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Håkonsen et al. BMC Health Services Research (2019) 19:642
https://doi.org/10.1186/s12913-019-4450-1
RESEARCH ARTICLE Open Access
Lack of focus on nutrition and
documentation in nursing homes, home
care- and home nursing: the self-perceived
views of the primary care workforce
1,2* 1,2 3 4 1,2,4
S. J. Håkonsen , P. U. Pedersen , A. Bygholm , C. N. Thisted and M. Bjerrum
Abstract
Background: Malnutrition is a comprehensive challenge for the nursing home, home care- and home nursing
sector. Nutritional care and the subsequent documentation are a common and multifaceted healthcare practice
that requires that the healthcare professionals possess complex combinations of competencies in order to deliver
high-quality care and treatment. The purpose of this study was to investigate how a varied group of healthcare
professionals’ perceive their own competencies within nutrition and documentation and how organizational structures
influence their daily work and the quality of care provided.
Methods: Two focus groups consisting of 14 healthcare professionals were conducted. The transcribed focus group
interviews was analyzed using the qualitative content analysis approach.
Results: Six categories were identified: 1) Lack of uniform and systematic communication affect nutritional care
practices 2) Experience-based knowledge among the primary workforce influences daily clinical decisions, 3) Different
attitudes towards nutritional care lead to differences in the quality of care 4) Differences in organizational culture affect
quality of care, 5) Lack of clear nutritional care responsibilities affect how daily care is performed and 6) Lack of clinical
leadership and priorities makes nutritional care invisible.
Conclusions: The six categories revealed two explanatory themes: 1) Absent inter- and intra-professional collaboration
and communication obstructs optimal clinical decision-making and 2) quality deterioration due to poorly-established
nutritional care structure. Overall, the two themes explain that from the healthcare professionals’ point of view, a visible
organization that allocates resources as well as prioritizing and articulating the need for daily nutritional care and
documentation is a prerequisite for high-quality care and treatment. Furthermore, optimal clinical decision making
amongthehealthcare professionals are compromised by imprecise and unclear language and terminology in the
patients’ healthcare records and also a lack of clinical guidelines and standards for collaboration between different
healthcare professionals working in nursing homes, home care or home nursing.
The findings of this study are beneficial to support organizations within these settings with strategies focusing on
increasing nutritional care and documentation competencies among the healthcare professionals. Furthermore, the
results advocate for the daily involvement and support of leaders and managers in articulating and structuring the
importance of nutritional care and treatment and the subsequent documentation.
Keywords: Focus group, Content analysis, Nutrition, Documentation, Nursing home, Home care, Home nursing
* Correspondence: sjh@cfkr.info
1
Centre of Clinical Guidelines – Danish National Clearing house, Department
of Health Science and Technology, University of Aalborg, Aalborg, Denmark
2
Danish Centre of Systematic Reviews: A Joanna Briggs Institute Centre of
Excellence, Aalborg, Denmark
Full list of author information is available at the end of the article
©The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Håkonsen et al. BMC Health Services Research (2019) 19:642 Page 2 of 15
Background and inconsistencies. Between 42.1 and 88.2% of the par-
Healthcare systems worldwide use an evidence-based ticipants in the study were unfamiliar with the locally
practice (EBP) approach aiming to provide care and recommended nutritional screening tools and 61.4–
treatment of high quality. In order to make the best clin- 71.4% knew where and how to document patients nutri-
ical decisions in day-to-day patient care, care and treat- tional problems, including developing care plans [18].
ment must be based on information from various Variations were discovered across and in between three
sources, such as rigorous research, clinicians’ expertise different groups of health care professionals and across
and patients’ perspectives and preferences [1]Many health care settings (home care versus nursing home)
countries and international organizations have developed [18], hence the conclusion that the skills and competen-
evidence based practice guidelines for nutritional care cies to practice nutritional care are challenged within
that can be applied and transferred to areas within the these specific contexts.
primary healthcare sector [2]. Despite the existence of In order for organizations to implement strategies
these evidence based practice guidelines [2], malnutri- aiming at increasing nutritional care competencies
tion, especially undernutrition, and the causes of nutri- among their workforce, studies have suggested that re-
tional-related issues are poorly identified in both nursing search examining the specific competencies of primary
homes, home care- and home nursing [3, 4]. The poor health professionals in providing nutrition care and
identification within of malnutrition within these setting documentation, and the factors associated with deliver-
have led to malnutrition rates that range from 40 to 90% ing a safe and effective care and treatment are conducted
[5–7]. Malnutrition results in negative outcomes for pa- [19, 20]. In 2016 a project aiming to map healthcare pro-
tients, caregivers and the healthcare system, including fessionals´ level of knowledge, routines and attitudes
increased morbidity, mortality, increased care needs and towards nutrition and documentation within nursing
hospital readmissions [8, 9]. Nutritional care does not homes and home care/home nursing was launched. The
only encompass the basic duty to provide adequate and present study, part of this project, explore some of the
appropriate food and drinks to patients. It also com- questions raised in the first study in the project, the
prises the consistent and systematic assessment, diagno- cross-sectional study [18] as it raised a number of ques-
sis, intervention, monitoring and evaluation of factors tions about possible causal links within nutritional care
that can directly or indirectly influence patients nutri- and documentation.
