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To have and to hold nutritional control: Balancing between individual and routine care
Intensive and Critical Care Nursing (2009) 25, 155—162
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journal homepage: www.elsevier.com/iccn
ORIGINAL ARTICLE
To have and to hold nutritional control: Balancing between individual and routine care A grounded theory study Mona Wentzel Persenius a,∗, Bodil Wilde-Larsson a,b,1, Marie Louise Hall-Lord a,c,2 a
Department of Nursing, Karlstad University, SE-651 88 Karlstad, Sweden Department of Nursing, Hedmark University College, Norway c Department of Nursing, Gjøvik University College, Norway b
Accepted 17 March 2009
KEYWORDS Enteral nutrition; Enrolled nurses; Grounded theory; Intensive care and registered nurses
Summary Objectives: Gaining insight into nutritional processes can help nurses and other staff in their work. The aim was to provide a theoretical understanding of the concerns and strategies of nutritional nursing care for patients with enteral nutrition in intensive care units. Design: A grounded theory approach was used. Observations of patient’s nutritional care and twelve interviews with eight registered nurses and four enrolled nurses were conducted. Setting: The study was carried out in one intensive care unit at a medium sized hospital in Sweden. Results: The substantive theory developed included the core category ‘‘To have and to hold nutritional control — balancing between individual care and routine care’’. The core category was reflected in and related to the categories ‘‘knowing the patient’’, ‘‘facilitating the patient’s involvement’’, ‘‘being a nurse in a team’’, ‘‘having professional confidence’’ and ‘‘having a supportive organisation’’. Finding a balance between individual care and routine care was a way of enhancing the patient’s well-being, security and quality of care. Conclusion: To have and to hold nutritional control over the patient’s nutrition was found to be a balancing act between individual care and routine care. Organisation and teamwork are both challenging and supporting the provision, maintenance and development of nutritional care. © 2009 Elsevier Ltd. All rights reserved.
∗
Corresponding author. Tel.: +46 54 7002291; fax: +46 54 836996. E-mail addresses: [email protected] (M. Wentzel Persenius), [email protected] (B. Wilde-Larsson), [email protected] (M.L. Hall-Lord). 1 Tel.: +46 54 7002486; fax: +46 54 836996. 2 Tel.: +46 54 7002420; fax: +46 54 836996. 0964-3397/$ — see front matter © 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.iccn.2009.03.002
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Introduction Early enteral nutrition (EN) via a feeding tube is a recommended and common nutrition strategy for patients in intensive care units (ICUs) who are not expected to be taking a full oral diet within three days (Kreymann et al., 2006). When the patient cannot be fed totally via the enteral route, the deficit should be supplemented parenterally (Kreymann et al., 2006). However, there are many studies reporting underfeeding among patients with EN (Adam and Batson, 1997; Binnekade et al., 2005). Even when the patients are managing an oral diet, often used at the end of the ICU stay, underfeeding is reported (Berger et al., 1997; Villet et al., 2005). Interruption, a common cause for underfeeding, is due to many factors, such as feeding intolerance, procedures and examination (Adam and Batson, 1997; Binnekade et al., 2005; Elpern et al., 2004; Marshall and West, 2006). The majority of ICUs across Europe use a clinical protocol or guideline for enteral feeding, but many of them do not conform to international guidelines and there are limitations in nutritional practices and procedures across European ICUs (Fulbrook et al., 2007). Gaps between recommended nursing care and practice are identified (Wentzel Persenius et al., 2006). After implementing nutritional guidelines, studies have shown enhanced early initiation of EN (Rice et al., 2005), increases in the amount of EN delivery and greater consistency in nursing practice (Wøien and Bjørk, 2006), shorter mean stay in hospital and a trend towards reduced mortality (Martin et al., 2004). But there are also reports of no improvements in clinical outcomes (Jain et al., 2006). Little evidence supporting nutritional nursing practice recommendations (Williams and Leslie, 2004, 2005), lack of nutritional knowledge among nurses (Hansson and Wenström, 2005; Kowanko et al., 1999; Lindorff-Larsen et al., 2007; Mowe et al., 2008) and unclear role responsibility regarding nutritional issues (Hansson and Wenström, 2005) seem to be hampering nursing practice. Nutritional care forms part of successful medical treatment and nursing care (Mossberg, 2000). The physician has an overall nutritional responsibility, making sure that an assessment is performed and prescribing nutritional treatment in consultation with registered nurses (RNs) and enrolled nurses (Cederholm and Rothenberg, 2000). When it comes to tube feeding and oral intake, teamwork around the planning and calculation is common in the ICU (Martensson and Fridlund, 2002). Patient safety is fundamental to quality nursing care (International Council of Nurses, 2000). RNs have a key role securing the delivery of intended nutritional support to the patients (Howard et al., 2006), but also with regard to the nursing process model (SOSFS, 1993:17). The work of enrolled nurses includes nursing care, service tasks, monitoring, medical—technical tasks and assisting RNs and physicians (Socialstyrelsen, 2006). Enrolled nurses can perform assessment and enteral tube feeding if delegated this task by the RNs (SOSFS, 1988:25). In summary, most previous studies in ICUs have focused on performing nutritional practices, revealing obvious variations and limitations in a lack of evidence-based care and lack of knowledge. Minimal attention has been paid to how the care of the patient in need of enteral nutrition is expe-
M. Wentzel Persenius et al. rienced by RNs and enrolled nurses. Gaining insight into nutritional processes can help nurses and their colleagues in their work with these patients. The aim was to provide a theoretical understanding of the concerns and strategies of nutritional nursing care for patients with EN in ICU.
Methods Setting The present study was carried out in an ICU with 15 beds, of which eight beds were intended for ICU patients (medical/surgical) and seven for postoperative care. The chief physician, an anaesthetist, had the legal responsibility for the overall care in cooperation with the patient’s physician from the primary unit. The registered nurses (RNs) and enrolled nurses were usually caring for one or two patients, with the enrolled nurses functioning under the supervision of the RNs. At the beginning of the study, all medical and nursing documentation was paper-based, but from January 2007, an electronic health care record system for nursing and medical records was introduced. Apart from national guidelines, there were also local guidelines regarding enteral nutrition.
Informants Following the RNs’ three years of university studies, where a Bachelor’s degree is earned and a licence is executed by The National Board of Health and Welfare; one additional year of nursing specialisation in intensive care nursing is required for working in an ICU. For enrolled nurses educated in an upper secondary school health care programme for three years, there is limited access to intensive care training. The choice of informants was dictated through their bedside presence in the ICU. In the text, all informants are referred to as nurses, when not specified. Data obtained were based on interviews with nurses and observations of their nursing care related to nutrition. The informants were caring for patients included in another study (Wentzel Persenius et al., 2009) where the aim was to provide a theoretical understanding of nutritional experiences for patients with EN during their ICU stay. A total of eight RNs and four enrolled nurses were interviewed, all but one female, ranging from 33 to 51 years (Md 39.5 years). Years as a nurse ranged from 6 to 29 (Md 14 years) and years in ICU ranged from <0.5 to 28 (Md 8 years). Years as a specialist RN in intensive care ranged from <0.5 to 16 (Md 7 years).
