Table 4 Staffs’ responses to intervention components

Perceptions of the intervention

(1) Nutrition-related messages are important, but require improvement

While staff from all disciplines spoke about the importance of doctors providing nutrition-related messages to patients, there was consensus that the specificity of these messages could be improved. Some staff suggested dietitians should provide this specific advice, considering doctors receive minimal training around nutrition.

 “I think it’s good that [doctors] are able to provide that information to the patients, but there’s still that confusion from patients about ‘what can I have when I go home’ and ‘what can I have when I’m here?’ … but I think it’s good that they’re at least having some involvement with [patients’] nutrition.” (P02, Nurse, F).

(2) Information sessions were successful at increasing awareness among nurses

Staff said the information sessions were successful in achieving widespread awareness of the intervention among nurses. This in turn appeared to increase nurses’ acceptance of the strategies implemented, with staff highlighting positive changes in ward practices and attitudes towards postoperative nutrition delivery.

  “I think we had a pretty good work up to it … and I think most of the staff were pretty well aware of it … [The purpose of the study was] to protect them [patients] from nutrition deficiencies immediately post-op and rehabilitate their gut quicker.” (P04, Nurse, F).

(3) Dietary prescription preferences differ to those outlined in the pathway

Doctors, particularly registrars, spoke of ideally prescribing solids after patients had passed wind/and or opened their bowels, and using a soft diet prior to prescribing a full diet, to test patients’ gut tolerance; criteria which were not outlined in the EOF pathway.

  “I think there is healthy medical belief, maybe not held in any great evidence-base, but a healthy medical belief that until the bowels are opening, until something is coming out of the back end, at least wind, and we know that the bowels are working, putting things [food and liquid] in the top end is kind of stupid.” (P08, Doctor, M).

(4) Divergent views on the generic prescription of ONS

Staffs’ responses to the blanket prescription of ONS among elective colorectal patients ranged from high to minimal support. Some staff held the belief that ONS should only be used where indicated and food should be encouraged first.

  “I definitely think we should be encouraging patients with food first … So, I would be going with food first, then supplements.” (P06, Dietitian, F).

“I think it’s good that the option is there, and whether or not the patient can tolerate it or not, can deal with that when it comes.” (P02, Nurse, F).

Perceived impact of the intervention

(1) Improved initial nutrition prescription, but minimal change in diet progression

Staff described how the intervention facilitated improved nutrition prescription (e.g. greater use of ONS and HEHP diets) early in patients’ admissions, however, minimal change was acknowledged in regard to progressing patients through the different postoperative diets (e.g. from liquids to solids). Additionally, the widespread prescription of ONS appeared to be driven by an influential senior doctor on the ward.

  “I think I did become more aware of making sure we did understand...that we need to put patients on high protein diets.” (P09, Doctor, M).

“The only change I have seen … has come from a person who … in the vast majority of cases is the one guiding ward rounds and in control of bedside patient care … [who] began demanding that all of [their] juniors chart Resource [an ONS] on a regular basis.” (P08, Doctor, M).

(2) Greater awareness of and responsibility for nutrition among HCPs

Many participants, particularly those present on the ward pre-intervention, perceived that the intervention had made staff more conscious of nutrition. Further, it appeared that nurses had increased interest in confirming/checking patients’ diet prescriptions with doctors.

  “Overall, I think the ward is more aware that people should be eating; even the nurses sometimes will remind us, you know, ‘can you upgrade their diet?’, rather than just leaving everything to us.” (P09, Doctor, M).

(3) Enhanced patient participation in care

Some staff associated the intervention with improving patients’ psychological wellbeing (due to nutrition being available earlier) and facilitating patient participation in care (a result of patients being more aware of nutrition).

  “I think it’s probably better for the patient’s wellbeing, and like I said one of the first things they like to ask you is ‘when can I eat?’ So, I think being able to give them something that’s a bit substantial is good for them, rather than just some jelly, you know. That really helps them mentally.” (P03, Nurse, F).