tional status [10]. In order for healthcare professionals Firstly; when managers do not consider documentation
to deliver high-quality nutritional care, several studies important enough to give it priority by requesting it as a
stress that the healthcare professionals competencies, necessity in the organization, this might have a negative
the context in which care is delivered (home care or impact on the healthcare professionals’ daily clinical deci-
nursing home), collaboration between different health- sions. Secondly; inadequate competencies among the
care providers and the organizational approach taken are healthcare professionals to perform goal-oriented nutri-
important influential factors [11–18]. Nutritional care is tional care could be an obstacle to high-quality nutritional
a common, complex and multifaceted healthcare prac- care and documentation. These questions are explored
tice that requires precise communication and coordin- more thoroughly in the present qualitative study to gain a
ation among different healthcare providers in order to moredetailed understanding of the issues and associations
ensure continuity of care and treatment. Nutritional care outlined in the survey.
and the subsequent documentation therefore require Studies have previously investigated nurses, nursing aids
that the healthcare professionals possess complex com- and physicians’ level of knowledge, their practices and their
binations of nutritional and documentation knowledge, attitudes towards nutrition [25, 26], and other studies have
routines and attitudes [3, 19–21]. Lack of nutritional examined documentation routines among different health-
care competencies among healthcare professionals nega- care professionals [27]. The present study is unique in that
tively influences patient-outcomes and safety-measures it is the first qualitative study to investigate nutrition and
[22, 23]. So, despite being a large part of their daily work documentation within a collaborative frame and dynamic,
assignments and tasks it is problematic that healthcare as it examines three different groups of collaborative health-
professionals, regardless of their educational level or care professionals, registered nurses, social and health ser-
skills, typically receive minimal training on nutritional vice assistants and social and health service helpers and
care and treatment, as well as the subsequent documen- their self-perceived knowledge, routines and attitudes to-
tation thereof [3, 24]. wards nutrition, documentation, as well as their perceptions
The results from a cross-sectional study in a Danish of factors that influence their daily work and quality of care
municipality among collaborative healthcare profes- provided. The purpose of this study is to investigate how
sionals displayed that the documentation routines and healthcare professionals’ self-perceived views on competen-
level of nutritional knowledge had noticeable variations cies within nutrition and documentation and organizational
Håkonsen et al. BMC Health Services Research (2019) 19:642 Page 3 of 15
structures influence their daily work and the quality of care length of education ranged from 1 yr and 2 months (SSH),
provided within the nursing home, home care- and home to 1 yr and 8 months (SSA) to 3 yrs and 6 months (RN)
nursing setting. within the three groups of healthcare professionals. The
theoretical part of the SSH and SSA education comprises
Methods app. 30–40% of the total. The RN education consists of
Setting 60%theoretical education. The practical and clinical train-
The study was conducted in a Danish municipality (popu- ing parts of the SSH and SSA education consists of 60–
lation>70.000) that employs 1134 Social and Health 70% of the total whereas the RN education consists of
Service Helpers (SSH), 143 Social and Health Service 40% practical training. Table 1 depicts the professional
Assistants (SSA) and 120 Registered Nurses (RN). The characteristics of the participants.
municipality is divided into four districts with local man-
agements referring to an overall management within nurs- Data collection
ing homes, home care and home nursing. Data was collected using focus group interviews in order
to capture the collaborative interactions among the
Sampling healthcare professionals included [28, 29]. The focus
The sampling of the participants was carried out by a groups were composed of people with similar character-
local coordinator working in the municipality and was istics as they all were employed within the same munici-
based on a convenient sample. This implied that the pality, had different educations and collaborated on a
local coordinator selected those employees fulfilling not daily basis (see inclusion criteria in Table 2).
only the inclusion criteria’s but also who she assessed It thereby provides authentic insights into a cultural
would provide the study with the best information. In- collaborative group, through direct access to their inter-
clusion criteria matched the workforce within nursing actions, their language and dynamics. Seven healthcare
homes and home care/home nursing with maximum professionals participated in focus group one and seven
variation concerning the following: healthcare professionals participated in focus group two,
The two focus groups were composed of a mix of the for a total of 14 healthcare professionals. In focus group
inclusion criteria in order to obtain a true reflection of one, the years of working within these specific settings
the clinical reality and to enhance discussion. varied from 18months – 14 yrs. In focus group two, the
years of working within nursing homes and/or home
Participants care/home nursing varied from 1 yr to 31 yrs.