Data collection Data collection was carried out by the first author (MWP) from December 2005 until June 2008, during morning and afternoon shifts. The multimethod principle, the multisensory principle and the principle of aesthetic distance were used to increase the theoretical sensitivity (Glaser and Strauss, 1967). Observations regarding patients’ nutritional care were made at the bedside, during reporting between nurses and during rounds. Observations about the patient’s nutri-
Balancing between individual and routine care
Figure 1
157
Core category, categories and properties.
tional care were later followed up in the interviews. The researcher was a complete observer. The time period for the observations could vary between 45 min to several hours. Field notes were made during or immediately following the observation. A total of twelve interviews with nurses were made; eight RNs and four enrolled nurses. Each interview was carried out in a place chosen by the informants. The nurses were asked to talk about the patient’s nutritional care. The interviews started with questions about the patient’s nutritional care and the observations were followed up. Observations were followed up and deeper questioning was dependent on topics that the nurses themselves addressed. As the analysis progressed, the interviews focused more on the categories and their properties. In addition, the analysis guided further sampling of informants. The interviews, lasting between 40 and 60 min (except for one of 15 min), were audiotape-recorded and transcribed verbatim by the first author (MWP).
Data analysis Data collection and analysis were carried out concurrently by the first author (MWP) according to ‘‘the constant comparative method of analysis’’. In this way, credibility can be seen as inherent in the method (Glaser and Strauss, 1967). The process moved back and forth between data and emergent pattern, constantly moving between inductive and deductive thinking and categories were reviewed, renamed and consolidated during the entire analysis, and confirmed with the two co-authors throughout the whole process. Memos about the researcher’s ideas, reflections and hypotheses based on the data were noted during the analysis, since the use of memos increases the theoretical sensitivity, and is considered a vital link between coding and the emerging of a theory (Glaser and Strauss, 1967; Glaser, 1992, 1998).
In accordance with the grounded theory methodology, observational and interview data were coded into two types of codes: substantive and theoretical. In open coding, data was analysed line by line along with a constantly coding of each sentence, carrying meaning into substantive codes. An effort was made to code different incidences into as many substantive codes as possible, even for what was not obvious. These substantive codes were compared for similarities, differences and grade of consistency. Codes with similar meanings were clustered into broader, more comprehensive and abstract categories. The set of questions asked of the data were: ‘‘What is this data a study of?’’, ‘‘What category does this incidence indicate?’’ and ‘‘What is actually happening here?’’. The analysis further guided the data collection and new ideas inspired new questions to be asked of both the data and the nurses (Glaser, 1978). The identified core category was central, reflected the entire data and seemed to be appropriate. Open coding ended when the core category was discovered and selective coding begun. From then, only those categories that related to the core category in significant ways were used (Glaser, 1978). The core category became a guide to further data collection, in order to add, and saturate the categories. After 10 interviews a theoretical saturation was achieved, that is, new data did not add new information. A further two interviews were performed to verify the developing theory. The relation between the core category and its inherent categories were searched for and described (theoretical coding), and then a substantive theory was outlined. In the result section, properties were used to designate the defining characteristics, meaning and precision of the categories, as well as to differentiate between the categories (Figure 1).
Ethical approval The nurses were informed verbally and in writing about the study, confidentiality and that they would be participating
158 on a voluntary basis and could withdraw from the study at any time. The study was approved by the ethical research committee at Karlstad University.
Results This substantive theory emerged from one core category and five categories. The core category was ‘‘To have and to hold nutritional control — balancing between individual care and routine care’’, and the five categories were ‘‘knowing the patient’’, ‘‘facilitating the patient’s involvement’’, ‘‘being a nurse in a team’’, ‘‘having professional confidence’’ and ‘‘having a supportive organisation’’. All five categories were related to the core category and to each other. The core category and each of the five categories are described below.
To have and to hold nutritional control — balancing between individual care and routine care To have and to hold nutritional control over the patient’s nutritional care was found to be balancing between individual care and routine care. When having balance between individual care and routine care, nurses felt that the patient’s well-being, security and quality of care improved. In addition, it made the nurses feel proud to do a good job and be satisfied with their work. When the balance was not achieved, or when it was disturbed, such as when the routine care was felt to take precedence over the unique patient’s individual care, disappointment was expressed: ‘‘It just feels dull, you can’t see who you’ve got. . . a bit more personal. . . people in the beds are different.’’ Individual needs however, could also challenge the existing routines, by demanding food or beverages that was not kept in stock, or to refuse a route of recommended nutritional administration. Knowing the patient (nutritional history, needs and preferences, and feeding tolerance) in combination with professional confidence (having knowledge, having experience) and being a nurse in a team (seeking dialogue and cooperation, challenged by attitudes and values, ruled by responsibilities, having influence), helped nurses to facilitate patient’s involvement (creating options for choices and decisions, encouraging intake of food and fluid, inviting next of kin to take part in nutritional care) in nutritional care. By creating options for nutritional choices and encouragement the patient could take part in the decisions. Next of kin were invited to participate and thereby further enhance the patient’s nutritional intake. Nurses connected the individual patient’s nutritional need and preferences to their earlier experiences and knowledge of similar types of patients. The patients’ general condition was also taken into consideration. Being aware of one’s own knowledge regarding nutritional matters, gave nurses confidence in their own ability. Limited knowledge and experiences in combination with an open mind looking for new solutions led them to seek dialogue and cooperation with team members. The team was ruled by responsibilities, providing influence, but also challenging the nurses through attitudes and values. Within the organisation some important factors were highlighted, such as the environment, tools, continuity and channels of information.
M. Wentzel Persenius et al.
Knowing the patient Being familiar with the nutritional history of the patient was of importance. For example, one nurse described her patient as being unable to eat and drink enough at home due to loose stools. This had led to weight-loss and the patient was now running out of steam. The nurses asked the patient’s next of kin about the patient’s preferences about food and fluid ‘‘Her daughter told me that she (the patient) had always been very thin, but might even have gained some weight now.’’ To continuously find out the patients’ individual nutritional needs and preferences during the ICU stay gave the nurses a base for the nutritional care. The patient’s need for energy, preferably measured via indirect calorimetry, gave the nurses feelings of security and control, as this measure could be compared with the actual intake. They knew what the patient needed and could set daily goals for energy delivery. The patient’s feelings of hunger and appetite were welcome signs of nutritional improvement. It emerged as a milestone in the nutritional care, as the nurses then felt that the patients ‘‘were feeling better’’. A close monitoring and evaluation of the patient’s individual feeding tolerance, by assessing the patient’s abdominal status, including bowel function, was another property. The gastrointestinal feeding intolerance could vary from no stools at all to many loose stools per day and gastric residual volume (GRV) often increased. The stomach could be a big problem and even affect the breathing. ‘‘Sometimes it is difficult to know in advance what can be expected from the patients, then a close monitoring and evaluation of feeding tolerance and what the patient benefits from is of importance’’. Decreased feeding tolerance due to the feeding tube made the patients sometimes refuse to eat and drink and wanted to remove the feeding tube.
Facilitating the patient’s involvement Creating options for choices and decisions for the patients were of importance. . . . there’s a strong fixation with dietary supplements as their first drink. . . Personally, I think they should be given a choice about what the first thing they will drink is. It shouldn’t have to be so nutritious the first few times they drink. If they want a coke or a beer or just water, then they should be given that, so that they feel that they have been granted at least one wish. That’s better than going on about dietary supplements from the very star. Giving time for reflection was a strategy used by the nurses when creating options for choices and decisions. When observed, an elderly woman told the RN in charge of her that she thought it would be better for her to have her wide bore tube replaced with a small bore feeding tube. Later, when interviewing the nurse in charge of the patient, she said that the patient had been informed about the advantages of having a thin bore tube the evening before. The nurse thought that it was valuable to the patient to be given some time to think this over: ‘‘To point something out and let it settle for a while. Think about it.’’
