.00

9 (n=5) 1 0.20 4 0.80

14 (n=6) 0 0.00 6 1.00

Total 13 0.46 15 0.54

Rural ICT (n=27)

2 (n=6) 6 1.00 0 0.00

5 (n=10) 1 0.10 9 0.90

10 (n=4) 0 0.00 4 1.00

11 (n=7) 2 0.29 5 0.71

Total 9 0.33 18 0.67

OPMH (n=11)

3 (n=8) 5 0.63 3 0.38

7 (n=3) 2 0.67 1 0.33

Total 7 0.64 4 0.36

Specialist ICT (n=7) 13 (n=7) 0 0.00 7 1.00

Total 29 0.40 44 0.60 Table 2 - Numbers and percentages of INSSCOPe participants taking part in training by category and team.

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Role Participants (n)

Pre-check respondents (n)

Pre-score (mean)

Post-check respondents

Post-score (mean)

Difference, post-pre (mean) (n=93 completing both checks)

Associate Practitioner 6 5 0.57 6 0.58 0.07

Healthcare Support Worker 13 13 0.50 13 0.71 0.23

Mental Health Nurse 22 21 0.60 22 0.73 0.12

Occupational Therapist 12 11 0.60 11 0.66 0.07

Physical Health Nurse 29 27 0.48 28 0.61 0.14

Physiotherapist 12 10 0.54 11 0.72 0.20

Student 3 3 0.39 3 0.58 0.19

Unspecified 14 12 0.59 14 0.76 0.15

Total 111 102 0.54 108 0.68 0.15

Table 3 - Participant pre/post training knowledge check scores by role

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Additional File 4 - Wilcoxon signed-rank, Wilcoxon rank-sum test

results NPT Construct Cognitive Participation

NPT Component Initiation Legitimation Enrolment Activation

Question / observation point Value Q8T0-Q8T1 Q9T0-Q9T1 Q10T0-Q10T1

Q11T0-Q11T1

Participated in training (n=13)

T. 22.50 8.00 0.00 0.00

r. -0.11 -0.22 -0.32 -0.39

Z -0.54 -1.13 -1.63 -2.00

p. 0.59 0.26 0.10 0.05

Did not participate in

training (n=19)

T. 22.00 10.50 7.00 7.00

r. -0.09 0.00 -0.13 -0.13

Z -0.58 0.00 -0.82 -0.82

p. 0.56 1.00 0.41 0.41

All participants (n=32)

T. 84.50 35.00 9.00 11.00

r. -0.10 -0.10 -0.22 -0.24

Z -0.81 -0.83 -1.73 -1.90

p. 0.42 0.41 0.08 0.06

Table 1 - Results of Wilcoxon signed rank test for differences between T0 and T1 responses within the Cognitive Participation construct (Q8-11).

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NPT Construct Collective Action

NPT Component

Interactional Workability Relational Integration Skill set Workability Contextual Integration


Q15T0-Q15T1

Q16T0-Q16T1

Q17T0-Q17T1

Q18T0-Q18T1


T. 7.00 9.00 7.00 6.00 9.50 6.50 6.00

r. -0.16 -0.28 -0.16 -0.09 -0.16 -0.05 -0.14

Z -0.82 -1.41 -0.82 -0.45 -0.79 -0.27 -0.71

p. 0.41 0.16 0.41 0.66 0.43 0.79 0.48


training (n=19)

T. 13.50 8.00 24.00 26.50 35.50 40.00 26.00

r. -0.19 -0.29 -0.21 -0.22 -0.12 -0.13 -0.17

Z -1.16 -1.81 -1.29 -1.37 -0.71 -0.81 -1.07

p. 0.25 0.07 0.20 0.17 0.48 0.42 0.28


T. 52.50 32.00 72.00 61.00 79.50 75.00 66.00

r. -0.06 -0.29 -0.08 -0.14 -0.12 -0.10 -0.07

Z -0.47 -2.30 -0.66 -1.11 -0.97 -0.82 -0.53

p. 0.64 0.02 0.51 0.27 0.33 0.41 0.60

Table 2 - Results of Wilcoxon signed rank test for differences between NoMad T0 and T1 responses within the Collective Action construct (Q12-18).

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NPT Construct Reflexive monitoring

NPT Component Systematisation

Communal appraisal

Individual appraisal Reconfiguration


Q22T0-Q22T1

Q23T0-Q23T1


T. 12.00 12.00 16.00 17.50 8.00

r. -0.25 -0.07 -0.06 -0.01 -0.22

Z -1.28 -0.38 -0.30 -0.07 -1.13

p. 0.20 0.71 0.76 0.94 0.26


training (n=19)

T. 22.00 0.00 8.50 0.00 18.50

r. -0.17 -0.16 -0.15 -0.34 -0.08

Z -1.07 -1.00 -0.95 -2.12 -0.49

p. 0.29 0.32 0.34 0.03 0.62


T. 65.00 18.00 49.50 29.50 65.00

r. -0.20 0.00 -0.08 -0.15 -0.02

Z -1.56 0.00 -0.63 -1.18 -0.17

p. 0.12 1.00 0.53 0.24 0.87

Table 3 - Results of Wilcoxon signed rank test for differences between NoMad T0 and T1 responses within the Reflexive monitoring construct (Q19-23).

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Coherence

Value Q4-T1 Q5-T1 Q6-T1 Q7-T1

W. 167.5 169 156.5 124

r. -0.27 -0.22 -0.33 -0.43

Z -1.54 -1.22 -1.89 -2.45

p. 0.12 0.22 0.06 0.01

Table 4 - Results of Wilcoxon rank-sum tests for differences between participant and non-participant sub-groups NoMad responses within the Coherence construct (Q4-7)

Cognitive Participation

Q8-T0 Q8-T1 Q9-T0 Q9-T1 Q10-T0 Q10-T1 Q11-T0 Q11-T1

W. 210 309 172.5 199.5 183 199.5 183 206

r. -0.03 -0.03 -0.32 -0.12 -0.25 -0.12 -0.25 -0.07

Z -0.18 -0.18 -1.83 -0.66 -1.43 -0.66 -1.43 -0.37

p. 0.86 0.85 0.07 0.51 0.15 0.51 0.15 0.71

Table 5 - Results of Wilcoxon rank-sum tests for differences between participant and non-participant sub-group NoMad responses within the Cognitive Participation construct (Q8-11)

Collective Action

Q12T0 Q12T1 Q13T0 Q13T1 Q14T0 Q14T1 Q15T0 Q15T1 Q16T0 Q16T1 Q17T0 Q17T1 Q18T0 Q18T1

W. 201.00 177.00 290.00 281.50 256.00 207.00 295.50 247.00 191.50 206.50 296.50 203.50 298.00 193.50

r.

Z -0.58 -1.60 -0.99 -1.50 -1.39 -0.05 -0.73 -1.75 -0.44 -0.33 -0.32 -0.44 -0.26 -0.87

p. 0.56 0.11 0.32 0.13 0.16 0.96 0.47 0.08 0.66 0.74 0.75 0.66 0.79 0.39

Table 6 - Results of Wilcoxon rank-sum tests for differences between participant and non-participant sub-group NoMad responses within the Collective Action construct (Q12-18)

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Reflexive monitoring

Q19T0 Q19T1 Q20T0 Q20T1 Q21T0 Q21T1 Q22T0 Q22T1 Q23T0 Q23T1

W. 311.00 199.50 187.50 196.50 205.50 193.50 279.50 288.00 177.00 213.50

r. -0.02 -0.11 -0.25 -0.10 -0.07 -0.11 -0.07 0.00 -0.28 -0.01

Z -0.10 -0.62 -1.44 -0.58 -0.38 -0.62 -0.38 0.00 -1.56 -0.04

p. 0.92 0.54 0.15 0.56 0.71 0.53 0.70 1.00 0.12 0.96

Table 7 - Results of Wilcoxon rank-sum tests for differences between participant and non-participant sub-group NoMad responses within the Reflexive Monitoring construct (Q19-23)

A1 A2 A3 A4 A5 A6 A7 A8

W. 184.00 182.50 178.50 202.50 208.50 210.00 165.00 190.00

r. -0.14 -0.19 -0.19 -0.04 0.00 -0.01 -0.29 -0.09

Z -0.77 -1.10 -1.05 -0.23 -0.02 -0.08 -1.66 -0.51

p. 0.44 0.27 0.29 0.82 0.98 0.93 0.10 0.61

Table 8 - Results of Wilcoxon signed-rank tests for differences between participant and non-participant subgroup dietetic question responses at T1 (A1-A8)

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For peer review onlyImplementing professional behaviour change in teams

under pressure – results from phase one of a prospective process evaluation of a new procedure for screening and

treatment of malnutrition in community care for older people (INSCCOPe).

Journal: BMJ Open

Manuscript ID bmjopen-2018-025966.R1


Date Submitted by the Author: 21-Feb-2019

Complete List of Authors: Bracher, Mike; University of Portsmouth, School of Health Sciences and Social Work; Bournemouth University, Humans Sciences & Public Health, Faculty of Health & Social SciencesSteward, Katherine; Southern Health NHS Foundation TrustWallis, Kathy; Wessex Academic Health Science Network (AHSN)May, Carl; London School of Hygiene and Tropical Medicine Faculty of Epidemiology and Population HealthAburrow, Annemarie; Wessex Academic Health Science Network (AHSN)Murphy, Jane; Bournemouth University, Humans Sciences & Public Health

<b>Primary Subject Heading</b>: Health services research

Secondary Subject Heading: Nutrition and metabolism, Geriatric medicine



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Implementing professional behaviour change in teams under pressure – results from phase one of a prospective process evaluation of a new procedure for screening and treatment of malnutrition in community care for older people (INSCCOPe).







1. School of Health Sciences and Social Work (SHSSW), University of Portsmouth2. Ageing and Dementia Research Centre (ADRC), Bournemouth University3. Southern Health NHS Foundation Trust4. Wessex Academic Health Science Network (AHSN)5. Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine




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Abstract

Objectives: To report findings of the implementation phase of a new procedure for screening and treatment of malnutrition for older people in community settings.


Setting and participants: Community teams (nursing and allied health professionals) within one area of a UK National Health Service Trust. 73 participants were recruited, of which 32 completed both pre and post-implementation surveys.

Main outcome measures: NoMad survey for pre-post intervention measures; telephone interviews exploring participant experiences and wider organisational/contextual processes.

Methods: Data prior to implementation of training, baseline (T0 – survey and telephone interview), and 2 months following training (T1 – follow-up survey). Quantitative data described using frequency tables reporting team type, healthcare provider role group, and total study sample; analysis using Wilcoxon rank-sum (sub-group comparison) and Wilcoxon signed-rank (within-group observation point comparison) tests. Qualitative interview data (audio and transcription) analysed through directed content analysis using Normalization Process Theory.

Results: High levels of support were shown for nutrition screening and treatment activity among participants, as well as areas of concern in relation to logistical and organisational support. Interviews indicated access to specialist dietetic support as a concern. Results indicated a positive impact of training on knowledge of the new procedure; however, most implementation measures saw no significant changes between time points or between sub-groups (training participants vs. non-participants). Implementation barriers included: high levels of training non-completion; vulnerability to attrition of trained staff; lack of monitoring of post-intervention compliance; lack of access to specialist nutritional support.

Conclusion: Greater support appears necessary to fully implement and embed the new procedure, particularly around monitoring of training completion, and organisational support for nutrition screening and treatment activity. Findings also support and extend observations of previous studies regarding the importance of Collective Action and Reflexive Monitoring-type processes.


Prospective investigation of factors promoting or inhibiting implementation of service development, allowing for feedback to inform ongoing development of the programme.

To our knowledge, this is the first time that a prospective process evaluation has been conducted specifically on implementation of nutritional care in community settings process evaluations conducted on implementation of nutritional care in community settings.

Integrated use of mixed methods to provide reproducible measures at each observation point (quantitative, survey), and explore processes underpinning them (qualitative, semi-structured telephone interviews).

Lack of quota sample due to lack of data on workforce composition may mean that sample is unrepresentative of the role/seniority profile of the target population.

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Limitations of the study include: lack of observation of new procedures applied in situ, meaning that processes relating to implementation can only be explored retrospectively through interviews, and therefore recall and response bias may affect the data; lack of available data on composition of the target population (i.e. the area of the organisation in which the intervention was implemented) limits reporting on representativeness of the study sample.

Word Count = 5,732

Keywords: Nutrition, screening, process evaluation, community care, malnutrition, normalization process theory, implementation

Background

Implementation of new procedures or technologies in healthcare settings involves complex processes, bringing together individuals of different professional groups in varied kinds of work [1,2]. Process evaluation studies help us to understand the success or failure of interventions, and illuminate the wide range of factors that shape intervention outcomes [3,4]. The dynamics of practice implementation in open systems, like community health and social care – is not well understood. Implementation conditions in community settings are different from those of closed systems (secondary/hospital settings) because of the spatial distribution of service users and healthcare providers and their focus on domiciliary screening and care. and contextual factors such as funding, resource, and staffing pressures, which may have consequences that differ from those found in hospitals [5,6].

Screening for malnutrition represents an important aspect of routine care for those working with older people in the community [7–9]. However, malnutrition is often undiagnosed and frequently under-recognised in this area [10]. Previous studies in hospital and care home settings have indicated that contextual and organisational barriers can impede introduction of new procedures for nutritional care [11,12]. To our knowledge, no published studies have focused specifically and prospectively on implementation of nutrition screening in community settings. This paper contributes to understanding implementation of professional behaviour change in community settings, by presenting results from the implementation phase of a new procedure for screening and treatment of malnutrition in community care for older people.


In this paper, we use the term ‘malnutrition’ to refer to ‘undernutrition’ [13,14]. More than 3 million individuals are estimated to be malnourished or at risk of malnutrition in the UK, the majority (93%) living in the community [15,16], of which over one million are over the age of 65 [17]. Malnutrition has many negative consequences that both affect the individual, and impose a strain on health-care resources through delayed recovery from illness, increased need for health care provision at home, more frequent visits by nurses, and a greater number of hospital admissions [10,14,18]. Evidence suggests that malnutrition in older people can be prevented through screening and early intervention, and that the benefits of treating malnutrition far outweigh the costs [19].


There is good evidence to suggest that nutrition screening of older people living in the community together with appropriate intervention and monitoring improves their nutritional status [20]. Health care staff providing care and treatment within community settings (in both physical and mental healthcare) who already review and manage older people, are well placed to perform routine nutrition screening as part of practice (and in accordance with guidelines from the UK National Institute for Clinical Excellence (NICE)) [9,21]. The feasibility of introducing a validated screening tool and nutrition resource kit has been shown in older adults attending general practices in an Australian study [22]. In the UK, local protocols concerning nutritional screening and assessment often exist within National Health Service

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(NHS) hospital trusts, based on national protocols. However, previous service development work around nutrition in the community indicates that it is often not considered a routine part of interactions with older people [23].

This paper reports on the implementation phases of a new procedure for screening and treatment of malnutrition in older people within an NHS Trust in England. It focuses on the work of community nursing and allied health professionals (covering physical and mental health services respectively), mobilising this procedure in the community (see Additional File 1).

