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Table 3 Summary of themes and applicable quotes based on the focus groups and interviews

From: Changing nutrition care practices in hospital: a thematic analysis of hospital staff perspectives

Building a Reason To Change

 Using drivers to change

If they think it’s affecting patient care, if they think they’ll make the patients better and if they think it’ll make the care more efficient and less expensive, I don’t think it’s a tough sell at all. [Site B-I2: Attending Physician]

What drove this was... it’s one of the competencies for the students is they have to learn, I don’t know if it’s SGA or if they have to learn physical assessment, so we were like, ‘We don’t do this’. We have to be able to teach the students and able to meet their competencies so we better learn it ourselves, which I am so thrilled that I was like yay. It’s more than just [name of interviewee] saying so. [Site A-I7: RD, Dietetics Manager]

 Facilitating the change process

I think if it doesn’t have a lot of meaning for people and there’s no associated actions tied to it so people don’t see it as valuable so I think that’s probably one of the questions that people tend to skip some of the time. If they can see that value I think that would be very helpful in that change management piece. [Site A-I1: RN, Manager]

But it’s numbers. That’s the challenge. You get to the VP level, all they want to talk about is numbers and right now we’re all talking this is a great idea and nobody argues with them. It’s a great idea but until we get some good numbers that we can prove it, then it’s going to be a lot more powerful then. [Site B-I7: Senior Management]

Simple, effective, with a clear meaningful impact then it’ll be fine. This [nutrition screening with CNST] is an easy one. This is not adding an extra 45, you know, we get asked to do, you need to do this now when you’re discharging a patient and it’s actually 40 min for every discharge and we’re like, whoa, you just increased my day by two hours. So that’s hard to sell. [Site B-I2: Attending Physician]

 Being ready for change

I think when you talk honestly and you talk openly about [the change] to them and you tell them right off the bat we don’t promise to have all of the answers. We don’t promise to know everything but we’re going to work with you and we’re going to figure it out as we go, right? I think the thing is, is we’ve been talking about it and we’ve done other changes and they’ve seen how we’ve proceeded to do those other changes and we’ve done them exactly how we’ve said is that we have to start somewhere. Here’s where we’re starting. We’ve taken two or three weeks where we’ve tweaked them and made changes. We’ve listened to their comments and suggestions and then we’ve improved it. [Site B-I3: Food Service Manager]

… when they start balking the system and not wanting to change, the thing that we always remind them is that, do you have a cell phone? Do you have an iPhone? “Yes.” How many times have you updated your iPhone in the last year? “Well three or four.” Then why is your work not the same? And I think if you put it into those terms, that speaks to every single one of them. They say, “Oh yeah, that makes sense.” [Site B-I3: RD, Manager]

Involving Relevant People in the Change Process

 Involving staff in the change process

It’s almost like saying every patient needs to walk but that doesn’t mean that physio needs to walk with every patient. Right. Every patient needs proper nutrition care but that doesn’t mean it should necessarily be a dietitian. [Site E-FG2: Physiotherapist]

I think it’s really important to get down to that front level staff so they understand what the process and what the impact might be but also that they also have an impact as to how it’s going to be rolled out and positive, how those interactions are going to be played out. [Site 5, Int 3: Food Service Manager]

Getting feedback from those involved. Whenever I roll out change with my staff, I always get their feedback because they’re so knowledgeable; because they’re the ones actually doing it. [Site C-I3: Food Service Supervisor]

 Involving patients, families and friends in the change process

A large group that would be good to involve is the patients, and or the families. … They’re sitting here for long periods of time with nothing to do. If they, if we have some way of involving them, I think. And if they understood, because it’s the families who have to sustain whatever plans we put into place when they leave here. [Site B-FG1]

 Involving volunteers

We would love to use volunteers. … that would be wonderful to have them on the unit because at mealtimes, because then they can go in and visit the patients and get them the assistance. Those that don’t need to be fed they can take care of setting them up or maybe helping setting the trays prior to us getting there; that kind of thing. We would love to see volunteers. [Site C-I3: Food Service Supervisor]

 Obtaining buy-in from stakeholders

They need to understand why they’re doing it and then I always think personalizing it to the client or patient that usually is a pretty good sell. Then I think people will buy in and we could get some sustainability. [Site A-I12: Manager]

Embedding change into current practice

 Incorporating small changes slowly

So you have to start small, iron out the kinks if you will and then replicate it as you can if humanly possible so. [Site A-I12: Senior Management]