Balancing between individual and routine care The nurses encouraged intake of food and fluid. It was observed that they listened carefully to what the patient said and explained things in a clear manner. When talking to patients who were afraid of asking for help because they did not want to bother the nurses it was ‘‘important to point out that they are allowed to ask for cold water or ice cubes. Very small things.’’ An effort was made to motivate the patient, to make them realise that they must give it a try. Sometimes distractive manoeuvres were performed. The nurses felt that they sometimes abandoned the encouraging manoeuver in favour of ‘‘very persistent pressing’’ to make a patient drink or eat, something they dislike. When the patient started eating and/or drinking, the next of kin could be invited to participate. They were encouraged to talk about food with the patient, to find out what the patient wanted to eat.
159 had obligations to fulfil during each shift. Communication and trust in each other was needed. Having influence within the ICU team meant that the nurses could suggest improvements, which were then considered further. They were pleased when they felt that there was an open atmosphere to express wishes, while not being listened to resulted in feelings of disappointment. ‘‘I have tried to raise the question many times, but finally you give up.’’ Ahead of the patients’ transfer to their home ward, extended concerns were raised regarding the nutritional care that should continue. The nurses wished that their reports and care plan for the patient were used and useful, but they were afraid that their nursing notes would not be acknowledged at the home ward. When observed, encouraging the patient’s intake of food and fluid was mentioned as being very important, when reporting the patient to the RN on the ward.
Being a nurse in a team The nurses were seeking dialogue and cooperation regarding nutritional matters among or outside their own profession, because ‘‘we are all a link in the chain and all strive to do what’s best for the patient.’’ The teams mentioned were of various configerations. Sometimes the team was the RN and the enrolled nurse on the ICU, sometimes it was the entire ICU staff and sometimes the ICU and other wards. It was favourable to have others, such as the nutritional team, the physicians and the dieticians to consult in nutritional matters. However, the nurses were also aware that the nutritional knowledge among fellow workers could vary: ‘‘People do bring different knowledge into the team. . . something you realise after a while.’’ One strategy used to handle this and to secure the care, was to remind each other about what to do, something that was both observed and mentioned in the interviews. The nurses were challenged by attitudes and values in their daily nutritional work. Nutrition in general was not considered as important as technical and surgical procedures. Yet, nurses with long experience had noticed an increase in positive attitudes towards nutritional issues among all staff. Reasons mentioned were increased knowledge and the presence of nutritional teams. However, it was easy to be updated and understand all the changes. Nutrition has become fashionable with focus on a few issues, for example the nutritional feeding pumps, which overshadows nursing care. Going beyond the routine would be a dilemma. You are not supposed to change the traditional ways and the unwritten rules of performing care. The nurses were ruled by responsibilities within the team. Planning and prescribing the patients’ nutrition was taken care of during the rounds by the physicians, along with RNs and enrolled nurses. The only differences noted between RNs and enrolled nurses were regarding their responsibility. The delivery of enteral feeding was often delegated from the RNs to the enrolled nurses, while the RNs were mainly handling the parenteral nutrition. This routine is a way of sharing responsibility, which worked smoothly and securely, but some RNs experienced a loss of control when EN was delegated to the enrolled nurse. Some enrolled nurses had experienced loss of control when RNs took over the checking of the location of the feeding tube. Everybody
Having professional confidence Having knowledge of the complexity of the patient’s condition was wanted, but limitations of their own knowledge and clinical judgement made them open for new solutions of problems. Having experience of different types of patients helped the nurses to separate the standard patient, or the so-called ‘‘easy ones’’ in need of standard care, from the more ill or specific patient in need of special attention. Having former experience of how to deal with nutritional matters gave the nurses confidence. Sometimes they went beyond the framework and deviated from guidelines and attitudes. Lack of former experience, expressed by nurses with short experience of intensive care, made it more difficult to know what to expect, because they did not have anything to compare with.
Having a supportive organisation The environment was of importance for the patient’s nutritional intake in several ways. By placing the patients in an ICU module (a room with two beds) the nurses thought it was easier to carry out nutritional nursing care compared with having the patients placed in the large postoperative unit. In the ICU rooms with two beds, there were more hands and less technical events, and the patient could really be seen, compared with ICU patients cared for in the large postoperative room. Having a comfortable armchair for the patient to sit in and look out through the window during the meals was appreciated. Serving preferred food in an attractive way, for example by pouring fluid into stemmed glasses and adding ice and fruit, and placing it on a nice tray, were important. Tools like guidelines, documentation and feeding pumps were all supportive for the daily nutritional care, but they could also be an obstacle. Guidelines regarding nutrition and gut motility were considered clear, available, uniform, easy to handle and safe: ‘‘We base our work on these memos, so not a lot can go wrong, you know. . . you know what to do then.’’ Deviations from guidelines were also described and observed. The nurses described both advantages and disadvantages regarding the flow sheets and nursing docu-
160 mentation. The flow sheets did not support all nutritional issues of importance. The use of feeding pumps led to slower, continuous delivery with fewer complications, such as diarrhoea. Malfunctioning pumps caused a lot of irritation, putting patients at risk. Continuity in the nurses’ schedule was experienced as making nurses take more responsibility and actively making sure that the patients gut motility was under close observation, and thereby facilitating the delivery of enteral feeds. Having channels of information was needed in order to provide secure care. For example when establishing new nutritional routines, adequate information was expected to be available. Lack of appropriate information channels led to rumours and confusion about what to do.