Existing organisational policy within the Trust has established when a patient should be screened for malnutrition, and the care that a patient should receive depending on their malnutrition risk (assessed by Malnutrition Universal Screening Tool –‘MUST' screening) [7]. The new procedure introduced a number of updates to existing policy: firstly, only patients at medium or high risk of malnutrition (those with a ‘MUST’ score of 1 or more) require monthly re-screening and follow up (previously all patients were expected to receive monthly screening), while patients at low risk are now re-screened annually, unless there is a significant change in their health status. Secondly, a nutritional pathway including appropriate care planning actions to be taken depending on the risk level and each specific case, which included provision of malnutrition information resource sheets to medium and high-risk patients as a mandatory activity (previously these were not routinely provided to patients in these categories). New information resources were produced as part of the project, and guidance for when to use existing resources was specified within the new procedure. Thirdly, the electronic patient records system provides facility to store screening information for malnutrition in one place (previously paper and electronic processes ran separately and in parallel). Prior to implementation of this electronic system, concerns had been raised regarding the storage and availability of screening information to inform treatment decisions as part of care planning. As part of the new procedure, a form was generated within the electronic system to record screening results and enable care planning activity. Fourthly, the new procedure emphasised that staff at all roles and grades who provide community care to older people have responsibility for malnutrition screening and delivery of appropriate treatment. Introduction of the new procedure was provided through staff training delivered by a registered dietitian. 12 sessions were offered to enable as many staff as possible to attend a one-hour training session. Immediate effectiveness of training was assessed through pre-and-post training knowledge check questionnaires.


The current study is informed by Normalization Process Theory (NPT), which identifies, characterises and explains the mechanisms that motivate and shape implementation processes [24,25]. NPT focuses on three aspects of implementation processes: how the components of complex interventions confer particular capabilities on their users; what the work of implementing, embedding and integrating these capabilities In everyday practice is, and how intervening mechanisms (coherence, cognitive participation, collective action and reflexive monitoring), motivate and shape implementation processes and explain their operation; and finally, how participants in implementation processes mobilise structural and cognitive resources as they invest in them. NPT is now widely used to inform process evaluation research, a recent systematic review shows 130 reports of feasibility studies and process evaluations of controlled and uncontrolled interventions in open and closed systems, most of these published in the last five years.

In nutritional care, NPT has been used in two previous studies focused on: development the role of the nurse as a link advisor for research and champion for nutrition in the neonatal intensive care unit [26]; and implementing nutrition guidelines for older people in residential care homes [12]. However, the present study is the first to apply this to implementation of procedures for screening and treatment of malnutrition in community settings. The theory can be used prospectively (i.e. to identify potential areas of importance with respect to embedding and implementation within a given topic area) and retrospectively (i.e. to analyse existing processes, practices, and technologies with respect to the social and organisational activities that relate to their implementation and embedding) [27,28]. NPT does not provide a framework of causal prediction; rather, its intended use has been to help anticipate the trajectory of a new practice, technology, or process, with respect to the success of its implementation, and embedding in routine practice (that is, given attention to activities in areas identified in the framework, whether implementation and embedding is more or less likely to be successful) [24].

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The relationship between implementation of the new procedure and the process evaluation

Complex relationships and divisions of labour often exist between those implementing service development in healthcare, and those evaluating these processes [29]. In some cases, both kinds of work are undertaken by the same people [11], while in others the process evaluation may be undertaken by those not involved in either initial development or implementation of the intervention [30]. In both cases, findings from process evaluations commonly inform ongoing development of implementation strategies for the intervention in focus [25]. It is therefore necessary to define the relationship between these two kinds of work within the project reported in this paper. Implementation and embedding (‘normalization’) of the new procedure for screening and treatment of malnutrition was the focus of this process evaluation. Development and implementation of the procedure was led by KS with input from AA and other colleagues within the implementation site (see Additional File 1). Process evaluation work was undertaken primarily by MB, JS, KW and CRM, with input from KS and AA relating to recruitment strategy. Findings from the process evaluation were provided to the procedure development and implementation team following completion of T1 data collection, to inform ongoing development.

Aims and objectives

The process evaluation was entitled: Implementing Nutrition Screening in Community Care for Older People (INSCCOPe). The aim of the study was (i) to undertake a process evaluation of the implementation of the screening procedure and its associated training, and (ii) identify factors that promote or inhibit embedding of nutritional screening as a routine aspect of care. Outcomes relating to clinical effectiveness of the new procedure were assessed by the procedure development and implementation team and will be reported separately. Outcomes relating to specific processes affecting implementation and embedding are the focus of this process evaluation, and methods for their investigation are now described.

Methods


Eligible staff were community-based members of staff (e.g. Nurses, Occupational Therapists, Healthcare Support Workers, Physiotherapists, and Associate Practitioners in physical or mental healthcare) involved in screening and/or treatment activity relating to malnutrition, expected to be in post for the duration of the study (12 months) either full or part time. Those not involved in nutrition screening and treatment activity (e.g. team administrators, other support staff), and staff not expecting to be in post for the duration of the study were ineligible. The research team sought to recruit the maximum number of willing participants of all roles and grades, due the lack of available demographic data to support a quota sample.

Recruitment

Prior to an in-person invitation to participate in the study by the researcher (MB), potential participants (n=89) were sent a Participant Information Sheet with contact details for the research team, circulated by team leads who received it via email. Potential participants were then approached at a team meeting by the researcher (MB), at a time agreed with the team lead, where the study was introduced, and participants’ questions answered. Participants were informed of their right to withdraw at any stage without negative consequences, and without giving a reason. Participants then completed an agreement form (indicating consent to use of survey and interview audio data by the study team), a participant data form, and the T0 NoMad instrument (paper based).

Study procedures

At T0, questionnaires were completed at the point of recruitment. At T1, questionnaires were circulated via team leads. Data collection for phase one occurred at baseline (T0 – pre-implementation of procedure and training), and approximately 2-3 months following completion of training (T1). Each point involved completion of a 23-item questionnaire adapted from the NoMad instrument (a measure of normalization based on the NPT framework, see Table 1) [27,31], and a follow-up semi-structured telephone interview (completed by a sub-sample of participants).

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Rationale for the methods and study design are now described in accordance with Good Reporting of a Mixed Methods Study (GRAMMS) criteria [32], and summarised in Figure 1.

[INSERT FIGURE 1]

NoMad questionnaire

NoMad provides a measure of the constructs of NPT in terms of their constituent components, indicating degree of success in relation to specific aspects of implementation (see table 1). This facilitates comparison across time points and between sub-groups, and provides a basis for exploring experiences of respondents in more detail through telephone interviews (described in the following section). Each participant was given an envelope containing a questionnaire, which was completed and sealed before returning to the team lead (return envelopes did not contain identifiable information). At T0, participants completed and returned these directly to the researcher (MB). At T1, participants were informed by email/text message that the questionnaires were available for completion; two weeks thereafter a reminder email/text message was sent, and completed questionnaires were then collected by a researcher (MB) after a further week (the three-week interval accommodated staff annual leave).

NPT Construct Question (NPT component) NPT Construct Question (NPT component)Q1— When you screen and treat patients

for malnutrition, how familiar does it feel? Q12—I can easily integrate screening and treatment

for malnutrition into my existing work. (Interactional workability)

Q2— Do you feel that screening and treatment for malnutrition is currently a

normal part of your work?

Q13—Screening and treatment for malnutrition disrupts working relationships.

(Relational integration)

(questions not linked to specific

constructs)Q3— Do you feel that screening and

treatment for malnutrition will become a normal part of your work?

Q14—I have confidence in other people’s ability to screen and pro-vide treatment for malnutrition.


Q4—I can see how the new procedure for screening and treatment of malnutrition

differs from usual ways of working.(Differentiation)

Q15—Work is assigned to those with skills appropriate to screening and treatment for

malnutrition. (Skill set workability)

Q5—Staff in this organisation have a shared understanding of the purpose of

new procedure for screening and treatment of malnutrition. (Communal specification)

Q16—Sufficient training is provided to enable staff to implement screening and treatment for mal-

nutrition. (Skill set workability)

Q6—I understand how new procedure for screening and treatment of malnutrition

affects the nature of my own work.(Individual specification)

Q17—Sufficient resources are available to support screening and treatment for malnutrition.

(Contextual integration)

Coherence ‘The sense-

making work that people do

individually and collectively

when they are faced with the

problem of operationalizing

some set of practices’. Q7—I can see the potential value of new

procedure for screening and treatment of malnutrition for my work

(Internalisation)

Collective action‘The

operational work that

people do to enact a set of

practices, whether these

represent a new technology or

complex healthcare

intervention.’

Q18—Management adequately supports screening and treatment for malnutrition.


Q8—There are key people who drive screening and treatment for malnutrition

forward and get others involved. (Initiation)

Q19—I am aware of reports about the effects of screening and treatment for malnutrition.

(Systematisation)

Q9—I believe that participating in screening and treatment for malnutrition

is a legitimate part of my role. (Enrolment)

Q20—The staff agree that screening and treatment for malnutrition is worthwhile.

(Communal appraisal)

Q10—I’m open to working with colleagues in new ways to screen and treat for

malnutrition.(Legitimation)

Q21—I value the effects that screening and treatment for malnutrition has had on my work.

(Individual appraisal)

Cognitive participation

‘The relational work that

people do to build and sustain a

community of practice around

a new technology or

complex intervention.’

Q11—I will continue to support screening and treatment for malnutrition.

(Activation)


‘The appraisal work that

people do to assess and

understand the ways that a new set of practices affect them and others around

them.’ Q22—Feedback about screening and treatment for malnutrition can be used to improve it in the

future.(Reconfiguration)

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Q23—I can modify how I work with tools and/or procedures for screening and treatment for

malnutrition.(Reconfiguration)

Table 1 - NoMad questions grouped by relationship to NPT constructs as statements for evaluation (Q1 response variables: Still feels very new, 0-10, Feels completely familiar. Q2 & Q3 response variables: Not at all, 0 – Somewhat, 5 – Completely, 10. Q4-23 response variables: Strongly

agree, 1 – 5, Strongly disagree; Not relevant to my role – 6; Not relevant at this stage – 7; Not relevant to screening and treatment for malnutrition – 8.) (Questions 4-7 mapped to the construct ‘Coherence’ and were not included at T0; Questions 1-3 explore general feelings of

familiarity and normalization, and are not reported in this article)[33].


Following T0 NoMad completion, a sub-sample of participants were invited to participate in a follow-up semi-structured telephone interview. In addition to exploring NoMad responses for each of the NPT components, qualitative interviews offered several benefits. Firstly, identification of factors not visible through the NoMad instrument (e.g. how implementation may affect local contexts, for example, within different teams [34]), allowing for iterative development of additional questions (to be added after the items adapted from NoMad) at future observation points (interviews at T0 generated questions which were added to the questionnaire at T1, which are reported in the findings section). Secondly, interviews offered opportunities to elaborate on responses to NoMad. This was particularly useful for exploring congruence between beliefs and attitudes on the one hand, and actions and experiences on the other. Given that NPT focuses primarily on individual and collective action (that is, the work that people do as individuals and within collectives in order to enact and embed a new set of practices), semi-structured interviewing offered an opportunity to ensure that this was explored effectively.



Questionnaire responses were collected via paper instruments, and audio data from interviews were collected using digital dictaphones; both were stored electronically and securely on Bournemouth University (BU) servers, in password protected folders to which only the project team had access. For transcription, files were sent using a secure drop off-service, to a transcription service with which the study team had a confidentiality and nondisclosure agreement.

Data Analysis

Results from NoMad were analysed using descriptive and inferential (Wilcoxon rank-sum test for between group differences in response, Wilcoxon signed-rank test for pre-post differences within groups) statistics using SPSS v.23 (threshold for statistical significance was defined at the 0.05 level in this study)[35]. NoMad results contain no domain-specific scores, and only answers to individual questions were calculated. Mean scores with accompanying standard deviations are here reported for Q4-23. The decision to report NoMad results as mean values rather than medians was taken for two reasons. Firstly, computing the mean value gives a more precise indication of the direction of response (e.g. for a distribution of scores where the mean = 2.5 and the median = 2, the former provides meaningful additional detail indicating direction closer to neutral response than is visible from reporting of the median score). Secondly, reporting to one decimal place provides a more detailed basis for the colour gradient used to aid interpretation of results tables (that is, the intensity of colour is linked to the tendency towards the response, i.e. strongly agree (blue), neither agree nor disagree (white), strongly disagree (yellow)). Neutral colours were chosen due to the mixed direction of NoMad questions (i.e. agreement with statements does not always indicate a desirable response). Further exploration of methodological literature was undertaken to confirm appropriateness of this approach for analysis of likert-type data [36,37]. Qualitative data were analysed through deductive thematic analysis informed by NPT, using a constant comparative approach, performed using NVivo v11 software [38,39]. Nvivo allows the user to attach labels (or ‘codes’) to text, audio, video or image data, and provides a tool for data management through which

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deductive thematic analysis can be conducted by a competent user. In this study, a list of codes was established based upon the NPT framework described above and used to identify relevant portions of the audio and transcription data from interviews.

Interviews were performed by one researcher (MB), and audio data sent to an external transcription service immediately upon completion (all interviews were returned within 14 days of submission). Upon receipt of the interviews, data integrity checks were performed by one researcher (MB), which involved reading the entire transcript along with the audio recording to ensure congruence between the two. This also served as a familiarisation procedure prior to initial deductive thematic analysis, where initial themes relating to specific components of NPT and linked questions within the NoMad survey were identified by one researcher (MB). Emerging content of these themes were then discussed at group meetings with all co-authors (MB, JM, KW, KS, CRM), the aims of which were to agree relevance of identified material to individual themes (e.g. whether an interview extract applied to a specific NPT construct, and/or whether it may be relevant to other constructs). Following group discussion, amendments were made as necessary. This process repeated across three team meetings as interviews were completed (following the constant comparative approach), with themes agreed at the final meeting following completion of all interviews (a flowchart detailing this process is given in Figure 2).

[INSERT FIGURE 2]

Study sample

Staff (n=89) were approached at T0, of which 73 consented to participate. The recruitment rate at T0 was 79%. The recruited sample T0 comprised: 42 physical health (community) nurses, seven mental health nurses, 16 Healthcare Support Workers, four Occupational Therapists, one Physiotherapist, and one other practitioner of Consultant-level1. Further details of the study sample are given in table 2. A sub-sample of 16 participants also completed the semi-structured telephone interview following completion of NoMad at T0 (see table 2; for a full description of the approach process for interview, see Additional File 2). At T1, 32 participants completed the follow-up NoMad questionnaire (attrition rate = 56%), 13 of which participated in the training while 19 did not. Of the 41 participants who did not complete T1, 12 participants (16% of the T0 recruited sample) were identified as having left their teams, including four team leads representing a third of those included in the study (n=12). Reasons for non-completion at T1 by the remaining 29 participants were not given. NoMad results reported here reflect only those who completed at both T0 and T1 (n=32 participants).

