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Table 4 Representative quotations for theme 2: Modifying prescription practices to align with patient-related factors

From: A qualitative exploration of factors influencing medical staffs’ decision-making around nutrition prescription after colorectal surgery

Subtheme

TDF domain

Quotes

Considering surgical factors and patient demographics

Knowledge/ Behavioural regulation/ Belief about consequences

We used to use clear fluids years ago, but not anymore – only in cases where there might be an ileus then we introduce that step” [P17: Consultant]

There are some conditions where we do delay the feeding deliberately depending on the amount of adhesions we have intraoperatively, but even then a small amount of feed is usually useful. The way I deal with it is I usually give a small amount of clear fluids” [P06: Consultant]

“Sometimes with elderly patients...[for a] lady who’s day one post right hemi... you sort of say ‘oh, should I just leave her on free fluids today, or no it doesn’t matter - it’s good for her to eat and get going?’. The risk for her is that if you upgrade things, and she gets distended, and she vomits; she might then go backward...because once someone vomits and someone puts a nasogastric tube in, then it’s clear fluids for a while…so it might set her back 48–72 h if you do upgrade things too early in an elderly patient” [P03: Fellow]

I would be happy to prescribe ERAS to all patients. The only privy I make to that is the very elderly or the very frail...I titrate their feeding to their gut function a lot more” [P16: Fellow]

Progressing feeding in line with patients’ clinical status

Knowledge/ Behavioural regulation

The next morning [POD1]… depending on how they went [on clear fluids overnight], if they had any nausea or vomiting, then they stay on clear fluids… but if they were feeling fine, then they’d slowly upgrade to free [fluids], and if they’ve started opening their bowels and they’re tolerating free fluid that’s when we start upgrading them to a full solid diet” [P04: Junior House Officer]

“Quite often the patients request it themselves [to be upgraded]; they get sick of it [a fluid diet], so they’re asking for food” [P02: Intern]

I commence earlier feeding. I would start normally from day one [night of surgery] …on free fluids and then if it is tolerated move them onto a light diet [usually the next day]…… I do not rely so much on bowel opening or bowel sounds – I find that is not as reliable” [P15: Consultant]

Meeting patients’ expectations and needs

Memory, attention and decision processes

“[Postoperative feeding] should be patient driven really, that’s the point I’m trying to make, is that the patient actually knows best what they’re ready for… saying ‘you can have whatever you feel like’…that’s probably the best thing. At the moment they’re not. I mean many patients are told, “you can have this, and then you can have that” [P01: Consultant]

“There might be a patient who feels a little bit anxious about eating and they say they want to stay on the free fluids for an extra day. In that kind of situation, I would probably let them have that because if we give them solids their anxiety might mean they eat less and therefore they are not reaching their nutritional requirements” [P09: Fellow]

No [I don’t think patients should be involved in decisions regarding their dietary status]…Ah, well that’s unfair. Some of them are probably sensible enough, but some of them have no idea what we’ve done, and I guess if I’m doing 200 bowel resections a year, I’m probably more experienced than they are despite their five hours on the internet researching what they think they should be doing” [P20: Consultant]

I don’t think they really are actually [involved in their diet-related decisions]. Even when they say ‘oh you know I’m really hungry’…often…oh not so much this team actually, they’re pretty good…but it’s still not viewed as a partnership thing, it’s very much the team…the fellow will say ‘yes’ or ‘no’” [P19: Intern]

  1. TDF Theoretical domains framework