Discussion The findings led to a substantive theory, which gives a deeper understanding of the concerns and strategies of nutritional care for patients with EN in ICU. This theory implies that it is important for the nurses to have and to hold nutritional control over the patient’s nutrition. Furthermore, it was found to be a balancing act between individual care and routine care. Finding a balance between individual care and routine care was a way of enhancing the patient’s wellbeing, security and quality of care. A mutual understanding between the patient and the nurse regarding the patients’ needs for nursing care, relevant actions to the goals of care as well as the roles between patients and nurses is in line with patient-centered or individualised nursing care. As a consequence of knowing the patient, nurses can give individualised nursing care. However, the patients cannot always participate and give their opinion. There are also times when nurses need to plan and provide for care without having a mutual understanding (Florin, 2007). The nurses’ daily nutritional care was based on knowing the patient. The return of the patients’ hunger and appetite was considered as a milestone in the patients’ recovery. Changes in appetite related to gut hormones in patients in the ICU have been found (Nematy et al., 2006), which might explain the reduced or altered taste sensations that make the nutritional intake more difficult. Individual assessment of the patients’ favourite taste of food and fluid are important to improve adherence with the nutritional care. Assessing the patient’ feeding tolerance is a concern for nurses in ICU, because impaired gastro intestinal motility, altered cough and gag reflex, and endotracheal and nasogastric tubes increases the risk of aspiration (Marshall and West, 2004). Despite this, there is no consensus regarding assessment of the feeding tolerance (Reintam et al., 2008). Current management of monitoring tolerance to enteral feeding like withholding EN in patients with diarrhoea and ceasing EN when GRV is high, may result in inadequate delivery of nutrition (Marshall and West, 2004). Further research addressing the assessment and management of feeding tolerance is therefore required. Many patients in the ICU are unable to participate in the decision-making process, but as their general condition stabilises, the opportunity to participate arises. The nurses
M. Wentzel Persenius et al. were facilitating the patients’ involvement in care and thereby their ability to (re)gain an influence on what to eat and drink. There sometimes was a dilemma between following routines and taking the patient’s own will into account. Strictly following nutritional guidelines could sometimes contradict the patient’s own will. It is known from other areas that when the patient’s own will is not obvious, the staff are using the principle of doing good. Situations where the patient’s will is clearly grasped, the staff become more respectful about the patients right to self-determination (Jansson and Norberg, 1989, 1992). Inviting the next of kin to participate in the nutritional care was also appreciated according to the nurses. Similar findings have been reported by Hupcey (1999), who found that next of kin wanted to do something more than just be there, as it provided them with a sense of control and enabled them to support and look after the patient (Hupcey, 1999). There is a need for research focusing on the next of kin’s involvement in nutritional nursing care within the ICU. Being a nurse in a team was to seek dialogue and cooperation regarding nutritional matters, among or outside their own profession. Within the ICU team, problems are known to be (dis)solved jointly with other health care professionals (Wikström and Larsson, 2004). However, different levels of skill acquisition to function as a team member have been found to be a barrier for teams working in acute health care. Assertiveness and confidence are essential skills that are needed in order to function as an effective team member (Atwal and Caldwell, 2006). Being ruled by responsibilities highlighted the demands on communication and trust, because if that failed, they expressed feelings of fear of losing control. Interestingly, the only differences noted between RNs and enrolled nurses was regarding their responsibility. The nurses were challenged by attitudes and values in the team, something that had an impact on their daily nutritional care of the patients. Nutritional care in general was not considered as important as other treatments, something found in other studies (Lennard-Jones et al., 1995). In our study RNs and enrolled nurses with greater experience did emphasise that nutrition had a higher importance than previously. Team work requires many skills, because it involves not only one’s own role but also the role of the other team members. Therefore team playing skills must be an integral part of continued professional development (Atwal and Caldwell, 2006). In spite of the differences in nursing level, the RNs’ and enrolled nurses’ nutritional experiences were similar. Having professional confidence implies that nurses connected each individual patient’s nutritional need and preferences to their knowledge and earlier experiences of similar types of patients. It was found that the combination of knowing the patients condition over time, as well as being aware of and reflecting on one’s own knowledge in connection with former experiences regarding nutritional care, gave confidence in how to handle the present situation. Benner et al. (1996) found that nursing actions in the ICU were response-based, relying on intuition of what had worked in similar situations in the past, individually modified in accordance with the patient’s response. However, often a more systematic process represents the rationale of nurses’ intuitive practice. For example a strong clinical
Balancing between individual and routine care knowledge base in combination with an ability to apply this to the needs of the individual patient used in a continuum of decision making (Harbison, 2001). Furthermore, classification has been suggested as a model for clinical decision making (Buckingham and Adams, 2000), and prioritisation of nursing problems (Hendry and Walker, 2004). The nurses were also aware of that they did not always fully embrace the patient’s complexity of problems and needs or the options for nutritional care. They were aware that they did not know everything regarding nutrition and were keen to find new solutions that could lead to seek dialogue with fellow workers. According to Benner et al. (1999) they remain open for being wrong, making an inaccurate judgment, and they have openness in relation to that their preconception must be reconsidered. Being able to recognise when they do not have a good grasp of a situation is perceptual skill. A good clinician, she means, is thinking in action and reasoning through transitions in the patient’ condition (Benner et al., 1999). Organisational factors were referred to as more or less supportive to nutritional care. The caring environment could have an impact on the patients’ intake of food and fluid. It also made the nurses pleased with their care, which hopefully is mirrored in the care, because when patients feel safe, are receiving extra care and participate in care, it is within a positive environment (Wåhlin et al., 2006). The guidelines used in the ICU were considered supportive in the care of the patients, yet some deviations from current guidelines were described. Insufficient awareness of the benefits of the guidelines, real and perceived deterrents, poor agreement about implementation responsibility and lack of enabling and reinforcing strategies, were all reasons for underuse of semi-recumbency for pneumonia prevention (Cook et al., 2002). Intentional deviations from the guidelines were described as well, in order to meet patients’ requests for what they wanted to eat and drink. More research is required about why nurses do not follow accepted guidelines. RNs consider both standards and individual judgments as important to patient safety (Berland and Natvig, 2005).
Methodological consideration In Grounded Theory, credibility may be seen as inherent in the method, as the emerging substantive theory is based on the method of constant comparison in which categories and properties repeatedly emerge and guide the continuing research (Glaser and Strauss, 1967). In this study, the use of the multi-method principle was a way to further improve the credibility, and the combination of observations, interviews and memos made the data rich and extensive. In addition, the analysis was continuously discussed with the two coauthors. Furthermore, the data collection period was long in the study the reference they are referring to that was linked to this, as it was difficult to find patients alert enough to participate. Prior to this study, the researcher (MWP) had worked as an RN at the ICU in focus. The findings may be biased when the researcher is familiar with the actual setting, here an ICU, but it can also be seen as an advantage as it makes it possible to identify and reflect on nutritional matters that
161 might have escaped the attention of a researcher without such a background (Lykkeslet and Gjengedal, 2007). However, this study does not have the possibility to embrace every aspect of the patients’ nutrition while in an ICU. Further research is therefore needed to develop this substantive theory in other ICU settings.
Conclusion This study shows that nurses have a key role in knowing the patients nutritional situation. This, in combination with their professional confidence and collaboration within the team, helped them to facilitate patient’s involvement in nutritional care. The teamwork as well as the organisation can be both challenging and supporting to the provision, maintenance and development of nutritional nursing care. Nutritional care, a multidisciplinary responsibility with a joint approach, needs continuously time for reflection, development and training in clinical care. This study has deepened the understanding of RNs and enrolled nurses concerns and strategies of nutritional nursing care for patients in ICU. This can be of importance in the daily nutritional nursing care for all health care professionals. To have and to hold nutritional control over the patient’s nutrition was found to be a balancing act between individual care and routine care.
Acknowledgement We wish to express our gratitude to Ellinor Larsen, for linguistic supervision.