RoleNoMad T0 (n)

Interview (T0)

NoMad T1 (n)

Mental Health Nurse (MHN) 7 2 1Physical Health (Community) Nurse (PHN) 42 13 22Occupational Therapist (OT) 4 1 4Healthcare Support Worker (HSW) 16 0 4Physiotherapist (PT) 1 0 1Associate Practitioner (AP) 2 0 0Other (consultant-grade practitioner) (Oth) 1 0 0Total participants (all roles/bands) 73 16 32

Table 2 - Demographic characteristics of study sample.


There was no patient or public involvement in the design or conduct of this study, which was a process evaluation of practice change and involved only staff.


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Results

Baseline (T0)

Staff already support nutrition screening and treatment activity, see its value, and do not view it as disruptive to other work.

T0 NoMad responses indicate strong support for, and value placed upon, nutrition screening and treatment activity. 94% (n=30) of total participants (n=32) strongly/agreed that staff see this activity as worthwhile (Q20, mean score = 2.0, see Table 3). 97% (n=31) strongly/agreed that screening and treatment of malnutrition was a legitimate part of their role (Q9, mean score = 1.6, see table 4). 81% (n=26) strongly/agreed that they valued the effect that screening and treatment for malnutrition has had on their work (Q21, mean score = 2.0, table 3). 97% (n=31) strongly/agreed that they were open to working with colleagues in new ways to support this work (Q10, mean score = 1.4, Table 4). 97% (n=31) also strongly/agreed that they would continue to support this work (Q11, mean score = 1.4, Table 4). This was reflected in responses of 14 participants to telephone interview (T1), all of which were compatible with openness to introducing new ways of working, though three also raised concerns with respect to the time/resource implications of implementation and embedding (see box 1).

Existing arrangements for nutrition screening and treatment could easily be integrated into their overall body of work, and were not seen to disrupt working relationships. 78% (n=25) of total respondents strongly/agreed that existing nutrition screening and treatment activity could easily be integrated into their overall body of work (Q12, mean score = 2.0, see table 5). 79% strongly/disagreed that screening and treatment of malnutrition disrupts working relationships (Q13, mean score = 1.9, see table 5). Six respondents from interviews described discussion of screening and treatment of malnutrition as a common feature of team meetings (see box 1).

Concerns exist as to wider organisational support for nutrition screening and treatment by community teams, as well as access to dietetic support.

Uncertainty or doubt was expressed by many participants regarding logistical and organisational support for screening and treatment related activity. 59% of respondents were uncertain (44%) or strongly/disagreed (15%) with the statement ‘[t]here are key people who drive screening and treatment for malnutrition forward and get others involved’ (Q8, mean score = 2.9, see table 4). Of the 16 interview participants asked to about their response, 13 could not identify a key person. Of these 13, six highlighted absence of a ‘key’ or ‘link’ member of staff to provide advice, support, and best practice updates (identified as being in place in other areas of practice, e.g. infection control – see box 1).

Sixteen interview participants were asked about dietetic referral in previous practice. Of these, two participants confirmed that they had been able to refer to a dietitian, the remainder (n=13) had not referred in their current role. Of the 13 who had not referred: three stated that this should be possible in principle through the GP; six further participants were unsure if or how this would be possible. Of total (n=16) respondents, five stated explicitly that access to dietetic services in the community needed improvement (see box 1).

Box 1 – interview findings and illustrative quotesFinding Interview quote

Openness to introducing new ways of working (14 respondents); concerns regarding time/resource implications of implementation and embedding (three respondents).

[T]he thing that does concern me is the time to imbed the new practice because there is so much to take in, so much change, there’s so many boxes to tick sometimes; trying to imbed the practice is really challenging when it’s moving so fast and the work load is going through the roof; I think taking the time with the patient to be able to completely embed it is a challenge but I don’t think, I think as a team, I’ve only been here a short while, but as a team they seem really keen to improve and implement anything that’s new and that’s better. (P00905, PHN)

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Discussion of screening and treatment of malnutrition as a common feature of team meetings (six respondents)

No it’s never disruptive and it’s never caused an issue for anyone, that’s why I disagreed, we are quite a good stable team that get on well together and support each other when we are doing the work. (P00611, PHN)

Absence of a ‘key’ or ‘link’ member of staff to provide advice, support, and best practice updates (six respondents)

It would be a preference definitely to implement some kind of key worker strategy which I know they do try and do but quite often falls you know dead on the ground so, I think yeah with regards to that yes it definitely would be a more effective way of working if that was possible so that would be something good to be implemented I guess. (P00614, PHN)

Access to dietetic services in the community in need of improvement (five respondents)

I mean my only concern is, my understanding is there is not many community dietitians you know so it’s just sort of getting advice, obviously we will refer to the GP but it’s not often we get input from dietitians themselves. We’ve sort of got basic guidelines on how to go through, so to have some more input from dietitians would be really good, really useful. (P00210, PHN)

56% (n=18) were uncertain or strongly/disagreed in relation to the statement ‘Work is assigned to those with skills appropriate to screening and treatment for malnutrition’ (Q15, mean score = 2.8, see table 5). 62% (n=12) strongly/disagreed with or were uncertain in relation to the statement ‘Sufficient training is provided to enable staff to implement screening and treatment for malnutrition’ (Q16, mean score = 3.1, see table 5). 59% were uncertain (40%) or strongly/disagreed (19%) that ‘Sufficient resources are available to support screening and treatment for malnutrition’ (Q17, mean score = 2.9, table 5). 66% (n=21) were uncertain or strongly/disagreed that ‘Management adequately supports screening and treatment for malnutrition’ (Q18, mean score = 2.5, table 5).


Component

Systematisation Communal appraisal


Question / observation point

Q19-T0

Q19-T1

Q20-T0

Q20-T1

Q21-T0

Q21-T1

Q22-T0

Q22-T1

Q23-T0

Q23-T1

3.2 2.8 1.8 1.8 2.0 1.9 2.0 2.0 1.8 2.0

1.01 0.93 0.60 0.69 0.91 0.76 1.22 0.41 0.83 0.41

Training Participants (n=13)

Question / component mean score, SD, range. 2 - 5 2 - 4 1 - 3 1 - 3 1 - 4 1 - 3 1 - 5 1 - 3 1 - 3 1 - 3

3.2 3.0 2.0 1.9 2.0 2.2 1.7 2.0 2.2 2.1

0.98 1.11 0.33 0.42 1.37 1.06 0.59 0.69 0.71 0.94

Non-training participants (n=19)


3.2 2.9 1.9 1.9 2.0 2.1 1.8 2.0 2.0 2.1

0.97 1.03 0.47 0.54 1.19 0.94 0.91 0.58 0.78 0.76All participants (n=32)


Table 3 - NoMad T0-T1 responses for 'Reflexive Monitoring' score colour intensity tends toward: blue (strongly agree – 1); white (neither agree nor disagree – 3); yellow - strongly disagree – 5)..


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Component



Q8-T0

Q8-T1

Q9-T0

Q9-T1

Q10-T0

Q10-T1

Q11-T0 Q11-T1

2.9 2.7 1.3 1.5 1.2 1.5 1.2 1.5

1.44 0.85 0.48 0.52 0.44 0.66 0.44 0.52


Question / component mean score, SD, range. 2 - 5 2 - 5 1 - 4 1 - 4 1 - 3 2 - 2 1 - 3 1 - 3

2.9 2.7 1.7 1.7 1.5 1.6 1.5 1.6

0.94 0.93 0.73 0.73 0.61 0.50 0.61 0.60Non-training participants (n=19)


2.9 2.7 1.6 1.7 1.4 1.6 1.4 1.6

1.15 0.89 0.67 0.65 0.56 0.56 0.56 0.56



Table 4 - NoMad T0-T1 scores for 'Cognitive Participation' score colour intensity tends toward: blue (strongly agree – 1); white (neither agree nor disagree – 3); yellow - strongly disagree – 5).


Component Interactional Workability Relational Integration Skill set Workability Contextual Integration


Q12-T0

Q12-T1

Q13-T0

Q13-T1

Q14-T0

Q14-T1

Q15-T0

Q15-T1

Q16-T0

Q16-T1

Q17-T0

Q17-T1

Q18-T0

Q18-T1

1.9 1.8 1.8 2.1 2.6 2.5 2.8 2.9 2.9 2.7 2.9 2.9 2.6 2.4

0.64 0.44 0.73 0.76 0.77 0.52 0.90 0.95 1.12 0.85 1.24 0.86 1.08 0.65


Question / component mean score, SD, range. 1 - 3 1 - 2 3 - 5 2 - 5 1 - 4 2 - 3 1 - 4 2 - 5 1 - 4 2 - 4 1 - 5 2 - 4 1 - 4 1 - 3

2.1 2.3 2.1 2.4 2.2 2.5 2.7 2.3 3.2 2.9 2.8 3.1 2.5 2.8

0.81 1.00 0.78 0.69 0.73 0.62 1.00 1.03 1.07 1.39 0.69 1.20 0.84 1.08



2.0 2.1 1.9 2.3 2.4 2.5 2.8 2.6 3.1 2.8 2.9 3.0 2.5 2.6

0.74 0.86 0.76 0.73 0.76 0.57 0.95 1.03 1.08 1.19 0.92 1.06 0.93 0.94



Table 5 - NoMad T0-T1 responses for 'Collective Action' score colour intensity tends toward: blue (strongly agree – 1); white (neither agree nor disagree – 3); yellow - strongly disagree – 5).

Training outcomes

126 staff members within the implementation area completed the training, representing 56% of full time staff (n=223) at initiation of training (23% (n=30) of those completing were INSCCOPe participants). 40% (n=29) of INSCCOPe participants (n=73) completed the training; 60% did not (see Additional File 3, tables 1 & 2). Pre-post knowledge check scores indicated that the training had been effective in raising average knowledge check score for all participants from 54% immediately prior to the training to 68% for immediately post-training (see Additional File 3, table 3). All role groups saw an increase in average scores, the largest (23%) being for Healthcare Support Workers, while the smallest (7%) was for Occupational Therapists and Associate Practitioners (see Additional File 3, table 3).

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T1 Results


Four questions (Q4-7) mapping to the NPT domain of ‘Coherence’ and its components were added to NoMad instrument at T1 (between agreement and uncertain, see table 6). For all participants completing T1, 46% (n=15) disagreed or were uncertain in response to the statement (Q4): ‘I can see how the new procedure for screening and treatment of malnutrition differs from usual ways of working’ (mean score = 2.7, see table 6). The same responses represented 38% (n=5) of training participants (mean score = 2.5), and 52% (n=10) of non-training participants (mean score = 2.7, see table 6). This indicates that for those who both did and did not complete the training, differentiation of the new procedure introduced through training for existing practice requires further attention.

In the all T1 participant group, 41% (n=13) disagreed or were uncertain regarding the statement (Q5): ‘Staff in this organisation have a shared understanding of the purpose of new procedure for screening and treatment of malnutrition’ (mean score = 2.7, see table 6). Responses of this type represented 38% (n=5) in the training participant group (mean score = 2.5, and 42% (n=9) of the training non-training group (mean score = 2.9, see table 6). Results indicate a large proportion in both sub-groups for whom shared understanding (Communal Specification) of the procedure remains vague.

25% (n=8) of the all participant group disagreed or were uncertain in relation to the statement (Q6): ‘I understand how the new procedure for screening and treatment of malnutrition affects the nature of my own work’ (mean score = 2.4, see table 6). Respondents providing such answers represented only one response in the training participant subgroup (mean score = 2.0), with the seven remaining respondents of this type representing 37% of training non-training group (mean score = 2.7, see table 6). Here, results indicate a difference in how well participants in respective sub-groups understood the new procedure in terms of their own practice (Individual Specification), and the difference between groups approached significance (p=0.06, see Additional File 4, table 1). Comparing this with results from Q5, results indicate a greater effect of training on understanding implications for individual working compared with team working.

75% (n=24) of all participants strongly/agreed with the statement (Q7): ‘I can see the potential value of the new procedure for screening and treatment of malnutrition for my work’ (mean score = 2.2, see table 6). 92% (n=12) of the training participant group (mean score = 1.7), and 37% (n=7) of the non-training participant group (mean score = 2.6, see table 6), gave responses of this type. This difference between sub-groups was significant (p=0.01, see Additional File 4, table 1), and indicates a potential impact of training on value placed on the new procedure.

Construct Coherence

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Component

Differentiation Communal specification

Individual specification Internalisation

Question / observation point Q4 Q5 Q6 Q7

2.5 2.5 2.0 1.7

0.66 0.66 0.41 0.49Training Participants (n=13)

Question / component mean score, SD, range.

2 - 4 2 - 4 1 - 3 1 - 2

2.7 2.9 2.7 2.6

1.59 1.50 1.63 1.59Non-training participants (n=19)

Question / component mean score, SD, range. 1 - 4 1 - 5 1 - 5 1 - 5

2.6 2.7 2.4 2.2

1.31 1.23 1.33 1.37All participants (n=32)


Table 6 - NoMad T1 mean scores for 'Coherence' (score colour intensity tends toward: blue (strongly agree – 1); white (neither agree nor disagree – 3); yellow - strongly disagree – 5).


Wilcoxon signed-rank tests were used to investigate differences between responses to Q8-23 for all participants (n=32), training participants (n=13), and non-training participants (n=19) respectively. For all participants, only Q13 saw a significant change from T0 (mean score = 1.9) to T1 (mean score – 2.3, see table 5), which involved a shift towards uncertainty or disagreement with the statement ‘Screening and treatment for malnutrition disrupts working relationships’ (T = 32.00, r = -0.29, p = 0.02; see Additional File 4, table 2). This indicates small-to-moderate effect on responses during the period in which the training took place. Changes in Q13 responses for non-training participants (2.1 (T0) – 2.4 (T1)) also approached significance (T = 8.00, r = -0.29, p = 0.07, see Additional File 4, table 2). No other significant changes were observed (see Additional File 4, tables 2-4).


A significant difference was observed for Q7-T1 (W = 124, r = -0.43, p = 0.01), while Q6-T1 approached statistical significance (W = 156.5, r = -0.33, p = 0.06 – see Additional File 1, table 1). No significant differences were found for any other questions at either of the time points (see Additional File 4, tables 1; 5-7).

Dietetic questions

Interview responses at T0 indicated that access to dietetic services was a significant concern for many participants. Additional questions regarding availability and adequacy of dietetic services were appended to the questionnaire at T1. Overall, results show that 30-90% of all participants had concerns about or were uncertain in relation to, all aspects of dietetic service explored by the question statements (see table 7). Proportions of responses were similar for both training and non-training participants in most areas (A1-2, A4-6), and Wilcoxon rank-sum test results between sub-group response to each question showed no statistically significant differences (see Additional File 4, table 8). These results echo those indicated by the telephone interview, that many participants appear to have doubts regarding current adequacy of dietetic services in relation to procedure, support, and resource allocation.