I certainly think that people feel a lot less, I think, angst knowing that they’re trialing something for a short period of time and of it is not going to work out we can tweak it and modify it and that it’s not something that’s for, you know longer periods of time. [Site E-I3: RD, Clinical Site Lead]

 Benefiting from existing structures and processes

… what I can offer is looking at ways of reducing a length of stay by designing systems… how do I connect the process and identify these patients early on so that the discussion, the conversation can happen earlier on a lead time is always money. How I would try to embed this process? … How I do embed it would be…there would be a way of identifying them right off the bat, upon admission on our board. [Site D-I3: Manager]

 Accounting for staff perceptions of best practice

…when and how we roll this out if we can involve the staff as much as we can to bring them into it, the more they play a part in the pre-rollout the more successful we’ll be. [Site B-I5: Clinical Manager]

Yeah, give examples, maybe give some concrete patient examples that they can see that relate to medicine. [Site B-I1: RN]

 Facilitating the integration of sustainable change

So it has to be standardized, right, and it has to be there all the time so, yeah. And part of the problem is there’s, you know you’re going to have this problem on a ward or - we have patients all scattered throughout the hospital and this ward sometimes has non-medicine patients on it so you have to pick your audience and decide what you want to do. It’s totally doable. [Site B-I2: Attending Physician]

Accounting for Climate

 Working within the constraints of the hospital structure

… we had to bring more hours back into the department because some of those hours were with housekeeping. … got involved with the union, reallocating hours, job re-assignments, redevelopment of job routines. There was a lot involved with that. Summary training, because new employees coming in maybe didn’t do tray delivery so we had to retrain. There’s a lot involved with that. [Site C-I3: Food Service Supervisor]

 Presenting nutrition as a benefit or value to the hospital

Nursing to patient ratio’s gotten lower and lower, higher and higher, lower and lower. Patient and nurse ratio has gotten higher and also can’t afford to make it lower. It’s bad care. No one says it corporately but we all know it. Even the hospital says they’re firing 57 nurses and then [name] gets on the radio and says, “But it won’t affect any patient care.” Come on. [Site B-I2: Attending Physician]

I think that we’re pretty engaged. As a health region we’re engaged and again I think that’s one of the benefits of having a smaller health region is initiatives like this can gain a lot of momentum and be shared because they’re interdisciplinary, they cross so many different areas and we’ve had lots of opportunity to talk about it. [Site A-I6: RD, Manager]

Building strong relationships within the hospital team

 Using the right amount of communication with the right message

I think that one of the keys if we want to make sure that this is something that’s well known and people can anticipate potentially being replicated, is to do a good amount of communication. So not over-communicating but making sure that it at least stays in the forefront of peoples’ minds and I don’t think we should isolate that just to one group because I know that a more senior leadership level or the people that are directly involved. [Site A-I12: Senior Management]

 Developing and maintaining trust

Feeling comfortable enough to know who to ask and knowing that it’s going to happen. … And I think the relationship, like KE1 and I, the CCL and I have with our staff is that they’re very comfortable to come and tell us what they need and how they feel. [Site B-I5: Clinical Manager]

 Engaging the team

Our group has met several times so we obviously feel comfortable as a group but actually working together on behaviour change and the PDSA cycles and all that. [Site E-I3: RD, Clinical Manager]

 Breaking down individual silos

I like to see allied help because I’m a nurse; my background is nursing. I really like to the allied members of the health team engage the nursing side of it, because so often we’re so siloed in our specialties that we don’t come together. [Site C-I1: RN]

 Using communication tools

I have a communication book in my department. If I’m making departmental changes, I always leave them there. I hold huddle meetings when I’m here on site. … I try to bring people together to go over the issues and the communication book to reach staff that I don’t see. Then if it’s a huge impact that needs to happen right away, I will call staff even at home and say, “This is changing immediately. This is what’s happening.” This is what I try to do. [Site C-I3: Food Service Supervisor]

 Using face to face communication

Just speaking from the change management project that we work with, it was a really interesting experience; first for myself on that level for having that many people around that table representing different areas that are touched by nutrition services. I was pleasantly surprised at the input and the feedback from everybody but equally as much surprised that through the discussion there was a lot of aha moments for people. [Site E-I3: RD, Manager]

How we can improve communication ... We did a walk around. We met with [name] the manager, found ways to identify to nursing staff whether a patient ate less than half of their tray. We did some brainstorming. [Site A-I5: RD, Food Service Manager]