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M. Wentzel Persenius et al. Marshall A, West S. Enteral feeding in the critically ill: are nursing practices contributing to hypocaloric feeding? Intensive Crit Care Nurs 2006;22:95—105. Marshall A, West S. Nutritional intake in the critically ill: improving practice through research. Aust Crit Care 2004;17:6—15. Martensson IE, Fridlund B. Factors influencing the patient during weaning from mechanical ventilation: a national survey. Intensive Crit Care Nurs 2002;18:219—29. Martin CM, Doig GS, Heyland DK, Morrison T, Sibbald WJ. Multicentre, cluster-randomized clinical trial of algorithms for critical-care enteral and parenteral therapy (ACCEPT). CMAJ 2004;170:197—204. Mossberg T. Summary. In: Problems of nutrition in health care and human services: prevention and treatment. Stockholm: The National Board of Health and Welfare; 2000. p. 9—12. http://www.sos.se/fulltext/110/2001-110-14/2001-11014.pdf. Mowe M, Bosaeus I, Rasmussen HH, Kondrup J, Unosson M, Rothenberg E, et al. Insufficient nutritional knowledge among health care workers? Clin Nutr 2008;27:196—202. Nematy M, O’Flynn JE, Wandrag L, Brynes AE, Brett SJ, Patterson M, et al. Changes in appetite related gut hormones in intensive care unit patients: a pilot cohort study. Crit Care 2006;10:R10. Reintam A, Parm P, Kitus R, Starkopf J, Kern H. Gastrointestinal failure score in critically ill patients: a prospective observational study. Crit Care 2008;12:R90. Rice TW, Swope T, Bozeman S, Wheeler AP. Variation in enteral nutrition delivery in mechanically ventilated patients. Nutrition 2005;21:786—92. Socialstyrelsen. Vård- och omsorgsassistenters kompetens—–en litteraturgenomgång (in swedish). Stockholm: Socialstyrelsen; 2006. SOSFS, 1988:25. Föreskrifter och allmänna råd om ansvarsfördelning inom den slutna hälso- och sjukvården vid sondmatning samt vid användning av intravasal kateter och epiduralkateter (in swedish). Stockholm: Socialstyrelsen. SOSFS, 1993:17. Socialstyrelsens allmänna råd. omvårdnad inom hälso- och sjukvården (in swedish). Stockholm: Socialstyrelsen. Wentzel Persenius M, Hall Lord M, Larsson BW. Grasping the nutritional situation: a grounded theory study of patients’ experiences in intensive care. Nurs Crit Care 2009; accepted. Wentzel Persenius M, Larsson BW, Hall Lord M. Enteral nutrition in intensive care nurses’ perceptions and bedside observations. Intensive Crit Care Nurs 2006;22:82—94. Wikström AC, Larsson US. Technology—–an actor in the ICU. A study in workplace research tradition. J Clin Nurs 2004;13:555— 61. Villet S, Chiolero RL, Bollmann MD, Revelly J, Cayeux M, Delarue J, et al. Negative impact of hypocaloric feeding and energy balance on clinical outcome in ICU patients. Clin Nutr 2005;24:502— 9. Williams TA, Leslie GD. A review of the nursing care of enteral feeding tubes in critically ill adults: part II. Intensive Crit Care Nurs 2005;21:5—15. Williams TA, Leslie GD. A review of the nursing care of enteral feeding tubes in critically ill adults: part 1. Intensive Crit Care Nurs 2004;20:330—43. Wåhlin I, Ek A, Idvall E. Patient empowerment in intensive care—–an interview study. Intensive Crit Care Nurs 2006;22:370—7. Wøien H, Bjørk IT. Nutrition of the critically ill patient and effects of implementing a nutritional support algorithm in ICU. J Clin Nurs 2006;15:168—77.
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ORIGINAL ARTICLE
To have and to hold nutritional control: Balancing between individual and routine care A grounded theory study Mona Wentzel Persenius a,∗, Bodil Wilde-Larsson a,b,1, Marie Louise Hall-Lord a,c,2 a
Department of Nursing, Karlstad University, SE-651 88 Karlstad, Sweden Department of Nursing, Hedmark University College, Norway c Department of Nursing, Gjøvik University College, Norway b
Accepted 17 March 2009
KEYWORDS Enteral nutrition; Enrolled nurses; Grounded theory; Intensive care and registered nurses
Summary Objectives: Gaining insight into nutritional processes can help nurses and other staff in their work. The aim was to provide a theoretical understanding of the concerns and strategies of nutritional nursing care for patients with enteral nutrition in intensive care units. Design: A grounded theory approach was used. Observations of patient’s nutritional care and twelve interviews with eight registered nurses and four enrolled nurses were conducted. Setting: The study was carried out in one intensive care unit at a medium sized hospital in Sweden. Results: The substantive theory developed included the core category ‘‘To have and to hold nutritional control — balancing between individual care and routine care’’. The core category was reflected in and related to the categories ‘‘knowing the patient’’, ‘‘facilitating the patient’s involvement’’, ‘‘being a nurse in a team’’, ‘‘having professional confidence’’ and ‘‘having a supportive organisation’’. Finding a balance between individual care and routine care was a way of enhancing the patient’s well-being, security and quality of care. Conclusion: To have and to hold nutritional control over the patient’s nutrition was found to be a balancing act between individual care and routine care. Organisation and teamwork are both challenging and supporting the provision, maintenance and development of nutritional care. © 2009 Elsevier Ltd. All rights reserved.
∗
Corresponding author. Tel.: +46 54 7002291; fax: +46 54 836996. E-mail addresses: [email protected] (M. Wentzel Persenius), [email protected] (B. Wilde-Larsson), [email protected] (M.L. Hall-Lord). 1 Tel.: +46 54 7002486; fax: +46 54 836996. 2 Tel.: +46 54 7002420; fax: +46 54 836996. 0964-3397/$ — see front matter © 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.iccn.2009.03.002
156
Introduction Early enteral nutrition (EN) via a feeding tube is a recommended and common nutrition strategy for patients in intensive care units (ICUs) who are not expected to be taking a full oral diet within three days (Kreymann et al., 2006). When the patient cannot be fed totally via the enteral route, the deficit should be supplemented parenterally (Kreymann et al., 2006). However, there are many studies reporting underfeeding among patients with EN (Adam and Batson, 1997; Binnekade et al., 2005). Even when the patients are managing an oral diet, often used at the end of the ICU stay, underfeeding is reported (Berger et al., 1997; Villet et al., 2005). Interruption, a common cause for underfeeding, is due to many factors, such as feeding intolerance, procedures and examination (Adam and Batson, 1997; Binnekade et al., 2005; Elpern et al., 2004; Marshall and West, 2006). The majority of ICUs across Europe use a clinical protocol or guideline for enteral feeding, but many of them do not conform to international guidelines and there are limitations in nutritional practices and procedures across European ICUs (Fulbrook et al., 2007). Gaps between recommended nursing care and practice are identified (Wentzel Persenius et al., 2006). After implementing nutritional guidelines, studies have shown enhanced early initiation of EN (Rice et al., 2005), increases in the amount of EN delivery and greater consistency in nursing practice (Wøien and Bjørk, 2006), shorter mean stay in hospital and a trend towards reduced mortality (Martin et al., 2004). But there are also reports of no improvements in clinical outcomes (Jain et al., 2006). Little evidence supporting nutritional nursing practice recommendations (Williams and Leslie, 2004, 2005), lack of nutritional knowledge among nurses (Hansson and Wenström, 2005; Kowanko et al., 1999; Lindorff-Larsen et al., 2007; Mowe et al., 2008) and unclear role responsibility regarding nutritional issues (Hansson and Wenström, 2005) seem to be hampering nursing practice. Nutritional care forms part of successful medical treatment and nursing care (Mossberg, 2000). The physician has an overall nutritional responsibility, making sure that an assessment is performed and prescribing nutritional treatment in consultation with registered nurses (RNs) and enrolled nurses (Cederholm and Rothenberg, 2000). When it comes to tube feeding and oral intake, teamwork around the planning and calculation is common in the ICU (Martensson and Fridlund, 2002). Patient safety is fundamental to quality nursing care (International Council of Nurses, 2000). RNs have a key role securing the delivery of intended nutritional support to the patients (Howard et al., 2006), but also with regard to the nursing process model (SOSFS, 1993:17). The work of enrolled nurses includes nursing care, service tasks, monitoring, medical—technical tasks and assisting RNs and physicians (Socialstyrelsen, 2006). Enrolled nurses can perform assessment and enteral tube feeding if delegated this task by the RNs (SOSFS, 1988:25). In summary, most previous studies in ICUs have focused on performing nutritional practices, revealing obvious variations and limitations in a lack of evidence-based care and lack of knowledge. Minimal attention has been paid to how the care of the patient in need of enteral nutrition is expe-
M. Wentzel Persenius et al. rienced by RNs and enrolled nurses. Gaining insight into nutritional processes can help nurses and their colleagues in their work with these patients. The aim was to provide a theoretical understanding of the concerns and strategies of nutritional nursing care for patients with EN in ICU.