Training group % strongly/agree% strongly/disagree or uncertain

Non-training participants (n=19) 0.47 0.47A1 - I know where to get specialist support and

advice on treatment for malnutrition if I need it Training Participants (n=13) 0.54 0.38

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All (n=32) 0.50 0.44Non-training participants (n=19) 0.47 0.47Training Participants (n=13) 0.69 0.31

A2 - I have sufficient access to patient information resources relating to malnutrition


A3 - Patient information resources relating to malnutrition are useful and effective


A4 - My team has access to a dietician if a patient requires it


A5 - I know the procedure for referring a patient to a dietician if required


A6 - Availability of dieticians is sufficient to meet the needs of our patients


A7 - Current state of malnutrition screening is sufficient to meet the needs of our patients


A8 - Current arrangements for treatment of malnutrition are sufficient to meet the needs of

our patientsAll (n=32) 0.34 0.59


Discussion

The aim of the INSCCOPe study was to undertake a process evaluation of the implementation of the screening procedure and its associated training and identify factors that promote or inhibit embedding of nutritional screening as a routine aspect of care. Study findings indicate that staff value nutrition screening and treatment activity and are open to new ways of working (indicating favourable conditions relating to the Internalisation and Relational integration components of NPT). In addition, the training provided is effective in improving knowledge of the new procedure. However, participant responses highlighted lack of institutional support for nutrition screening (Contextual integration), as well as the absence of a ‘key’ person to support and drive forward service development (Initiation), indicating that significant barriers to implementation remain. Implications of these findings and recommendations for addressing barriers are discussed, in addition to wider implications for implementation of service developments in community settings.

NoMad responses mapping to the NPT construct of Cognitive participation indicate conditions conducive to building and sustaining a community of practice around nutrition screening and treatment. Findings (T0 and T1) indicate that staff view such work as a legitimate part of their role (Q9, Enrolment), are open to working with colleagues in new ways in relation to it (Q10, Legitimation), and will continue to support further development in this area (Q11, Activation). In addition, responses (both T0 and T1) indicate that both baseline arrangements for nutrition screening and treatment, as well as the new procedure, and can be easily integrated into existing work (Q12, Interactional workability). Between T0-T1, there was a shift in average scores towards ‘neither agree nor disagree’ and away from ‘strongly agree’ in relation to perceptions of disruptiveness of nutrition screening and treatment for working relationships (Q13, Relational integration). This shift was significant for non-training participants (p=0.02) and

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approached significance for training participants (p=0.07), indicating that implementation may have had some effect on staff perceptions of the effect of nutrition screening and treatment on working relationships. However, mean scores for both groups at T1 (2.1 for training, 2.4 for non-training) indicate that many participants still see this activity as disruptive to working relationships.

Results indicate several challenges to the current implementation design: firstly, non-completion of training (44% of total staff (n=223) did not complete). Concerns regarding time and resource constraints for nutrition screening and treatment activity (see Q17, table 5; and Box 1) were indicated in both NoMad (T0 & T1) and interview responses. Furthermore, experiences of the study team in recruitment to telephone interview indicated a number of participants who declined to participate, or agreed and then were forced to withdraw, in both cases due to changes in workload (see Additional File 2). These observations are indicative of the changeable demands that characterise community team working environments, and can be expected to affect attendance at in-person training sessions that are non-mandatory. Secondly, the working environment also includes significant attrition of key staff; 12 participants left post between T0-T1, of which four were team leads. This risks reduction in numbers trained in the new procedure, as well as key people able to monitor compliance and provide appropriate support (i.e. team leads). Thirdly, the effect of staff attrition on overall procedure compliance may be compounded by lack of monitoring of training (i.e. while pre-post knowledge checks were taken, no procedures for monitoring ongoing compliance currently exist). Fourthly, concerns about institutional support for nutrition screening and treatment activity (as indicated through interviews and responses to dietetic survey questions) persisted after introduction of the procedure through training. This indicates that further attention is necessary to Contextual integration processes, specifically the support provided by management for nutrition screening and treatment activity, and how this is made available to staff working in community teams.

In response, we propose two main changes to the implementation design. Firstly, appointment of a key person for the new procedure, with specialist nutritional expertise and remit to: monitor training completion rates and procedure compliance; disseminate practice updates; provide advice and support for nutrition screening and treatment. This addresses a suggestion by several interview participants, who cited the benefits of this role in other areas such as wound care, as well as a gap indicated by uncertain survey responses (NoMad Q8 – see table 4). The value of such a role in implementing new nutritional care procedures has also been demonstrated in secondary care settings [11,34]. Updates on compliance, training, and resource needs would be provided to senior managers at regular intervals, moving from a single-point intervention at the level of HCPs through training, to one that links the work of monitoring and resource allocation directly to those with responsibility to ensure successful implementation of the new procedure (thus creating an organisational feedback loop to promote sustainability and embedding in management practice). Secondly, training design needs to be adaptable to cope with the changeable working patterns, organisational and resource support challenges, and staff turnover that restricted training participation and left those who did complete the training vulnerable to attrition. We therefore recommend that training is delivered through the existing organisational e-learning portal, rather than in person. Combined with improvements in monitoring, support, and flexibility, this will help to promote successful implementation, and support resilience to organisational turbulence.

Implications

While the barriers here identified relate to specific processes within the study field, they point to processes relevant to implementation in general, which map to components of NPT; enabling participation (enrolment); responding to workforce turbulence (communal appraisal; reconfiguration); monitoring of compliance (systemisation); ensuring adequate provision of resource (contextual integration). These components fall within the ‘Collective Action’ and ‘Reflexive Monitoring’ domains of NPT, indicating importance these domains for successful implementation. The findings also echo those of Johnson & May’s (2015) theory-led overview of systematic reviews of interventions to promote professional practice change, insofar as positive attitudes of staff were outweighed by lack of engagement with collective action [40]. The present study points to the importance of key people as ‘pumps’ to drive and sustain organisational behaviour loops, adding to the extant literature emphasising the importance of individuals with the resource, authority, and legitimacy (both personal and institutional) to drive forward new developments in healthcare [11,26,34,41,42]. In addition, it indicates the importance of designing intervention objects that are resilient to organisational turbulence. Many healthcare interventions take place in complex settings wherein emergent and

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contextual factors can modify the conditions of implementation. Providing organisational ‘closure’ through monitoring and support of a key person is important in mitigating these effects; however, the objects of interventions (e.g. procedures, training seminars, technologies etc.) are important in this process. In the INSCCOPe study, the proposed move from in-person to online delivery of the training was an example of how an intervention object may be redesigned in response to turbulence encountered within the field of implementation.

These findings are interdependent; appropriate design choices for objects can only be expected to have effects if participants are directed to use them in some way, which typically involves the organisational work of key people. In their evaluation of an intervention to support carers of stroke survivors, Clarke et al. (2013) observed that participants unable to attend training did not make use of replacement resources (a DVD) because they were not directed to do so [34]. The observations from the present study add to the body of literature indicating the importance of contextual factors (i.e. turbulence) as well as creating practical (rather than simply attitudinal) conditions for professional behaviour change, as key determinants in the success (or failure) of service development initiatives.


Considerable work was necessary to recruit and conduct interviews with participants (see Additional File 2), and to obtain NoMad responses at T1 (where questionnaires were left with team leads for circulation and completion, instead of completing in the presence of a researcher as occurred during recruitment at T0). 116 telephone calls were made in order to secure 16 interviews, with seven participants requiring one or more rearrangements of their scheduled time, and four cancelling after initial agreement. In almost all cases where contact was made, inability to participate or need for rescheduling was attributed to volume and changeability of workload. We recommend that future studies involving community teams should be aware of this as a necessary condition of participation in this area of work and look to accommodate this. We would also recommend that questionnaire instruments are completed during in-person visits by a researcher where possible, to minimise participant attrition.

Conclusion

We have presented a prospective process evaluation, exploring initial implementation of a new procedure for screening and treatment of malnutrition in community settings. Guided by Normalization Process Theory, we have explored aspects of implementation and embedding, as well as areas of ongoing need in relation to organisational, specialist, and resource support for nutrition screening and treatment. In so doing, we have highlighted some generic aspects of implementation relevant to service development in community settings and proposed two specific areas of attention for those designing such interventions. These findings add to the wider knowledge base on implementation and embedding by supporting and extending observations regarding the importance of Collective Action and Reflexive Monitoring mechanisms.

Declarations


Ethical approval for the study has been granted through institutional ethical review (Bournemouth University); NHS Heath Research Authority approval (IRAS ID – 223214) was granted on 05/04/2017. NHS Research Ethics committee approval was not required for this study, as it involves only staff.


Not applicable.



Not applicable.

Competing interests


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Funding



JM, KW, and KS devised the project (for which CRM and AA also provided advice). JM obtained funding at the host institution, Bournemouth University. JM managed the study as chief investigator. MB was primarily responsible for study design, protocol, data collection and analysis with input from JM, KW, KS, AA and CRM. All authors contributed significant revisions to drafts of the manuscript, and have read and approved the final manuscript.

Acknowledgements

The study team would like to acknowledge the support of the Burdett Trust for Nursing, and of staff within Southern Health NHS Foundation Trust for their help and support in the development of this study.

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16 Russell C, Elia M. Screening for malnutrition in sheltered housing. A Report from BAPEN with the Group on Nutrition in Sheltered Housing (GNASH). BAPEN 2009.

17 Wilson L. State of the Nation - Older People and Malnutrition in the UK today. London, UK: 2017. http://www.malnutritiontaskforce.org.uk/wp-content/uploads/2017/10/AW-5625-Age-UK-MTF_Report.pdf

18 Edington J, Barnes R, Bryan F, et al. A prospective randomised controlled trial of nutritional supplementation in malnourished elderly in the community: clinical and health economic outcomes. Clin Nutr 2017;23:195–204. doi:10.1016/S0261-5614(03)00107-9

19 Wilson L, Health RP. A review and summary of the impact of malnutrition in older people and the reported costs and benefits of interventions. 2013;:1–30.

20 Hamirudin AH, Charlton K, Walton K. Outcomes related to nutrition screening in community living older adults: A systematic literature review. Arch Gerontol Geriatr 2016;62:9–25. doi:10.1016/j.archger.2015.09.007

21 Green SM, James EP, Latter S, et al. Barriers and facilitators to screening for malnutrition by community nurses: a qualitative study. J Hum Nutr Diet 2014;27:88–95. doi:10.1111/jhn.12104

22 Hodgkins A, Albert G, Bonney A, et al. Feasibility of implementing routine nutritional screening for older adults in Australian general practices: a mixed-methods study. BMC Fam Pract 2014;15:1–9. doi:10.1186/s12875-014-0186-5

23 Wessex Academic Health Sciences Network (AHSN). Older People’s Essential Nutrition (OPEN) Eastleigh Project. 2016.http://wessexahsn.org.uk/projects/60/older-people-s-essential-nutrition-open-eastleigh (accessed 29 Sep 2017).

24 May C, Finch T. Implementing, Embedding, and Integrating Practices: An Outline of Normalization Process Theory. Sociology 2009;43:535–54. doi:10.1177/0038038509103208

25 May CR, Cummings A, Girling M, et al. Using Normalization Process Theory in feasibility studies and process evaluations of complex healthcare interventions: a systematic review. Implement Sci 2018;13:80. doi:10.1186/s13012-018-0758-1

26 Westbury JA, Johnson MJ, Pond JP, et al. Developing the role of the nurse as a link advisor for research and a champion for nutrition in the neonatal intensive care unit. J Neonatal Nurs 2013;19:198–205. doi:http://dx.doi.org/10.1016/j.jnn.2013.01.003

27 Finch T, Rapley T, Girling M, et al. Improving the normalization of complex interventions: measure development based on normalization process theory (NoMAD): study protocol. Implement Sci 2013;8:43. doi:10.1186/1748-5908-8-43

28 Finch, T.L., Girling, M., May, C.R., Mair, F.S., Murray, E., Treweek, S., Steen, I.N., McColl, E.M., Dickinson, C., Rapley T. NoMAD: Implementation measure based on Normalization Process Theory. 2015.http://www.normalizationprocess.org/resources/ (accessed 21 Aug 2017).

29 Lund S, Richardson A, May C. Barriers to advance care planning at the end of life: An explanatory systematic review of implementation studies. PLoS One 2015;10:1–15. doi:10.1371/journal.pone.0116629

30 Pope C, Halford S, Turnbull J, et al. Using computer decision support systems in NHS emergency and urgent care: ethnographic study using normalisation process theory. BMC Health Serv Res 2013;13:111. doi:10.1186/1472-6963-13-111

31 Finch TL, Girling M, May CR, et al. Improving the normalization of complex interventions: part 2 - validation of the NoMAD instrument for assessing implementation work based on normalization process theory (NPT).

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19

BMC Med Res Methodol 2018;18:135. doi:10.1186/s12874-018-0591-x

32 O’Cathain A, Murphy E, Nicholl J. The quality of mixed methods studies in health services research. J Health Serv Res Policy 2008;13:92–8. doi:10.1258/jhsrp.2007.007074

33 May C, Rapley T, Mair FS, et al. Normalization Process Theory On-line Users’ Manual, Toolkit and NoMAD instrument. 2015.http://www.normalizationprocess.org

34 Clarke DJ, Godfrey M, Hawkins R, et al. Implementing a training intervention to support caregivers after stroke: A process evaluation examining the initiation and embedding of programme change. Implement Sci 2013;8:96. doi:10.1186/1748-5908-8-96

35 Field A. Discovering Statistics Using IBM SPSS Statistics. SAGE Publications 2013. https://books.google.co.uk/books?id=srb0a9fmMEoC

36 Norman G. Likert scales, levels of measurement and the ‘laws’ of statistics. Adv Heal Sci Educ 2010;15:625–32. doi:10.1007/s10459-010-9222-y

37 Sullivan GM, Artino ARJ. Analyzing and Interpreting Data From Likert-Type Scales. J Grad Med Educ 2013;:541–2.


39 Corbin J, Strauss A. Basics of Qualitative Research: Techniques and Procedures for Developing Grounded Theory. SAGE Publications 2014. https://books.google.co.uk/books?id=hZ6kBQAAQBAJ

40 Johnson MJ, May CR. Promoting professional behaviour change in healthcare: What interventions work, and why? A theory-led overview of systematic reviews. BMJ Open 2015;5. doi:10.1136/bmjopen-2015-008592

41 Hoddinott P, Britten J, Pill R. Why do interventions work in some places and not others: A breastfeeding support group trial. Soc Sci Med 2010;70:769–78. doi:10.1016/j.socscimed.2009.10.067

42 Jacobs RL, Russ-Eft D. Cascade Training and Institutionalizing Organizational Change. Adv Dev Hum Resour 2001;3:496–503. doi:10.1177/15234220122238427

Figure legends


Figure 2 - Process for deductive thematic analysis of interview data (responsible authors at each stage identified by initials).

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Additional File 1

Version Control

Change Record

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CONTENTS

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risk.















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Store.



possible.
















normal?







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2 Care Pathway










date.















• Poor appetite







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Additional File 1








sheet.














need.








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compliance.






4.3 Dementia














5. Hydration



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services.




this is a concern.




them.





monitoring.