Seven health care professionals participated in each focus The two focus groups interviews were conducted by
group giving a total of 14 healthcare professionals. Their SJH who is an experienced registered nurse and MB
Table 1 Professional characteristics of the participants
Profession Place of work Number of years Years of working in
(nursing home, educated (range) nursing homes
homecare, and/or home
homenursing) care/home nursing
(range)
Focus group 1 Registered nurse (1A) Homenursing (18months – 15years) (18months – 14years)
Registered nurse (1B) Homenursing
Social and health service assistant (1C) Homecare
Social and health service assistant (1D) Nursing home
Social and health service assistant (1E) Homecare
Social and health service helper (1F) Nursing home
Social and health service helper (1G) Homecare
Focus group 2 Registered nurse (2A) Homenursing (18months – 35years) (1 year – 31years)
Registered nurse (2B) Homenursing
Social and health service assistant (2C) Nursing home
Social and health service assistant (2D) Nursing home
Social and health service assistant (2E) Homecare
Social and health service Homecare
helper (2F)
Social and health service Homecare
helper (2G)
Håkonsen et al. BMC Health Services Research (2019) 19:642 Page 4 of 15
Table 2 Inclusion criteria the described assumptions [33–35]. The participants’
Education: views and perceptions were constantly analyzed and
- Registered nurses considered within the social interaction dynamics. All
- Social and healthcare assistants observations on group dynamics were written down dur-
- Social and healthcare helpers ing the focus groups and were subsequently analyzed
Number of years of education: and assessed within the context of their collaborative
- Maximum variation of years since completion of education
Number of years in a primary health care setting: interaction. No social interactions dynamics theory
- Maximum variation of years of employment in a primary health care was however included in the analysis, as the observa-
setting (home care, home nursing or nursing homes) tions on the participants interactions were analyzed
Employment: within the content analysis frame. Consensus, dis-
- Current employment and working in the municipality was a main agreements and diverse views among the informants
criterion were acknowledged and emphasized as equally im-
portant by the interviewers.
who is an experienced qualitative methodology re- The analysis was conducted in four steps. Firstly; the
searcher. MB primarily attended the focus groups as an interviews were read by SJH several times to gain an
observer ensuring that ethics and all interview aspects overall understanding of the transcripts and notes were
were addressed. The focus groups interviews were con- made throughout the reading. To increase reliability the
ducted in September 2017 and lasted 84–94min and reading started at different pages each time [36]. Sec-
took place in a secluded and private meeting room, ondly; meaning units relevant to the purpose of the
without the disturbance of colleagues or managers. The study was identified using two research questions: 1)
discussions among the focus groups participants were What are the self-perceived competencies (routines,
audiotaped and transcribed verbatim including non- knowledge and attitude) regarding nutrition and docu-
verbal signs such as laughter and hesitating by a tran- mentation among registered nurses, social and health
scription service and carefully checked for transcription service assistants and social and health service helpers
errors and accuracy by (SJH). working in nursing homes or home care or home nurs-
A semi-structured interview guide was used to steer ing? 2) Which factors (context, collaboration, and
the focus groups towards the phenomena of interest and organization) do registered nurses, social and health ser-
to ensure consistency. The interview guide have not vice assistants and social and health service helpers be-
been published elsewhere (see Additional file 1). In order lieve influence their daily work and the quality of care
to ensure internal validity the interview guide was de- provided? Thirdly; (the descriptive level), the derived
signed to respond to the nine assumptions revealed from meaning units were labelled and coded which described
the survey study [18], see Table 3. the condensed meaning units. The codes were then
The interview guide comprise six domains: 1) Rou- examined for similarities and grouped together into six
tines in relation to nutrition and documentation, 2) categories, hence describing the essence of the health-
Knowledge in relation to nutrition and documentation, care professionals self-perceived knowledge, routines
3) Attitudes towards nutrition and documentation, 4) and attitudes towards nutrition and documentation and
The context of their daily work, 5) Collaboration the quality of care delivered. Fourthly; (the explanatory
between different healthcare professionals and 6) The level), these categories were comparatively examined to
organization of their employment. Examples of ques- interpret and explain how healthcare professionals
tions are shown in Table 4. Each domain of the inter- perceive their own competencies as well as the
view guide consisted of several questions (between 4 organizational structures and finally compromised to
and 12 questions within each domain) and probing two overall themes [32]. The analysis was conducted in
questions which were used to explore and clarify the a constant dialogue between SJH and MB, and the main
participants views were used to assist and support SJH outlines were discussed with PUP and CNT in order to
and MB in the focus group situations if the conversa- rule out misunderstandings and maximize validity. An
tions and discussions among the participants were not example of the analysis process is shown in Fig. 1.
running smoothly or there were confusion or insecurity To increase the validity of the study, an inter-rater re-
related to the questions asked. liability test was performed. An inter-rater reliability test
examines the extent to which two or more independent
Data analysis coders obtain the same result when using the same cod-
The transcribed interviews were analyzed according to ing frame [38–40]. SJH and CNT both familiar with
the qualitative inductive content analysis methodology qualitative content analysis methodology coded part of
[30–32] and ensuring validity focused on how the mani- the transcripts [41]. Prior to the coding process SJH
fest and latent content of the informants’ views explain carefully introduced CNT to the coding frame. From a
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