Methods Setting The present study was carried out in an ICU with 15 beds, of which eight beds were intended for ICU patients (medical/surgical) and seven for postoperative care. The chief physician, an anaesthetist, had the legal responsibility for the overall care in cooperation with the patient’s physician from the primary unit. The registered nurses (RNs) and enrolled nurses were usually caring for one or two patients, with the enrolled nurses functioning under the supervision of the RNs. At the beginning of the study, all medical and nursing documentation was paper-based, but from January 2007, an electronic health care record system for nursing and medical records was introduced. Apart from national guidelines, there were also local guidelines regarding enteral nutrition.
Informants Following the RNs’ three years of university studies, where a Bachelor’s degree is earned and a licence is executed by The National Board of Health and Welfare; one additional year of nursing specialisation in intensive care nursing is required for working in an ICU. For enrolled nurses educated in an upper secondary school health care programme for three years, there is limited access to intensive care training. The choice of informants was dictated through their bedside presence in the ICU. In the text, all informants are referred to as nurses, when not specified. Data obtained were based on interviews with nurses and observations of their nursing care related to nutrition. The informants were caring for patients included in another study (Wentzel Persenius et al., 2009) where the aim was to provide a theoretical understanding of nutritional experiences for patients with EN during their ICU stay. A total of eight RNs and four enrolled nurses were interviewed, all but one female, ranging from 33 to 51 years (Md 39.5 years). Years as a nurse ranged from 6 to 29 (Md 14 years) and years in ICU ranged from <0.5 to 28 (Md 8 years). Years as a specialist RN in intensive care ranged from <0.5 to 16 (Md 7 years).
Data collection Data collection was carried out by the first author (MWP) from December 2005 until June 2008, during morning and afternoon shifts. The multimethod principle, the multisensory principle and the principle of aesthetic distance were used to increase the theoretical sensitivity (Glaser and Strauss, 1967). Observations regarding patients’ nutritional care were made at the bedside, during reporting between nurses and during rounds. Observations about the patient’s nutri-
Balancing between individual and routine care
Figure 1
157
Core category, categories and properties.
tional care were later followed up in the interviews. The researcher was a complete observer. The time period for the observations could vary between 45 min to several hours. Field notes were made during or immediately following the observation. A total of twelve interviews with nurses were made; eight RNs and four enrolled nurses. Each interview was carried out in a place chosen by the informants. The nurses were asked to talk about the patient’s nutritional care. The interviews started with questions about the patient’s nutritional care and the observations were followed up. Observations were followed up and deeper questioning was dependent on topics that the nurses themselves addressed. As the analysis progressed, the interviews focused more on the categories and their properties. In addition, the analysis guided further sampling of informants. The interviews, lasting between 40 and 60 min (except for one of 15 min), were audiotape-recorded and transcribed verbatim by the first author (MWP).
Data analysis Data collection and analysis were carried out concurrently by the first author (MWP) according to ‘‘the constant comparative method of analysis’’. In this way, credibility can be seen as inherent in the method (Glaser and Strauss, 1967). The process moved back and forth between data and emergent pattern, constantly moving between inductive and deductive thinking and categories were reviewed, renamed and consolidated during the entire analysis, and confirmed with the two co-authors throughout the whole process. Memos about the researcher’s ideas, reflections and hypotheses based on the data were noted during the analysis, since the use of memos increases the theoretical sensitivity, and is considered a vital link between coding and the emerging of a theory (Glaser and Strauss, 1967; Glaser, 1992, 1998).
In accordance with the grounded theory methodology, observational and interview data were coded into two types of codes: substantive and theoretical. In open coding, data was analysed line by line along with a constantly coding of each sentence, carrying meaning into substantive codes. An effort was made to code different incidences into as many substantive codes as possible, even for what was not obvious. These substantive codes were compared for similarities, differences and grade of consistency. Codes with similar meanings were clustered into broader, more comprehensive and abstract categories. The set of questions asked of the data were: ‘‘What is this data a study of?’’, ‘‘What category does this incidence indicate?’’ and ‘‘What is actually happening here?’’. The analysis further guided the data collection and new ideas inspired new questions to be asked of both the data and the nurses (Glaser, 1978). The identified core category was central, reflected the entire data and seemed to be appropriate. Open coding ended when the core category was discovered and selective coding begun. From then, only those categories that related to the core category in significant ways were used (Glaser, 1978). The core category became a guide to further data collection, in order to add, and saturate the categories. After 10 interviews a theoretical saturation was achieved, that is, new data did not add new information. A further two interviews were performed to verify the developing theory. The relation between the core category and its inherent categories were searched for and described (theoretical coding), and then a substantive theory was outlined. In the result section, properties were used to designate the defining characteristics, meaning and precision of the categories, as well as to differentiate between the categories (Figure 1).
Ethical approval The nurses were informed verbally and in writing about the study, confidentiality and that they would be participating
158 on a voluntary basis and could withdraw from the study at any time. The study was approved by the ethical research committee at Karlstad University.
Results This substantive theory emerged from one core category and five categories. The core category was ‘‘To have and to hold nutritional control — balancing between individual care and routine care’’, and the five categories were ‘‘knowing the patient’’, ‘‘facilitating the patient’s involvement’’, ‘‘being a nurse in a team’’, ‘‘having professional confidence’’ and ‘‘having a supportive organisation’’. All five categories were related to the core category and to each other. The core category and each of the five categories are described below.
To have and to hold nutritional control — balancing between individual care and routine care To have and to hold nutritional control over the patient’s nutritional care was found to be balancing between individual care and routine care. When having balance between individual care and routine care, nurses felt that the patient’s well-being, security and quality of care improved. In addition, it made the nurses feel proud to do a good job and be satisfied with their work. When the balance was not achieved, or when it was disturbed, such as when the routine care was felt to take precedence over the unique patient’s individual care, disappointment was expressed: ‘‘It just feels dull, you can’t see who you’ve got. . . a bit more personal. . . people in the beds are different.’’ Individual needs however, could also challenge the existing routines, by demanding food or beverages that was not kept in stock, or to refuse a route of recommended nutritional administration. Knowing the patient (nutritional history, needs and preferences, and feeding tolerance) in combination with professional confidence (having knowledge, having experience) and being a nurse in a team (seeking dialogue and cooperation, challenged by attitudes and values, ruled by responsibilities, having influence), helped nurses to facilitate patient’s involvement (creating options for choices and decisions, encouraging intake of food and fluid, inviting next of kin to take part in nutritional care) in nutritional care. By creating options for nutritional choices and encouragement the patient could take part in the decisions. Next of kin were invited to participate and thereby further enhance the patient’s nutritional intake. Nurses connected the individual patient’s nutritional need and preferences to their earlier experiences and knowledge of similar types of patients. The patients’ general condition was also taken into consideration. Being aware of one’s own knowledge regarding nutritional matters, gave nurses confidence in their own ability. Limited knowledge and experiences in combination with an open mind looking for new solutions led them to seek dialogue and cooperation with team members. The team was ruled by responsibilities, providing influence, but also challenging the nurses through attitudes and values. Within the organisation some important factors were highlighted, such as the environment, tools, continuity and channels of information.