6. Training









Change’ (2006)




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Additional File 1







MUST Score 0

Low Risk















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approach = 73








initial email = 9

Agreed initial

date for

interview = 4


email (passed to


Declined

interview

participation = 1

Email address

invalid (passed

to telephone

approach) = 12

No reply to

initial email

(passed to

telephone

approach) =

42

Stage 1 T0

interview

approach (email)



approach = 58



16


number provided = 6





by telephone = 36




= 3



reached cut-off)



Completed on date


Followed up after


interview = 7




interview)

Interview

rearranged and


completed = 16



2.2; range = 1-6)

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tables.

Role













Unspecified 15 1 0 0.00 0.00 1.00




Category Team





Urban ICT (n=28)

1 (n=4) 4 1.00 0 0.00

4 (n=5) 5 1.00 0 0.00

6 (n=4) 3 0.75 1 0.25

8 (n=4) 0 0.00 4 1.00

9 (n=5) 1 0.20 4 0.80

14 (n=6) 0 0.00 6 1.00

Total 13 0.46 15 0.54

Rural ICT (n=27)

2 (n=6) 6 1.00 0 0.00

5 (n=10) 1 0.10 9 0.90

10 (n=4) 0 0.00 4 1.00

11 (n=7) 2 0.29 5 0.71

Total 9 0.33 18 0.67

OPMH (n=11)

3 (n=8) 5 0.63 3 0.38

7 (n=3) 2 0.67 1 0.33

Total 7 0.64 4 0.36



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Pre-score (mean)


Post-score (mean)








Student 3 3 0.39 3 0.58 0.19

Unspecified 14 12 0.59 14 0.76 0.15

Total 111 102 0.54 108 0.68 0.15


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results Coherence


W. 167.5 169 156.5 124

r. -0.27 -0.22 -0.33 -0.43

Z -1.54 -1.22 -1.89 -2.45

p. 0.12 0.22 0.06 0.01


NPT Construct Cognitive Participation



Q11T0-Q11T1


T. 22.50 8.00 0.00 0.00

r. -0.11 -0.22 -0.32 -0.39

Z -0.54 -1.13 -1.63 -2.00

p. 0.59 0.26 0.10 0.05


training (n=19)

T. 22.00 10.50 7.00 7.00

r. -0.09 0.00 -0.13 -0.13

Z -0.58 0.00 -0.82 -0.82

p. 0.56 1.00 0.41 0.41


T. 84.50 35.00 9.00 11.00

r. -0.10 -0.10 -0.22 -0.24

Z -0.81 -0.83 -1.73 -1.90

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p. 0.42 0.41 0.08 0.06



NPT Component



Q15T0-Q15T1

Q16T0-Q16T1

Q17T0-Q17T1

Q18T0-Q18T1


T. 7.00 9.00 7.00 6.00 9.50 6.50 6.00

r. -0.16 -0.28 -0.16 -0.09 -0.16 -0.05 -0.14

Z -0.82 -1.41 -0.82 -0.45 -0.79 -0.27 -0.71

p. 0.41 0.16 0.41 0.66 0.43 0.79 0.48


training (n=19)

T. 13.50 8.00 24.00 26.50 35.50 40.00 26.00

r. -0.19 -0.29 -0.21 -0.22 -0.12 -0.13 -0.17

Z -1.16 -1.81 -1.29 -1.37 -0.71 -0.81 -1.07

p. 0.25 0.07 0.20 0.17 0.48 0.42 0.28


T. 52.50 32.00 72.00 61.00 79.50 75.00 66.00

r. -0.06 -0.29 -0.08 -0.14 -0.12 -0.10 -0.07

Z -0.47 -2.30 -0.66 -1.11 -0.97 -0.82 -0.53

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p. 0.64 0.02 0.51 0.27 0.33 0.41 0.60




Communal appraisal



Q22T0-Q22T1

Q23T0-Q23T1


T. 12.00 12.00 16.00 17.50 8.00

r. -0.25 -0.07 -0.06 -0.01 -0.22

Z -1.28 -0.38 -0.30 -0.07 -1.13

p. 0.20 0.71 0.76 0.94 0.26


training (n=19)

T. 22.00 0.00 8.50 0.00 18.50

r. -0.17 -0.16 -0.15 -0.34 -0.08

Z -1.07 -1.00 -0.95 -2.12 -0.49

p. 0.29 0.32 0.34 0.03 0.62


T. 65.00 18.00 49.50 29.50 65.00

r. -0.20 0.00 -0.08 -0.15 -0.02

Z -1.56 0.00 -0.63 -1.18 -0.17

p. 0.12 1.00 0.53 0.24 0.87


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W. 210 309 172.5 199.5 183 199.5 183 206

r. -0.03 -0.03 -0.32 -0.12 -0.25 -0.12 -0.25 -0.07

Z -0.18 -0.18 -1.83 -0.66 -1.43 -0.66 -1.43 -0.37

p. 0.86 0.85 0.07 0.51 0.15 0.51 0.15 0.71


Collective Action


W. 201.00 177.00 290.00 281.50 256.00 207.00 295.50 247.00 191.50 206.50 296.50 203.50 298.00 193.50

r.

Z -0.58 -1.60 -0.99 -1.50 -1.39 -0.05 -0.73 -1.75 -0.44 -0.33 -0.32 -0.44 -0.26 -0.87

p. 0.56 0.11 0.32 0.13 0.16 0.96 0.47 0.08 0.66 0.74 0.75 0.66 0.79 0.39




W. 311.00 199.50 187.50 196.50 205.50 193.50 279.50 288.00 177.00 213.50

r. -0.02 -0.11 -0.25 -0.10 -0.07 -0.11 -0.07 0.00 -0.28 -0.01

Z -0.10 -0.62 -1.44 -0.58 -0.38 -0.62 -0.38 0.00 -1.56 -0.04

p. 0.92 0.54 0.15 0.56 0.71 0.53 0.70 1.00 0.12 0.96


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A1 A2 A3 A4 A5 A6 A7 A8

W. 184.00 182.50 178.50 202.50 208.50 210.00 165.00 190.00

r. -0.14 -0.19 -0.19 -0.04 0.00 -0.01 -0.29 -0.09

Z -0.77 -1.10 -1.05 -0.23 -0.02 -0.08 -1.66 -0.51

p. 0.44 0.27 0.29 0.82 0.98 0.93 0.10 0.61


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For peer review onlyImplementing professional behaviour change in teams

under pressure – results from phase one of a prospective process evaluation (the Implementing Nutrition Screening in Community Care for Older People (INSCCOPe) project).

Journal: BMJ Open

Manuscript ID bmjopen-2018-025966.R2


Date Submitted by the Author: 30-Apr-2019

Complete List of Authors: Bracher, Mike; University of Portsmouth, School of Health Sciences and Social Work; Bournemouth University, Humans Sciences & Public Health, Faculty of Health & Social SciencesSteward, Katherine; Southern Health NHS Foundation TrustWallis, Kathy; Wessex Academic Health Science Network (AHSN)May, Carl; London School of Hygiene and Tropical Medicine Faculty of Epidemiology and Population HealthAburrow, Annemarie; Wessex Academic Health Science Network (AHSN)Murphy, Jane; Bournemouth University, Humans Sciences & Public Health

<b>Primary Subject Heading</b>: Health services research

Secondary Subject Heading: Nutrition and metabolism, Geriatric medicine



BMJ Open on S



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1

Implementing professional behaviour change in teams under pressure – results from phase one of a prospective process evaluation (the Implementing Nutrition Screening in Community Care for Older People (INSCCOPe) project).







1. School of Health Sciences and Social Work (SHSSW), University of Portsmouth2. Ageing and Dementia Research Centre (ADRC), Bournemouth University3. Southern Health NHS Foundation Trust4. Wessex Academic Health Science Network (AHSN)5. Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine




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mailto:[email protected])5






2

Abstract

Objectives: To evaluate implementation of a new procedure for screening and treatment of malnutrition for older people in community settings; to identify factors promoting or inhibiting its implementation as a routine aspect of care.


Setting and participants: Community teams (nursing and allied health professionals) within a UK National Health Service Community Trust. 73 participants were recruited, of which 32 completed both pre and post-implementation surveys.

Main outcome measures: NoMad survey for pre-post intervention measures; telephone interviews exploring participant experiences and wider organisational/contextual processes.

Methods: Data prior to implementation of training, baseline (T0 – survey and telephone interview), and 2 months following training (T1 – follow-up survey). Quantitative data described using frequency tables reporting team type, healthcare provider role group, and total study sample; analysis using Wilcoxon rank-sum (sub-group comparison) and Wilcoxon signed-rank (within-group observation point comparison) tests. Qualitative interview data (audio and transcription) analysed through directed content analysis using Normalization Process Theory.

Results: High support for nutrition screening and treatment indicated by participants. Concerns expressed around logistical, organisational, and specialist dietetic support. Pre-post training measures indicated a positive impact of training on knowledge of the new procedure; however, most implementation measures saw no significant changes between time points or between sub-groups (training participants vs. non-participants). Implementation barriers included: high levels of training non-completion; vulnerability to attrition of trained staff; lack of monitoring of post-intervention compliance; lack of access to dietetic support.

Conclusion: Greater support necessary to support implementation in relation to monitoring of training completion, and organisational support for nutrition screening and treatment activity. Recommended changes to implementation design are: appointment of a key person to support and monitor procedure compliance; adoption of training as an e-learning module within the existing organisational platform to increase participation in changeable working conditions.


Prospective investigation of factors promoting or inhibiting implementation of service development, allowing for feedback to inform ongoing development of the programme.

To our knowledge, this is the first time that a prospective process evaluation has been conducted specifically on implementation of nutritional care in community settings process evaluations conducted on implementation of nutritional care in community settings.

Integrated use of mixed methods to provide reproducible measures at each observation point (quantitative, survey), and explore processes underpinning them (qualitative, semi-structured telephone interviews).

Lack of quota sample due to lack of data on workforce composition may mean that sample is unrepresentative of the role/seniority profile of the target population.

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3

Limitations of the study include: lack of observation of new procedures applied in situ, meaning that processes relating to implementation can only be explored retrospectively through interviews, and therefore recall and response bias may affect the data; lack of available data on composition of the target population (i.e. the area of the organisation in which the intervention was implemented) limits reporting on representativeness of the study sample.

Word Count = 5,985

Keywords: Nutrition, screening, process evaluation, community care, malnutrition, normalization process theory, implementation

Background

Implementation of new procedures or technologies in healthcare settings involves complex processes, bringing together individuals of different professional groups in varied kinds of work [1,2]. Process evaluation studies help us understand the success or failure of interventions, and illuminate factors that shape intervention outcomes [3,4]. The dynamics of practice implementation in open systems, like community health and social care – is poorly understood. Implementation conditions in community settings are different from those of closed systems (secondary/hospital settings) because of the spatial distribution of service users and healthcare providers, and their focus on domiciliary screening and care. Contextual factors such as funding, resource, and staffing pressures, which may have consequences that differ from those found in hospitals [5,6].

Screening for malnutrition represents an important aspect of routine community care for those working with older people [7–9]; however, malnutrition is often undiagnosed and frequently under-recognised [10]. Previous studies in hospital and care home settings indicate that contextual and organisational barriers can impede introduction of new nutritional care procedures [11,12]. To our knowledge, no published studies have focused specifically and prospectively on nutrition screening implementation in community settings. This paper contributes to understanding professional behaviour change in community settings through results from the implementation phase of a new malnutrition screening and care procedure for community teams working with older people.


We use the term ‘malnutrition’ to refer to ‘undernutrition’ although the term ‘malnutrition’ can encompass both overnutrition/obesity and undernutrition [13,14]. Malnutrition is defined as a state in which a deficiency, excess or imbalance of energy, protein and other nutrients causes measurable adverse effects on tissue/body form (body shape, size and composition), function or clinical outcome [15]. Over 3 million individuals are estimated to be malnourished or at risk of malnutrition in the UK, the majority (93%) living in the community [16,17], of which over one million are aged 65+ [18]. Malnutrition has consequences that both affect individuals, and impose a strain on health-care resources through delayed recovery from illness, increased need for health care provision at home, more frequent visits by nurses, and a greater number of hospital admissions [10,13,19]. Evidence suggests that malnutrition in older people can be prevented through screening and early intervention, and that benefits of treating malnutrition far outweigh costs [20].


There is good evidence to suggest that nutrition screening of older people living in the community together with appropriate intervention and monitoring improves nutritional status [21]. Health care staff providing care and treatment within community settings (both physical and mental healthcare) who already review and manage older people, are well placed to perform nutrition screening in routine practice (in accordance with guidelines from the UK National Institute for Clinical Excellence (NICE)) [9,22]. The feasibility of introducing a validated screening tool and

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nutrition resource kit has been shown in older adults attending general practices in an Australian study [23]. In the UK, local protocols concerning nutritional screening and assessment often exist within National Health Service (NHS) hospital trusts, based on national protocols. However, previous service development work around nutrition in the community indicates that it is often not considered a routine part of interactions with older people [24]. Leading on from this service development project, we were alerted to the current situation across a local NHS Community Trust where nutritional care was only intermittently implemented (particularly the use and follow up of good care plans) due to other priorities of care and lack of awareness of the issue. This highlighted the need to change practice in delivery of nutritional care for older people across the community.

We report on the implementation phases of a new procedure for screening and treatment of malnutrition in older people within an NHS Community Trust in England. We focus on the work of community nursing and allied health professionals (covering physical and mental health services respectively), mobilising this procedure in the community (see Additional File 1).

Existing organisational policy within the Trust has established when patients should be screened for malnutrition, and care that they should receive depending on malnutrition risk (assessed by Malnutrition Universal Screening Tool –‘MUST' screening) [7]. The new procedure introduced several updates to existing policy: firstly, only patients at medium or high-risk of malnutrition (those with a ‘MUST’ score of 1 or more) require monthly re-screening and follow-up (previously all patients were expected to receive monthly screening), while patients at low-risk are now re-screened annually, unless there is a significant change in their health status. Secondly, a nutritional pathway including appropriate care planning actions to be taken depending on risk level and each specific case, including provision of malnutrition information resource sheets to medium and high-risk patients as a mandatory activity (previously these were not routinely provided to patients in these categories). New information resources were produced and guidance for when to use existing resources was specified within the new procedure. Thirdly, the electronic patient records system allows storage of screening information for malnutrition in one place (previously paper and electronic processes ran separately and in parallel). Prior to implementation of this electronic system, concerns had been raised regarding storage and availability of screening information to inform treatment and care planning. Within the new procedure, a form was generated within the electronic system to record screening results and enable care planning activity. Fourthly, the new procedure emphasised that community care staff at all roles and grades working with older people have responsibility for malnutrition screening and delivery of appropriate treatment. Introduction of the new procedure was provided through staff training delivered by a registered dietitian. 12 sessions were offered to enable as many staff as possible to attend a one-hour training session. Immediate effectiveness of training was assessed through pre-and-post training knowledge check questionnaires.