M. Wentzel Persenius et al.
Knowing the patient Being familiar with the nutritional history of the patient was of importance. For example, one nurse described her patient as being unable to eat and drink enough at home due to loose stools. This had led to weight-loss and the patient was now running out of steam. The nurses asked the patient’s next of kin about the patient’s preferences about food and fluid ‘‘Her daughter told me that she (the patient) had always been very thin, but might even have gained some weight now.’’ To continuously find out the patients’ individual nutritional needs and preferences during the ICU stay gave the nurses a base for the nutritional care. The patient’s need for energy, preferably measured via indirect calorimetry, gave the nurses feelings of security and control, as this measure could be compared with the actual intake. They knew what the patient needed and could set daily goals for energy delivery. The patient’s feelings of hunger and appetite were welcome signs of nutritional improvement. It emerged as a milestone in the nutritional care, as the nurses then felt that the patients ‘‘were feeling better’’. A close monitoring and evaluation of the patient’s individual feeding tolerance, by assessing the patient’s abdominal status, including bowel function, was another property. The gastrointestinal feeding intolerance could vary from no stools at all to many loose stools per day and gastric residual volume (GRV) often increased. The stomach could be a big problem and even affect the breathing. ‘‘Sometimes it is difficult to know in advance what can be expected from the patients, then a close monitoring and evaluation of feeding tolerance and what the patient benefits from is of importance’’. Decreased feeding tolerance due to the feeding tube made the patients sometimes refuse to eat and drink and wanted to remove the feeding tube.
Facilitating the patient’s involvement Creating options for choices and decisions for the patients were of importance. . . . there’s a strong fixation with dietary supplements as their first drink. . . Personally, I think they should be given a choice about what the first thing they will drink is. It shouldn’t have to be so nutritious the first few times they drink. If they want a coke or a beer or just water, then they should be given that, so that they feel that they have been granted at least one wish. That’s better than going on about dietary supplements from the very star. Giving time for reflection was a strategy used by the nurses when creating options for choices and decisions. When observed, an elderly woman told the RN in charge of her that she thought it would be better for her to have her wide bore tube replaced with a small bore feeding tube. Later, when interviewing the nurse in charge of the patient, she said that the patient had been informed about the advantages of having a thin bore tube the evening before. The nurse thought that it was valuable to the patient to be given some time to think this over: ‘‘To point something out and let it settle for a while. Think about it.’’
Balancing between individual and routine care The nurses encouraged intake of food and fluid. It was observed that they listened carefully to what the patient said and explained things in a clear manner. When talking to patients who were afraid of asking for help because they did not want to bother the nurses it was ‘‘important to point out that they are allowed to ask for cold water or ice cubes. Very small things.’’ An effort was made to motivate the patient, to make them realise that they must give it a try. Sometimes distractive manoeuvres were performed. The nurses felt that they sometimes abandoned the encouraging manoeuver in favour of ‘‘very persistent pressing’’ to make a patient drink or eat, something they dislike. When the patient started eating and/or drinking, the next of kin could be invited to participate. They were encouraged to talk about food with the patient, to find out what the patient wanted to eat.
159 had obligations to fulfil during each shift. Communication and trust in each other was needed. Having influence within the ICU team meant that the nurses could suggest improvements, which were then considered further. They were pleased when they felt that there was an open atmosphere to express wishes, while not being listened to resulted in feelings of disappointment. ‘‘I have tried to raise the question many times, but finally you give up.’’ Ahead of the patients’ transfer to their home ward, extended concerns were raised regarding the nutritional care that should continue. The nurses wished that their reports and care plan for the patient were used and useful, but they were afraid that their nursing notes would not be acknowledged at the home ward. When observed, encouraging the patient’s intake of food and fluid was mentioned as being very important, when reporting the patient to the RN on the ward.
Being a nurse in a team The nurses were seeking dialogue and cooperation regarding nutritional matters among or outside their own profession, because ‘‘we are all a link in the chain and all strive to do what’s best for the patient.’’ The teams mentioned were of various configerations. Sometimes the team was the RN and the enrolled nurse on the ICU, sometimes it was the entire ICU staff and sometimes the ICU and other wards. It was favourable to have others, such as the nutritional team, the physicians and the dieticians to consult in nutritional matters. However, the nurses were also aware that the nutritional knowledge among fellow workers could vary: ‘‘People do bring different knowledge into the team. . . something you realise after a while.’’ One strategy used to handle this and to secure the care, was to remind each other about what to do, something that was both observed and mentioned in the interviews. The nurses were challenged by attitudes and values in their daily nutritional work. Nutrition in general was not considered as important as technical and surgical procedures. Yet, nurses with long experience had noticed an increase in positive attitudes towards nutritional issues among all staff. Reasons mentioned were increased knowledge and the presence of nutritional teams. However, it was easy to be updated and understand all the changes. Nutrition has become fashionable with focus on a few issues, for example the nutritional feeding pumps, which overshadows nursing care. Going beyond the routine would be a dilemma. You are not supposed to change the traditional ways and the unwritten rules of performing care. The nurses were ruled by responsibilities within the team. Planning and prescribing the patients’ nutrition was taken care of during the rounds by the physicians, along with RNs and enrolled nurses. The only differences noted between RNs and enrolled nurses were regarding their responsibility. The delivery of enteral feeding was often delegated from the RNs to the enrolled nurses, while the RNs were mainly handling the parenteral nutrition. This routine is a way of sharing responsibility, which worked smoothly and securely, but some RNs experienced a loss of control when EN was delegated to the enrolled nurse. Some enrolled nurses had experienced loss of control when RNs took over the checking of the location of the feeding tube. Everybody
Having professional confidence Having knowledge of the complexity of the patient’s condition was wanted, but limitations of their own knowledge and clinical judgement made them open for new solutions of problems. Having experience of different types of patients helped the nurses to separate the standard patient, or the so-called ‘‘easy ones’’ in need of standard care, from the more ill or specific patient in need of special attention. Having former experience of how to deal with nutritional matters gave the nurses confidence. Sometimes they went beyond the framework and deviated from guidelines and attitudes. Lack of former experience, expressed by nurses with short experience of intensive care, made it more difficult to know what to expect, because they did not have anything to compare with.
Having a supportive organisation The environment was of importance for the patient’s nutritional intake in several ways. By placing the patients in an ICU module (a room with two beds) the nurses thought it was easier to carry out nutritional nursing care compared with having the patients placed in the large postoperative unit. In the ICU rooms with two beds, there were more hands and less technical events, and the patient could really be seen, compared with ICU patients cared for in the large postoperative room. Having a comfortable armchair for the patient to sit in and look out through the window during the meals was appreciated. Serving preferred food in an attractive way, for example by pouring fluid into stemmed glasses and adding ice and fruit, and placing it on a nice tray, were important. Tools like guidelines, documentation and feeding pumps were all supportive for the daily nutritional care, but they could also be an obstacle. Guidelines regarding nutrition and gut motility were considered clear, available, uniform, easy to handle and safe: ‘‘We base our work on these memos, so not a lot can go wrong, you know. . . you know what to do then.’’ Deviations from guidelines were also described and observed. The nurses described both advantages and disadvantages regarding the flow sheets and nursing docu-
160 mentation. The flow sheets did not support all nutritional issues of importance. The use of feeding pumps led to slower, continuous delivery with fewer complications, such as diarrhoea. Malfunctioning pumps caused a lot of irritation, putting patients at risk. Continuity in the nurses’ schedule was experienced as making nurses take more responsibility and actively making sure that the patients gut motility was under close observation, and thereby facilitating the delivery of enteral feeds. Having channels of information was needed in order to provide secure care. For example when establishing new nutritional routines, adequate information was expected to be available. Lack of appropriate information channels led to rumours and confusion about what to do.
Discussion The findings led to a substantive theory, which gives a deeper understanding of the concerns and strategies of nutritional care for patients with EN in ICU. This theory implies that it is important for the nurses to have and to hold nutritional control over the patient’s nutrition. Furthermore, it was found to be a balancing act between individual care and routine care. Finding a balance between individual care and routine care was a way of enhancing the patient’s wellbeing, security and quality of care. A mutual understanding between the patient and the nurse regarding the patients’ needs for nursing care, relevant actions to the goals of care as well as the roles between patients and nurses is in line with patient-centered or individualised nursing care. As a consequence of knowing the patient, nurses can give individualised nursing care. However, the patients cannot always participate and give their opinion. There are also times when nurses need to plan and provide for care without having a mutual understanding (Florin, 2007). The nurses’ daily nutritional care was based on knowing the patient. The return of the patients’ hunger and appetite was considered as a milestone in the patients’ recovery. Changes in appetite related to gut hormones in patients in the ICU have been found (Nematy et al., 2006), which might explain the reduced or altered taste sensations that make the nutritional intake more difficult. Individual assessment of the patients’ favourite taste of food and fluid are important to improve adherence with the nutritional care. Assessing the patient’ feeding tolerance is a concern for nurses in ICU, because impaired gastro intestinal motility, altered cough and gag reflex, and endotracheal and nasogastric tubes increases the risk of aspiration (Marshall and West, 2004). Despite this, there is no consensus regarding assessment of the feeding tolerance (Reintam et al., 2008). Current management of monitoring tolerance to enteral feeding like withholding EN in patients with diarrhoea and ceasing EN when GRV is high, may result in inadequate delivery of nutrition (Marshall and West, 2004). Further research addressing the assessment and management of feeding tolerance is therefore required. Many patients in the ICU are unable to participate in the decision-making process, but as their general condition stabilises, the opportunity to participate arises. The nurses
M. Wentzel Persenius et al. were facilitating the patients’ involvement in care and thereby their ability to (re)gain an influence on what to eat and drink. There sometimes was a dilemma between following routines and taking the patient’s own will into account. Strictly following nutritional guidelines could sometimes contradict the patient’s own will. It is known from other areas that when the patient’s own will is not obvious, the staff are using the principle of doing good. Situations where the patient’s will is clearly grasped, the staff become more respectful about the patients right to self-determination (Jansson and Norberg, 1989, 1992). Inviting the next of kin to participate in the nutritional care was also appreciated according to the nurses. Similar findings have been reported by Hupcey (1999), who found that next of kin wanted to do something more than just be there, as it provided them with a sense of control and enabled them to support and look after the patient (Hupcey, 1999). There is a need for research focusing on the next of kin’s involvement in nutritional nursing care within the ICU. Being a nurse in a team was to seek dialogue and cooperation regarding nutritional matters, among or outside their own profession. Within the ICU team, problems are known to be (dis)solved jointly with other health care professionals (Wikström and Larsson, 2004). However, different levels of skill acquisition to function as a team member have been found to be a barrier for teams working in acute health care. Assertiveness and confidence are essential skills that are needed in order to function as an effective team member (Atwal and Caldwell, 2006). Being ruled by responsibilities highlighted the demands on communication and trust, because if that failed, they expressed feelings of fear of losing control. Interestingly, the only differences noted between RNs and enrolled nurses was regarding their responsibility. The nurses were challenged by attitudes and values in the team, something that had an impact on their daily nutritional care of the patients. Nutritional care in general was not considered as important as other treatments, something found in other studies (Lennard-Jones et al., 1995). In our study RNs and enrolled nurses with greater experience did emphasise that nutrition had a higher importance than previously. Team work requires many skills, because it involves not only one’s own role but also the role of the other team members. Therefore team playing skills must be an integral part of continued professional development (Atwal and Caldwell, 2006). In spite of the differences in nursing level, the RNs’ and enrolled nurses’ nutritional experiences were similar. Having professional confidence implies that nurses connected each individual patient’s nutritional need and preferences to their knowledge and earlier experiences of similar types of patients. It was found that the combination of knowing the patients condition over time, as well as being aware of and reflecting on one’s own knowledge in connection with former experiences regarding nutritional care, gave confidence in how to handle the present situation. Benner et al. (1996) found that nursing actions in the ICU were response-based, relying on intuition of what had worked in similar situations in the past, individually modified in accordance with the patient’s response. However, often a more systematic process represents the rationale of nurses’ intuitive practice. For example a strong clinical
Balancing between individual and routine care knowledge base in combination with an ability to apply this to the needs of the individual patient used in a continuum of decision making (Harbison, 2001). Furthermore, classification has been suggested as a model for clinical decision making (Buckingham and Adams, 2000), and prioritisation of nursing problems (Hendry and Walker, 2004). The nurses were also aware of that they did not always fully embrace the patient’s complexity of problems and needs or the options for nutritional care. They were aware that they did not know everything regarding nutrition and were keen to find new solutions that could lead to seek dialogue with fellow workers. According to Benner et al. (1999) they remain open for being wrong, making an inaccurate judgment, and they have openness in relation to that their preconception must be reconsidered. Being able to recognise when they do not have a good grasp of a situation is perceptual skill. A good clinician, she means, is thinking in action and reasoning through transitions in the patient’ condition (Benner et al., 1999). Organisational factors were referred to as more or less supportive to nutritional care. The caring environment could have an impact on the patients’ intake of food and fluid. It also made the nurses pleased with their care, which hopefully is mirrored in the care, because when patients feel safe, are receiving extra care and participate in care, it is within a positive environment (Wåhlin et al., 2006). The guidelines used in the ICU were considered supportive in the care of the patients, yet some deviations from current guidelines were described. Insufficient awareness of the benefits of the guidelines, real and perceived deterrents, poor agreement about implementation responsibility and lack of enabling and reinforcing strategies, were all reasons for underuse of semi-recumbency for pneumonia prevention (Cook et al., 2002). Intentional deviations from the guidelines were described as well, in order to meet patients’ requests for what they wanted to eat and drink. More research is required about why nurses do not follow accepted guidelines. RNs consider both standards and individual judgments as important to patient safety (Berland and Natvig, 2005).
Methodological consideration In Grounded Theory, credibility may be seen as inherent in the method, as the emerging substantive theory is based on the method of constant comparison in which categories and properties repeatedly emerge and guide the continuing research (Glaser and Strauss, 1967). In this study, the use of the multi-method principle was a way to further improve the credibility, and the combination of observations, interviews and memos made the data rich and extensive. In addition, the analysis was continuously discussed with the two coauthors. Furthermore, the data collection period was long in the study the reference they are referring to that was linked to this, as it was difficult to find patients alert enough to participate. Prior to this study, the researcher (MWP) had worked as an RN at the ICU in focus. The findings may be biased when the researcher is familiar with the actual setting, here an ICU, but it can also be seen as an advantage as it makes it possible to identify and reflect on nutritional matters that
161 might have escaped the attention of a researcher without such a background (Lykkeslet and Gjengedal, 2007). However, this study does not have the possibility to embrace every aspect of the patients’ nutrition while in an ICU. Further research is therefore needed to develop this substantive theory in other ICU settings.
Conclusion This study shows that nurses have a key role in knowing the patients nutritional situation. This, in combination with their professional confidence and collaboration within the team, helped them to facilitate patient’s involvement in nutritional care. The teamwork as well as the organisation can be both challenging and supporting to the provision, maintenance and development of nutritional nursing care. Nutritional care, a multidisciplinary responsibility with a joint approach, needs continuously time for reflection, development and training in clinical care. This study has deepened the understanding of RNs and enrolled nurses concerns and strategies of nutritional nursing care for patients in ICU. This can be of importance in the daily nutritional nursing care for all health care professionals. To have and to hold nutritional control over the patient’s nutrition was found to be a balancing act between individual care and routine care.
Acknowledgement We wish to express our gratitude to Ellinor Larsen, for linguistic supervision.
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