This study is informed by Normalization Process Theory (NPT), which identifies, characterises and explains mechanisms that motivate and shape implementation processes [25,26]. NPT focuses on three aspects of implementation processes: how components of complex interventions confer particular capabilities on their users; what the work of implementing, embedding and integrating these capabilities in everyday practice is, and how intervening mechanisms (coherence, cognitive participation, collective action and reflexive monitoring), motivate and shape implementation processes and explain their operation; and finally, how participants in implementation processes mobilise structural and cognitive resources as they invest in them [25]. NPT is now widely used to inform process evaluation research, a recent systematic review shows 130 reports of feasibility studies and process evaluations of controlled and uncontrolled interventions in open and closed systems, most of these published in the last five years [26].

NPT has been used in two previous studies focused on: development the role of the nurse as a link advisor for research and champion for nutrition in the neonatal intensive care unit [27]; and implementing nutrition guidelines for older people in residential care homes [12]. However, the present study is the first to apply this to implementation of procedures for screening and treatment of malnutrition in community settings. The theory can be used prospectively (i.e. to identify potential areas of importance with respect to embedding and implementation within a given topic

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area) and retrospectively (i.e. to analyse existing processes, practices, and technologies with respect to social and organisational activities relating to implementation and embedding) [28,29]. NPT does not provide a framework of causal prediction; rather, its intended use has been to help anticipate the trajectory of a new practice, technology, or process, with respect to success of implementation and embedding in routine practice (that is, given attention to activities in areas identified in the framework, whether implementation and embedding is more or less likely to be successful) [25].

The relationship between implementation of the new procedure and the process evaluation

Complex relationships often exist between those implementing service development in healthcare, and those evaluating these processes [30]. In some cases, both kinds of work are undertaken by the same people [11], while in others the process evaluation may be undertaken by those not involved in either initial development or implementation of interventions [31]. In both cases, findings from process evaluations commonly inform ongoing development of implementation strategies [26]. It is therefore necessary to define the relationship between these two kinds of work within the current project. Implementation and embedding (‘normalization’) of the new procedure for screening and treatment of malnutrition was the focus of this process evaluation. Development and implementation of the procedure was led by KS with input from AA and other colleagues within the implementation site (see Additional File 1). Process evaluation work was undertaken primarily by MB, JS, KW and CRM, with input from KS and AA relating to recruitment strategy. Findings from the process evaluation were provided to the procedure development and implementation team following completion of T1 data collection, to inform ongoing development.

Aims and objectives

The process evaluation was entitled: Implementing Nutrition Screening in Community Care for Older People (INSCCOPe). The aim of the study was (i) to undertake a process evaluation of implementation of the screening procedure and its associated training, and (ii) identify factors promoting or inhibiting embedding of nutritional screening in routine care. Outcomes relating to clinical effectiveness of the new procedure were assessed by the procedure development and implementation team and will be reported separately. Outcomes relating to processes affecting implementation and embedding are the focus of this process evaluation, and methods for investigation are now described.

Methods


Eligible staff were: community-based (e.g. Nurses, Occupational Therapists, Healthcare Support Workers, Physiotherapists, and Associate Practitioners in physical or mental healthcare); involved in screening and/or treatment activity relating to malnutrition; and expected to be in post for the duration of the study (12 months) either full or part-time. Those not involved in nutrition screening and treatment activity (e.g. team administrators, other support staff), and staff not expecting to be in post for the duration of the study were ineligible. The research team sought to recruit the maximum number of willing participants of all roles and grades, due to lack of available demographic data to support a quota sample.

Recruitment

Prior to in-person invitation by the researcher (MB), potential participants (n=89) were sent a Participant Information Sheet with contact details for the research team, circulated by team leads who received it via email. Potential participants were then approached at team meetings by the researcher (MB), at a time agreed with the team lead, where the study was introduced and participants’ questions answered. Participants were informed of their right to withdraw at any stage without negative consequences, and without giving a reason. Participants then completed an agreement form (indicating consent to use of survey and interview audio data by the study team), a participant data form, and the T0 NoMad instrument (paper-based).

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Study procedures

At T0, NoMad questionnaires were completed at point of recruitment. At T1, questionnaires were circulated via team leads. Data collection for phase one occurred at baseline (T0 – pre-implementation of procedure and training), and approximately 2-3 months following completion of training (T1). Each point involved completion of a 23-item questionnaire adapted from the NoMad instrument (a measure of normalization based on the NPT framework, see Table 1) [28,32], and a follow-up semi-structured telephone interview (completed by a sub-sample of participants). Rationale for the methods and study design are now described in accordance with Good Reporting of a Mixed Methods Study (GRAMMS) criteria [33] (see Figure 1).

[INSERT FIGURE 1]

NoMad questionnaire

NoMad provides a measure of NPT construct in terms of their constituent components, indicating degree of success in relation to specific aspects of implementation (see table 1). This facilitates comparison across time points and between sub-groups and provides a basis for exploring experiences of respondents in more detail through telephone interviews (described below). Each participant was given an envelope containing a questionnaire, which was completed and sealed before returning to the team lead (return envelopes did not contain identifiable information). At T0, participants completed and returned these directly to the researcher (MB). At T1, participants were informed by email/text message that questionnaires were available for completion; two weeks thereafter a reminder email/text message was sent, and completed questionnaires were then collected by a researcher (MB) after a further week (three-week interval accommodated staff annual leave).

NPT Construct Question (NPT component) NPT Construct Question (NPT component)Q1— When you screen and treat patients

for malnutrition, how familiar does it feel? Q12—I can easily integrate screening and treatment

for malnutrition into my existing work. (Interactional workability)

Q2— Do you feel that screening and treatment for malnutrition is currently a

normal part of your work?

Q13—Screening and treatment for malnutrition disrupts working relationships.


(questions not linked to specific

constructs)Q3— Do you feel that screening and

treatment for malnutrition will become a normal part of your work?

Q14—I have confidence in other people’s ability to screen and pro-vide treatment for malnutrition.


Q4—I can see how the new procedure for screening and treatment of malnutrition

differs from usual ways of working.(Differentiation)

Q15—Work is assigned to those with skills appropriate to screening and treatment for

malnutrition. (Skill set workability)

Q5—Staff in this organisation have a shared understanding of the purpose of

new procedure for screening and treatment of malnutrition. (Communal specification)

Q16—Sufficient training is provided to enable staff to implement screening and treatment for mal-

nutrition. (Skill set workability)

Q6—I understand how new procedure for screening and treatment of malnutrition

affects the nature of my own work.(Individual specification)

Q17—Sufficient resources are available to support screening and treatment for malnutrition.


Coherence ‘The sense-

making work that people do

individually and collectively

when they are faced with the

problem of operationalizing

some set of practices’. Q7—I can see the potential value of new

procedure for screening and treatment of malnutrition for my work

(Internalisation)

Collective action‘The

operational work that

people do to enact a set of

practices, whether these

represent a new technology or

complex healthcare

intervention.’

Q18—Management adequately supports screening and treatment for malnutrition.


Q8—There are key people who drive screening and treatment for malnutrition

forward and get others involved. (Initiation)

Q19—I am aware of reports about the effects of screening and treatment for malnutrition.

(Systematisation)

Cognitive participation

‘The relational work that

people do to build and sustain a

community of

Q9—I believe that participating in screening and treatment for malnutrition

is a legitimate part of my role. (Enrolment)


‘The appraisal work that

people do to assess and

understand the ways that a new

Q20—The staff agree that screening and treatment for malnutrition is worthwhile.

(Communal appraisal)

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Q10—I’m open to working with colleagues in new ways to screen and treat for

malnutrition.(Legitimation)

Q21—I value the effects that screening and treatment for malnutrition has had on my work.

(Individual appraisal)

practice around a new

technology or complex

intervention.’Q11—I will continue to support screening

and treatment for malnutrition. (Activation)

Q22—Feedback about screening and treatment for malnutrition can be used to improve it in the

future.(Reconfiguration)

set of practices affect them and others around

them.’

Q23—I can modify how I work with tools and/or procedures for screening and treatment for

malnutrition.(Reconfiguration)

Table 1 - NoMad questions grouped by relationship to NPT constructs as statements for evaluation (Q1 response variables: Still feels very new, 0-10, Feels completely familiar. Q2 & Q3 response variables: Not at all, 0 – Somewhat, 5 – Completely, 10. Q4-23 response variables: Strongly

agree, 1 – 5, Strongly disagree; Not relevant to my role – 6; Not relevant at this stage – 7; Not relevant to screening and treatment for malnutrition – 8.) (Questions 4-7 mapped to the construct ‘Coherence’ and were not included at T0; Questions 1-3 explore general feelings of

familiarity and normalization, and are not reported in this article)[34].


Following T0 NoMad completion, a sub-sample of participants were invited to participate in a follow-up semi-structured telephone interview. In addition to exploring NoMad responses for each of the NPT components, qualitative interviews offered several benefits. Firstly, identification of factors not visible through NoMad (e.g. how implementation may affect local contexts, for example, within different teams [35]), allowing for iterative development of additional questions (to be added after the items adapted from NoMad) at future observation points (i.e. interviews at T0 generated questions which were added to the questionnaire at T1, which are reported in the findings section). Secondly, interviews offered opportunities to elaborate on responses to NoMad. This was useful for exploring congruence between beliefs/attitudes and actions/experiences. Given that NPT focuses primarily on individual and collective action (that is, the work that people do as individuals and within collectives to enact and embed a new set of practices), semi-structured interviewing offered an opportunity to ensure that this was explored effectively.



Questionnaire responses were collected via paper instruments, and audio data from interviews were collected using digital dictaphones; both were stored electronically and securely on Bournemouth University (BU) servers, in password protected folders to which only the project team had access. For transcription, files were sent using a secure drop off-service, to a transcription service with which the study team had a confidentiality and non-disclosure agreement.

Data Analysis

Results from NoMad were analysed using descriptive and inferential (Wilcoxon rank-sum test for between group differences in response, Wilcoxon signed-rank test for pre-post differences within groups) statistics using SPSS v.23 (threshold for statistical significance was defined at the 0.05 level) [36]. NoMad results contain no domain-specific scores, and only answers to individual questions were calculated. Mean scores with accompanying standard deviations are here reported for Q4-23. The decision to report NoMad results as means rather than medians was taken for two reasons. Firstly, the mean value gives a more precise indication of the direction of response (e.g. for a distribution of scores where mean = 2.5 and median = 2, the former provides meaningful additional detail indicating direction closer to neutral response than is visible from the median score). Secondly, reporting to one decimal place provides a more detailed basis for the colour gradient used to aid interpretation of results tables (that is, intensity of colour is linked to tendency towards the response, i.e. strongly agree (blue), neither agree nor disagree (white), strongly disagree (yellow)). Neutral colours were chosen due to the mixed direction of NoMad questions (i.e. agreement with

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statements does not always indicate desirable response). Further exploration of methodological literature was undertaken to confirm appropriateness of this approach for analysis of likert-type data [37,38]. Qualitative data were analysed through directed content analysis informed by NPT, using a constant comparative approach, performed using NVivo v11 software [39,40]. Nvivo allows users to attach labels (or ‘codes’) to text, audio, video or image data, and facilitates data management through which directed content analysis can be conducted by a competent user. In this study, a list of codes was established based on NPT (see Table 1) and used to identify relevant portions of audio and transcription data from interviews.

Interviews were performed by one researcher (MB), and audio data sent to an external transcription service immediately upon completion (all interviews were returned within 14 days). Upon receipt of transcripts, data integrity checks were performed by one researcher (MB), which involved reading the transcript along with audio to ensure congruence between the two. This also served as a familiarisation procedure prior to initial directed content analysis, where initial themes relating to NPT components and linked questions within the NoMad survey were identified by one researcher (MB). Emerging content of these themes was then discussed at group meetings with all co-authors (MB, JM, KW, KS, CRM), with the aim of agreeing relevance of material to individual codes (e.g. whether an interview extract applied to a specific NPT construct, and/or whether it is relevant to other constructs). Following group discussion, amendments were made as necessary. This process repeated across three team meetings as interviews were completed (following the constant comparative approach), with themes agreed at the final meeting following completion of all interviews (a flowchart detailing this process is given in Figure 2).

[INSERT FIGURE 2]

Study sample

Staff (n=89) were approached at T0, of which 73 consented to participate. The recruitment rate at T0 was 79%. The recruited sample T0 comprised: 42 physical health (community) nurses, seven mental health nurses, 16 Healthcare Support Workers, four Occupational Therapists, one Physiotherapist, and one other practitioner of Consultant-level1. Further details of the study sample are given in table 2. A sub-sample of 16 participants also completed semi-structured telephone interviews following completion of NoMad at T0 (see table 2; for a full description of approach process for interview, see Additional File 2). At T1, 32 participants completed follow-up NoMad questionnaires (attrition rate = 56%), 13 of which participated in the training while 19 did not. Of the 41 participants who did not complete T1, 12 participants (16% of the T0 recruited sample) were identified as having left their teams, including four team leads representing a third of those included in the study (n=12). Reasons for non-completion at T1 by the remaining 29 participants were not given. NoMad results reported here reflect only those who completed at both T0 and T1 (n=32 participants).

RoleNoMad T0 (n)

Interview T0 (n)

NoMad T1 (n)

Mental Health Nurse (MHN) 7 2 1Physical Health (Community) Nurse (PHN) 42 13 22Occupational Therapist (OT) 4 1 4Healthcare Support Worker (HSW) 16 0 4Physiotherapist (PT) 1 0 1Associate Practitioner (AP) 2 0 0Other (consultant-grade practitioner) (Oth) 1 0 0Total participants (all roles/bands) 73 16 32

Table 2 - Demographic characteristics of study sample.


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There was no patient or public involvement in the design or conduct of this study, which was a process evaluation of practice change and involved only staff.

Results

Baseline (T0)

Staff already support nutrition screening and treatment activity, see its value, and do not view it as disruptive to other work.

T0 NoMad responses indicate strong support for, and value placed upon, nutrition screening and treatment activity. 94% (n=30) of total participants (n=32) strongly/agreed that staff see this activity as worthwhile (Q20, mean score = 2.0, see Table 3). 97% (n=31) strongly/agreed that screening and treatment of malnutrition was a legitimate part of their role (Q9, mean score = 1.6, see table 4). 81% (n=26) strongly/agreed that they valued the effect that screening and treatment for malnutrition has had on their work (Q21, mean score = 2.0, table 3). 97% (n=31) strongly/agreed that they were open to working with colleagues in new ways to support this work (Q10, mean score = 1.4, Table 4). 97% (n=31) also strongly/agreed that they would continue to support this work (Q11, mean score = 1.4, Table 4). This was reflected in responses of 14 participants to telephone interview (T1), all of which were compatible with openness to introducing new ways of working, though three also raised concerns with respect to the time/resource implications of implementation and embedding (see box 1).

Existing arrangements for nutrition screening and treatment could easily be integrated into their overall body of work, and were not seen to disrupt working relationships. 78% (n=25) of total respondents strongly/agreed that existing nutrition screening and treatment activity could easily be integrated into their overall body of work (Q12, mean score = 2.0, see table 5). 79% strongly/disagreed that screening and treatment of malnutrition disrupts working relationships (Q13, mean score = 1.9, see table 5). Six respondents from interviews described discussion of screening and treatment of malnutrition as a common feature of team meetings (see box 1).

Concerns exist as to wider organisational support for nutrition screening and treatment by community teams, as well as access to dietetic support.

Uncertainty or doubt was expressed by many participants regarding logistical and organisational support for screening and treatment related activity. 59% of respondents were uncertain (44%) or strongly/disagreed (15%) with the statement ‘[t]here are key people who drive screening and treatment for malnutrition forward and get others involved’ (Q8, mean score = 2.9, see table 4). Of the 16 interview participants asked to about their response, 13 could not identify a key person. Of these 13, six highlighted absence of a ‘key’ or ‘link’ member of staff to provide advice, support, and best practice updates (identified as being in place in other areas of practice, e.g. infection control – see box 1).

Sixteen interview participants were asked about dietetic referral in previous practice. Of these, two participants confirmed that they had been able to refer to a dietitian, the remainder (n=13) had not referred in their current role. Of the 13 who had not referred: three stated that this should be possible in principle through the GP; six further participants were unsure if or how this would be possible. Of total (n=16) respondents, five stated explicitly that access to dietetic services in the community needed improvement (see box 1).

Box 1 – interview findings and illustrative quotesFinding Interview quote

Openness to introducing new ways of working (14 respondents); concerns regarding time/resource implications of implementation and embedding (three respondents).

[T]he thing that does concern me is the time to imbed the new practice because there is so much to take in, so much change, there’s so many boxes to tick sometimes; trying to imbed the practice is really challenging when it’s moving so fast and the work load is going through the roof; I think taking the time with the patient to be able to completely embed it is a challenge but I don’t think, I think as a team, I’ve only been here a short while,

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but as a team they seem really keen to improve and implement anything that’s new and that’s better. (P00905, PHN)

Discussion of screening and treatment of malnutrition as a common feature of team meetings (six respondents)

No it’s never disruptive and it’s never caused an issue for anyone, that’s why I disagreed, we are quite a good stable team that get on well together and support each other when we are doing the work. (P00611, PHN)

Absence of a ‘key’ or ‘link’ member of staff to provide advice, support, and best practice updates (six respondents)

It would be a preference definitely to implement some kind of key worker strategy which I know they do try and do but quite often falls you know dead on the ground so, I think yeah with regards to that yes it definitely would be a more effective way of working if that was possible so that would be something good to be implemented I guess. (P00614, PHN)

Access to dietetic services in the community in need of improvement (five respondents)

I mean my only concern is, my understanding is there is not many community dietitians you know so it’s just sort of getting advice, obviously we will refer to the GP but it’s not often we get input from dietitians themselves. We’ve sort of got basic guidelines on how to go through, so to have some more input from dietitians would be really good, really useful. (P00210, PHN)

56% (n=18) were uncertain or strongly/disagreed with the statement ‘Work is assigned to those with skills appropriate to screening and treatment for malnutrition’ (Q15, mean score = 2.8, see table 5). 62% (n=12) strongly/disagreed or were uncertain in relation to the statement ‘Sufficient training is provided to enable staff to implement screening and treatment for malnutrition’ (Q16, mean score = 3.1, see table 5). 59% were uncertain (40%) or strongly/disagreed (19%) that ‘Sufficient resources are available to support screening and treatment for malnutrition’ (Q17, mean score = 2.9, table 5). 66% (n=21) were uncertain or strongly/disagreed that ‘Management adequately supports screening and treatment for malnutrition’ (Q18, mean score = 2.5, table 5).


Component

Systematisation Communal appraisal



Q19-T0

Q19-T1

Q20-T0

Q20-T1

Q21-T0

Q21-T1

Q22-T0

Q22-T1

Q23-T0

Q23-T1

3.2 2.8 1.8 1.8 2.0 1.9 2.0 2.0 1.8 2.0

1.01 0.93 0.60 0.69 0.91 0.76 1.22 0.41 0.83 0.41



3.2 3.0 2.0 1.9 2.0 2.2 1.7 2.0 2.2 2.1

0.98 1.11 0.33 0.42 1.37 1.06 0.59 0.69 0.71 0.94



3.2 2.9 1.9 1.9 2.0 2.1 1.8 2.0 2.0 2.1

0.97 1.03 0.47 0.54 1.19 0.94 0.91 0.58 0.78 0.76All participants (n=32)


Table 3 - NoMad T0-T1 responses for 'Reflexive Monitoring' score colour intensity tends toward: blue (strongly agree – 1); white (neither agree nor disagree – 3); yellow - strongly disagree – 5)..

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Component



Q8-T0

Q8-T1

Q9-T0

Q9-T1

Q10-T0

Q10-T1

Q11-T0 Q11-T1

2.9 2.7 1.3 1.5 1.2 1.5 1.2 1.5

1.44 0.85 0.48 0.52 0.44 0.66 0.44 0.52



2.9 2.7 1.7 1.7 1.5 1.6 1.5 1.6

0.94 0.93 0.73 0.73 0.61 0.50 0.61 0.60Non-training participants (n=19)


2.9 2.7 1.6 1.7 1.4 1.6 1.4 1.6

1.15 0.89 0.67 0.65 0.56 0.56 0.56 0.56



Table 4 - NoMad T0-T1 scores for 'Cognitive Participation' score colour intensity tends toward: blue (strongly agree – 1); white (neither agree nor disagree – 3); yellow - strongly disagree – 5).


Component Interactional Workability Relational Integration Skill set Workability Contextual Integration


Q12-T0

Q12-T1

Q13-T0

Q13-T1

Q14-T0

Q14-T1

Q15-T0

Q15-T1

Q16-T0

Q16-T1

Q17-T0

Q17-T1

Q18-T0

Q18-T1

1.9 1.8 1.8 2.1 2.6 2.5 2.8 2.9 2.9 2.7 2.9 2.9 2.6 2.4

0.64 0.44 0.73 0.76 0.77 0.52 0.90 0.95 1.12 0.85 1.24 0.86 1.08 0.65



2.1 2.3 2.1 2.4 2.2 2.5 2.7 2.3 3.2 2.9 2.8 3.1 2.5 2.8

0.81 1.00 0.78 0.69 0.73 0.62 1.00 1.03 1.07 1.39 0.69 1.20 0.84 1.08



2.0 2.1 1.9 2.3 2.4 2.5 2.8 2.6 3.1 2.8 2.9 3.0 2.5 2.6

0.74 0.86 0.76 0.73 0.76 0.57 0.95 1.03 1.08 1.19 0.92 1.06 0.93 0.94



Table 5 - NoMad T0-T1 responses for 'Collective Action' score colour intensity tends toward: blue (strongly agree – 1); white (neither agree nor disagree – 3); yellow - strongly disagree – 5).

Training outcomes

126 staff members within the implementation area completed training, representing 56% of full-time staff (n=223) at initiation of training (23% (n=30) of those completing were INSCCOPe participants). 40% (n=29) of INSCCOPe participants (n=73) completed training; 60% did not (see Additional File 3, tables 1 & 2). Pre-post knowledge check scores indicated that training had been effective in raising average knowledge check score for all participants from

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54% immediately prior to training to 68% for immediately post-training (see Additional File 3, table 3). All role groups saw an increase in average scores, the largest (23%) for Healthcare Support Workers, while the smallest (7%) was for Occupational Therapists and Associate Practitioners (see Additional File 3, table 3).

T1 Results


Four questions (Q4-7) mapping to ‘Coherence’ and its components were added to NoMad instrument at T1 (see table 6). For all participants completing T1, 46% (n=15) disagreed or were uncertain in response to the statement (Q4): ‘I can see how the new procedure for screening and treatment of malnutrition differs from usual ways of working’ (mean score = 2.7, see table 6). The same responses represented 38% (n=5) of training participants (mean score = 2.5), and 52% (n=10) of non-training participants (mean score = 2.7, see table 6). This indicates that for those who both did and did not complete the training, differentiation of the new procedure introduced through training for existing practice requires further attention.

In the T1 all participant group, 41% (n=13) disagreed or were uncertain regarding the statement (Q5): ‘Staff in this organisation have a shared understanding of the purpose of new procedure for screening and treatment of malnutrition’ (mean score = 2.7, see table 6). Responses of this type represented 38% (n=5) in the training participant group (mean score = 2.5, and 42% (n=9) of the non-training group (mean score = 2.9, see table 6). Results indicate a large proportion in both sub-groups for whom shared understanding (Communal Specification) of the procedure remains vague.

25% (n=8) of the all participant group were uncertain of disagreed with the statement (Q6): ‘I understand how the new procedure for screening and treatment of malnutrition affects the nature of my own work’ (mean score = 2.4, see table 6). Respondents providing such answers represented only one response in the training participant subgroup (mean score = 2.0), with seven such responses representing 37% of training non-training group (mean score = 2.7, see table 6). Here, results indicate a potential difference in how well participants in respective sub-groups understood the new procedure in terms of their own practice (Individual Specification), though difference between observations did not reach statistical significance (p=0.06, see Additional File 4, table 1). Comparing this with results from Q5, results indicate a greater effect of training on understanding implications for individual working compared with team working.

75% (n=24) of all participants strongly/agreed with the statement (Q7): ‘I can see the potential value of the new procedure for screening and treatment of malnutrition for my work’ (mean score = 2.2, see table 6). 92% (n=12) of the training participant group (mean score = 1.7), and 37% (n=7) of the non-training participant group (mean score = 2.6, see table 6), gave such responses. This difference between sub-groups was significant (p=0.01, see Additional File 4, table 1), and indicates a potential impact of training on value placed on the new procedure.

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Construct Coherence

Component

Differentiation Communal specification

Individual specification Internalisation

Question / observation point Q4 Q5 Q6 Q7

2.5 2.5 2.0 1.7

0.66 0.66 0.41 0.49Training Participants (n=13)

Question / component mean score, SD, range.

2 - 4 2 - 4 1 - 3 1 - 2

2.7 2.9 2.7 2.6

1.59 1.50 1.63 1.59Non-training participants (n=19)


2.6 2.7 2.4 2.2

1.31 1.23 1.33 1.37All participants (n=32)


Table 6 - NoMad T1 mean scores for 'Coherence' (score colour intensity tends toward: blue (strongly agree – 1); white (neither agree nor disagree – 3); yellow - strongly disagree – 5).


Wilcoxon signed-rank tests were used to investigate differences between responses to Q8-23 for all participants (n=32), training participants (n=13), and non-training participants (n=19) respectively. For all participants, only Q13 saw a significant change from T0 (mean score = 1.9) to T1 (mean score – 2.3, see table 5), which involved a shift towards uncertainty or disagreement with the statement ‘Screening and treatment for malnutrition disrupts working relationships’ (T = 32.00, r = -0.29, p = 0.02; see Additional File 4, table 2). This indicates small-to-moderate effect on responses during the period in which the training took place. No other significant changes were observed (see Additional File 4, tables 2-4).


A significant difference was observed for Q7-T1 (W = 124, r = -0.43, p = 0.01). No significant differences were found for any other questions at either time points (see Additional File 4, tables 1; 5-7).

Dietetic questions

Interview responses at T0 indicated access to dietetic services was a significant concern for many participants. Additional questions regarding availability and adequacy of dietetic services were appended to questionnaires at T1. Overall, results show that 30-90% of all participants had concerns about or were uncertain in relation to, all aspects of dietetic service explored by question statements (see table 7). Proportions of responses were similar for both training and non-training participants in most areas (A1-2, A4-6), and Wilcoxon rank-sum test results between sub-group response to each question showed no statistically significant differences (see Additional File 4, table 8). These results echo those indicated by telephone interviews, that many participants appear to have doubts regarding adequacy of dietetic services in relation to procedure, support, and resource allocation.

Training group % strongly/agree% strongly/disagree or uncertain

A1 - I know where to get specialist support and advice on treatment for malnutrition if I need it

Non-training participants (n=19) 0.47 0.47

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Training Participants (n=13) 0.54 0.38


A2 - I have sufficient access to patient information resources relating to malnutrition


A3 - Patient information resources relating to malnutrition are useful and effective


A4 - My team has access to a dietician if a patient requires it


A5 - I know the procedure for referring a patient to a dietician if required


A6 - Availability of dieticians is sufficient to meet the needs of our patients


A7 - Current state of malnutrition screening is sufficient to meet the needs of our patients


A8 - Current arrangements for treatment of malnutrition are sufficient to meet the needs of

our patientsAll (n=32) 0.34 0.59


Discussion

The aim of the INSCCOPe study was to undertake a process evaluation of implementation of the screening procedure and its associated training, and identify factors promoting or inhibiting embedding of nutritional screening in routine care. Study findings indicate that staff value nutrition screening and treatment activity and are open to new ways of working (indicating favourable conditions relating to the Internalisation and Relational integration components of NPT). In addition, training is effective in improving knowledge of the new procedure. However, participant responses highlighted lack of institutional support for nutrition screening (Contextual integration), as well as absence of a ‘key’ person to support and drive forward service development (Initiation), indicating that significant barriers to implementation remain. Implications of these findings and recommendations for addressing barriers are discussed, in addition to wider implications for implementation of service developments in community settings.

NoMad responses mapping to Cognitive participation indicate conditions conducive to building and sustaining a community of practice around nutrition screening and treatment. Findings (T0 and T1) indicate that staff view such work as a legitimate part of their role (Q9, Enrolment), are open to working with colleagues in new ways in relation to it (Q10, Legitimation), and will continue to support further development in this area (Q11, Activation). In addition, responses (both T0 and T1) indicate that both baseline arrangements for nutrition screening and treatment, as well as the new procedure, and can be easily integrated into existing work (Q12, Interactional workability). Between T0-T1, there was a shift in average scores towards ‘neither agree nor disagree’ and away from ‘strongly agree’ in relation to perceptions of disruptiveness of nutrition screening and treatment for working relationships (Q13, Relational

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integration). This shift was significant for non-training participants (p=0.02), and was observed but did not reach statistical significance for training participants (p=0.07), indicating that implementation may have had some effect on staff perceptions of effect of nutrition screening and treatment on working relationships. However, mean scores for both groups at T1 (2.1 for training, 2.4 for non-training) indicate that many participants still see this activity as disruptive to working relationships.

Results indicate several challenges to current implementation design: firstly, non-completion of training (44% of total staff (n=223) did not complete). Concerns regarding time and resource constraints for nutrition screening and treatment activity (see Q17, table 5; and Box 1) were indicated in both NoMad (T0 & T1) and interview responses. Furthermore, study team experiences in recruitment to telephone interview indicated a number of participants who declined to participate, or agreed and then were forced to withdraw, in both cases due to changes in workload (see Additional File 2). These observations indicate changeable demands that characterise community team working environments, and affect attendance at in-person training sessions that are non-mandatory. Secondly, working environments also include significant attrition of key staff; 12 participants left post between T0-T1, of which four were team leads. This risks reduction in numbers trained in the new procedure, as well as key people able to monitor compliance and provide appropriate support (i.e. team leads). Thirdly, effect of staff attrition on overall procedure compliance may be compounded by lack of monitoring of training (i.e. while pre-post knowledge checks were taken, no procedures for monitoring ongoing compliance currently exist). Fourthly, concerns about institutional support for nutrition screening and treatment activity (as indicated through interviews and responses to dietetic survey questions) persisted after introduction of the procedure through training. Further attention to Contextual integration processes is necessary, specifically support provided by management for nutrition screening and treatment activity, and how this is made available to community teams.

In response, we propose two main changes to implementation design. Firstly, appointment of a key person for the new procedure, with specialist nutritional expertise and remit to: monitor training completion rates and procedure compliance; disseminate practice updates; provide advice and support for nutrition screening and treatment. This addresses a suggestion by several interview participants, who cited benefits of this role in other areas such as wound care, as well as a gap indicated by uncertain survey responses (NoMad Q8 – see table 4). The value of such a role in implementing new nutritional care procedures has also been demonstrated in secondary care settings in helping staff understand new nutritional procedures (coherence) and work through changes to their existing practices and relationships (cognitive participation) [11,35]. Updates on compliance, training, and resource needs would be provided to senior managers at regular intervals, moving from a single-point intervention at the level of HCPs through training, to one that links monitoring and resource allocation directly to those with responsibility to ensure successful implementation of the new procedure (thus creating an organisational feedback loop to promote sustainability and embedding in management practice). Secondly, training design needs to be adaptable to cope with changeable working patterns, organisational and resource support challenges, and staff turnover that restricted training participation and left those who did complete training vulnerable to attrition. One option might be to make training mandatory for all staff; however, the procedure development and delivery team indicated that this would not be possible currently. We therefore recommend that training is delivered through existing organisational e-learning systems, rather than in person. This change is intended to deliver several improvements. Firstly, widening of scope for participation in changeable working conditions, thereby increasing resistance of implementation to organisation turbulence. Secondly, connecting training in the new procedure with existing nutritional e-learning resources on screening of malnutrition (see Additional File 1, Section 6.1) thereby increasing coherence (specifically differentiation, individual and communal specification) of the new procedure in terms of its relation to existing nutritional working practices. Thirdly, location of both new and existing training components within e-learning offers the potential to reduce costs associated both with training provision, and resources needed for monitoring and support of procedure training and compliance.

Implications and future research directions

While barriers here identified relate to specific processes within the study field, they are relevant to implementation in general such as: enabling participation (enrolment); responding to workforce turbulence (communal appraisal; reconfiguration); monitoring of compliance (systemisation); ensuring adequate provision of resource (contextual

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integration). These components fall within the ‘Collective Action’ and ‘Reflexive Monitoring’ domains of NPT, indicating importance these domains for successful implementation. These observations echo those of Johnson & May’s (2015) theory-led overview of systematic reviews of interventions to promote professional practice change, insofar as positive attitudes of staff were outweighed by lack of engagement with collective action [41]. The present study highlights importance of key people as ‘pumps’ to drive and sustain organisational behaviour loops, adding to extant literature emphasising importance of individuals with resource, authority, and legitimacy (both personal and institutional) to drive forward new developments in healthcare [11,27,35,42,43]. In addition, it indicates importance of designing intervention objects that are resilient to organisational turbulence. Many healthcare interventions take place in complex settings wherein emergent and contextual factors can modify the conditions of implementation. Providing organisational ‘closure’ through monitoring and support of a key person is important in mitigating these effects; however, objects of interventions (e.g. procedures, training seminars, technologies etc.) are important in this process. In the INSCCOPe study, the proposed move from in-person to online delivery of the training was an example of how an intervention object may be redesigned in response to turbulence encountered within the field of implementation.

These findings are interdependent; appropriate design choices for objects can only be expected to have effects if participants are directed to use them in some way, which typically involves organisational work of key people. In their evaluation of an intervention to support carers of stroke survivors, Clarke et al. (2013) observed that participants unable to attend training did not make use of replacement resources (a DVD) because they were not directed to do so [35]. The observations from the present study add to extant literature indicating importance of contextual factors (i.e. turbulence) as well as creating practical (rather than simply attitudinal) conditions for professional behaviour change, as key determinants in success (or failure) of service development initiatives.

Turning specifically to implementation in community settings, further empirical study of involvement of key decision makers at higher levels of governance is an important focus. In this study, a majority (66%) of NoMad respondents at T0 strongly/disagreed with the statement ‘Management adequately supports screening and treatment for malnutrition’ (Q18, see table 5), a finding which persisted at T1. Previous work in other settings by Bamford et al. (2012) has also highlighted importance of senior management support for implementation of nutritional care interventions within residential care homes [12]. While studies such as INSCCOPe contribute to understanding of implementation for staff and teams, it is also necessary to explore further how NPT mechanisms operate among those funding and overseeing services at a strategic level.


Considerable work was necessary to recruit and conduct interviews with participants (see Additional File 2), and to obtain NoMad responses at T1 (where questionnaires were left with team leads for circulation and completion, instead of completing in the presence of a researcher as occurred during recruitment at T0). 116 telephone calls were made in order to secure 16 interviews, with seven participants requiring one or more rearrangements of their scheduled time, and four cancelling after initial agreement. In almost all cases where contact was made, inability to participate or need for rescheduling was attributed to volume and changeability of workload. We recommend that future studies involving community teams be aware of this as a necessary condition of research in this field, and that questionnaire instruments are completed during in-person visits by a researcher where possible.

Limitations of the study

The study protocol stated that a quota sample would be used, derived from 'data on composition of target population by role (e.g. community nurse, physiotherapist) and NHS Agenda for Change (AfC) band (the current grading system for staff seniority within in the target population) [which would be] provided by the trust' [44]. Unfortunately, these data were not made available to the INSCCOPe team, and as such we adopted a strategy of maximum recruitment within each team. This limited our reporting of relationships between sample and target populations with respect to these characteristics. While 72 participants were originally recruited at T0, 32 went on to complete NoMad at T1. While 12 participants were identified as having left their teams (16% of the T0 sample), reasons for non-completion were unavailable for 29 further participants. This reduction indicates vulnerability of prospective studies in complex healthcare environments to participant attrition, a factor in which may have been that questionnaires at T1 were

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cascaded to participants at team meetings via team leads, whereas at T0 they were completed at the point of recruitment in the presence of a researcher. For data collection at T2, the INSCCOPe team will attend team meetings in person to administer instruments, to avoid potential risks of further attrition (e.g. questionnaires getting lost due to changeable working conditions of team leads). Both survey and interview contained questions relying on participant recollection of events over varying periods of time, and as such recall and response bias may be present. Finally, there are indications of differences between training and non-training participants in relation to implementation indicators, as well as differences between T0-T1, that did not reach statistical significance but may warrant further exploration. The aim of this article was to present results from phase one of implementation, to identify factors promoting or inhibiting its implementation and indicate how these have informed recommendations for further development. Further discussion is therefore beyond the scope of the current paper; however, we intend to explore these issues further in a future article reporting results from phase two of implementation, wherein we can explore them in relation to the effect of changes recommended here.

Conclusion

We have presented a prospective process evaluation, exploring initial implementation of a new procedure for screening and treatment of malnutrition in community settings. Guided by Normalization Process Theory, we have explored factors promoting implementation and embedding of the new procedure (i.e. staff understanding of the effectiveness, legitimacy, and appropriateness of the intervention). In addition, we have highlighted aspects of the implementation field presenting challenges to implementation (i.e. non-completion of training, staff attrition, lack of ongoing monitoring for procedure compliance, concerns around institutional support for nutrition screening and treatment activity). In so doing, we have highlighted some generic aspects of implementation relevant to service development in community settings and proposed two specific areas of attention for those designing such interventions. These findings add to the wider knowledge base on implementation and embedding by supporting and extending observations regarding the importance of Collective Action and Reflexive Monitoring mechanisms.

Declarations


Ethical approval for the study has been granted through institutional ethical review (Bournemouth University); NHS Heath Research Authority approval (IRAS ID – 223214) was granted on 05/04/2017. NHS Research Ethics committee approval was not required for this study, as it involves only staff.


Not applicable.



Not applicable.

Competing interests


Funding



JM, KW, and KS devised the project (for which CRM and AA also provided advice). JM obtained funding at the host institution, Bournemouth University. JM managed the study as chief investigator. MB was primarily responsible for study design, protocol, data collection and analysis with input from JM, KW, KS, AA and CRM. All authors contributed significant revisions to drafts of the manuscript, and have read and approved the final manuscript.

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Acknowledgements

The study team would like to acknowledge the support of the Burdett Trust for Nursing, and of staff within Southern Health NHS Foundation Trust for their help and support in the development of this study.

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Figure legends



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Additional File 1

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Additional File 1

Version Control

Change Record

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CONTENTS

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Additional File 1















risk.















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Store.



possible.
















normal?







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2 Care Pathway










date.















• Poor appetite







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Additional File 1








sheet.














need.








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compliance.






4.3 Dementia














5. Hydration



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services.




this is a concern.




them.





monitoring.

6. Training









Change’ (2006)




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Additional File 1







MUST Score 0

Low Risk















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approach = 73








initial email = 9

Agreed initial

date for

interview = 4


email (passed to


Declined

interview

participation = 1

Email address

invalid (passed

to telephone

approach) = 12

No reply to

initial email

(passed to

telephone

approach) =

42

Stage 1 T0

interview

approach (email)



approach = 58



16


number provided = 6





by telephone = 36




= 3



reached cut-off)



Completed on date


Followed up after


interview = 7




interview)

Interview

rearranged and


completed = 16



2.2; range = 1-6)

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tables.

Role













Unspecified 15 1 0 0.00 0.00 1.00




Category Team





Urban ICT (n=28)

1 (n=4) 4 1.00 0 0.00

4 (n=5) 5 1.00 0 0.00

6 (n=4) 3 0.75 1 0.25

8 (n=4) 0 0.00 4 1.00

9 (n=5) 1 0.20 4 0.80

14 (n=6) 0 0.00 6 1.00

Total 13 0.46 15 0.54

Rural ICT (n=27)

2 (n=6) 6 1.00 0 0.00

5 (n=10) 1 0.10 9 0.90

10 (n=4) 0 0.00 4 1.00

11 (n=7) 2 0.29 5 0.71

Total 9 0.33 18 0.67

OPMH (n=11)

3 (n=8) 5 0.63 3 0.38

7 (n=3) 2 0.67 1 0.33

Total 7 0.64 4 0.36



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Pre-score (mean)


Post-score (mean)








Student 3 3 0.39 3 0.58 0.19

Unspecified 14 12 0.59 14 0.76 0.15

Total 111 102 0.54 108 0.68 0.15


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results Coherence


W. 167.5 169 156.5 124

r. -0.27 -0.22 -0.33 -0.43

Z -1.54 -1.22 -1.89 -2.45

p. 0.12 0.22 0.06 0.01


NPT Construct Cognitive Participation



Q11T0-Q11T1


T. 22.50 8.00 0.00 0.00

r. -0.11 -0.22 -0.32 -0.39

Z -0.54 -1.13 -1.63 -2.00

p. 0.59 0.26 0.10 0.05


training (n=19)

T. 22.00 10.50 7.00 7.00

r. -0.09 0.00 -0.13 -0.13

Z -0.58 0.00 -0.82 -0.82

p. 0.56 1.00 0.41 0.41


T. 84.50 35.00 9.00 11.00

r. -0.10 -0.10 -0.22 -0.24

Z -0.81 -0.83 -1.73 -1.90

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p. 0.42 0.41 0.08 0.06



NPT Component



Q15T0-Q15T1

Q16T0-Q16T1

Q17T0-Q17T1

Q18T0-Q18T1


T. 7.00 9.00 7.00 6.00 9.50 6.50 6.00

r. -0.16 -0.28 -0.16 -0.09 -0.16 -0.05 -0.14

Z -0.82 -1.41 -0.82 -0.45 -0.79 -0.27 -0.71

p. 0.41 0.16 0.41 0.66 0.43 0.79 0.48


training (n=19)

T. 13.50 8.00 24.00 26.50 35.50 40.00 26.00

r. -0.19 -0.29 -0.21 -0.22 -0.12 -0.13 -0.17

Z -1.16 -1.81 -1.29 -1.37 -0.71 -0.81 -1.07

p. 0.25 0.07 0.20 0.17 0.48 0.42 0.28


T. 52.50 32.00 72.00 61.00 79.50 75.00 66.00

r. -0.06 -0.29 -0.08 -0.14 -0.12 -0.10 -0.07

Z -0.47 -2.30 -0.66 -1.11 -0.97 -0.82 -0.53

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p. 0.64 0.02 0.51 0.27 0.33 0.41 0.60




Communal appraisal



Q22T0-Q22T1

Q23T0-Q23T1


T. 12.00 12.00 16.00 17.50 8.00

r. -0.25 -0.07 -0.06 -0.01 -0.22

Z -1.28 -0.38 -0.30 -0.07 -1.13

p. 0.20 0.71 0.76 0.94 0.26


training (n=19)

T. 22.00 0.00 8.50 0.00 18.50

r. -0.17 -0.16 -0.15 -0.34 -0.08

Z -1.07 -1.00 -0.95 -2.12 -0.49

p. 0.29 0.32 0.34 0.03 0.62


T. 65.00 18.00 49.50 29.50 65.00

r. -0.20 0.00 -0.08 -0.15 -0.02

Z -1.56 0.00 -0.63 -1.18 -0.17

p. 0.12 1.00 0.53 0.24 0.87


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W. 210 309 172.5 199.5 183 199.5 183 206

r. -0.03 -0.03 -0.32 -0.12 -0.25 -0.12 -0.25 -0.07

Z -0.18 -0.18 -1.83 -0.66 -1.43 -0.66 -1.43 -0.37

p. 0.86 0.85 0.07 0.51 0.15 0.51 0.15 0.71


Collective Action


W. 201.00 177.00 290.00 281.50 256.00 207.00 295.50 247.00 191.50 206.50 296.50 203.50 298.00 193.50

r.

Z -0.58 -1.60 -0.99 -1.50 -1.39 -0.05 -0.73 -1.75 -0.44 -0.33 -0.32 -0.44 -0.26 -0.87

p. 0.56 0.11 0.32 0.13 0.16 0.96 0.47 0.08 0.66 0.74 0.75 0.66 0.79 0.39




W. 311.00 199.50 187.50 196.50 205.50 193.50 279.50 288.00 177.00 213.50

r. -0.02 -0.11 -0.25 -0.10 -0.07 -0.11 -0.07 0.00 -0.28 -0.01

Z -0.10 -0.62 -1.44 -0.58 -0.38 -0.62 -0.38 0.00 -1.56 -0.04

p. 0.92 0.54 0.15 0.56 0.71 0.53 0.70 1.00 0.12 0.96


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A1 A2 A3 A4 A5 A6 A7 A8

W. 184.00 182.50 178.50 202.50 208.50 210.00 165.00 190.00

r. -0.14 -0.19 -0.19 -0.04 0.00 -0.01 -0.29 -0.09

Z -0.77 -1.10 -1.05 -0.23 -0.02 -0.08 -1.66 -0.51

p. 0.44 0.27 0.29 0.82 0.98 0.93 0.10 0.61


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Documents

BMJ Open is committed to open peer review. As …...For peer review only 2 Abstract Objectives: To report findings of the implementation phase of a new procedure for screening and