ESPEN Congress Florence 2008 Malnutrition in the elderly - in the community Development of a Nutrition Education Intervention in the Community: Can it help GPs and Nurses with care of patients receiving enteral tube feeding? Sharon Madigan (United Kingdom)
Development of a Nutrition Education Intervention in the Community: Can it help GPs and Nurses with care of patients receiving enteral tube feeding? Sharon Madigan RD PhD Community Dietitian
Background to study The numbers of tube feeding patients in primary care in Northern Ireland caused concern among health professionals and patients / carers: Heaney and Tham (2001) reported that GPs have received little or no education about the topic. Patients and carers have a lack of confidence in their GPs knowledge in the area (McNamara et al. 2000). Guidelines in NI recommended that health care professionals receive education in this area (CREST, 2004).
Aim The aim of the study was to develop and implement an educational intervention with GPs and nurses using a randomised controlled trial to evaluate the outcomes of such an intervention.
The Challenge.
Educational Interventions CPD ensures that health professionals are kept up-to-date with current research findings, treatments and new developments. Ensures quality of care (Lin et al. 2001). Davis and co workers defined educational interventions as an attempt to persuade doctors to modify their practice performance by communicating clinical information. The reason why some types of educational interventions fail is due to the fact that they do not address organizational difficulties which may cause barriers to change
Educational Interventions in Primary Care. Recent reviews of educational interventions have focused on studies carried out in primary care. Consistently the literature has shown that Academic Detailing has been successful.
Academic Detailing. Academic detailing involves face-to-face education, which is intended to improve clinical decisions made by health care professionals. Is effective when used alone or in combination. One review suggests that the evidence does support the use of educational outreach visits in combination with additional interventions to reduce inappropriate prescribing (Thompson O Brien et al. 2002). However, it is still not known how performance changes over time and whether further visits are cost effective and the importance of the number of visits is still unclear.
Phase 1: Qualitative data collection A sample was drawn from GP s (n=339) who were registered in the Northern, Southern and Western Health and Social Services Board areas. GP s were invited to participate in an interview if they had either past or present experience of looking after a patient who was fed enterally in the community. Thirty-one GP s responded by telephone or e-mail yielding a sample of 25 GP s
Phase 1: Qualitative data: Results 25 GP interviews and 19 nursing interviews completed in three Board Areas of Northern Ireland. To ensure credibility an inter-rater check of the data analysis where two randomly selected transcriptions were independently coded and the results compared with the main analysis. NUD*IST4 software package used to facilitate data extraction and content analysis. Content analysis
General Practitioners Involvement in Home Enteral Tube Feeding: A qualitative Study (Madigan S et al. BMC Primary Care, 2007). Main themes identified were: Lack of knowledge which affected attitude to the treatment and confidence with dealing with patients. Lack of training Poor Communication between secondary and primary care especially at discharge.
General Practitioners Involvement in Home Enteral Tube Feeding: A qualitative Study. Madigan S et al 2007. GP13: Knowledge of enteral feeding:..it could be written on a postage stamp and not a very big one. GP10: Discharge information: inadequate with a capital I GP4: Decision to use HETF: we have this barrier between primary and secondary care so I don t expect that I shall be involved in it.
Nurses Practitioners Involvement in Home Enteral Tube Feeding (n=19): Themes identified were: Lack of knowledge which affected confidence with dealing with patients, however more day-to-day hands on experience than GP s which improves knowledge over time. Inaccurate knowledge due to little or no training Training mainly provided by company representatives. Better Communication between nursing staff and primary and secondary care dietetic staff. Nursing staff see the dietitian as the main professional that they want involved in the care of the patient. Attitudes to feeding varied
Patient and Carer Questionnaire Patient questionnaire developed, piloted and sent to patients and their carers. 149 questionnaires sent to patients receiving enteral feeding in the Eastern Board Area of Northern Ireland. 68% response rate. SPSS used for analysis. Qualitative comments used in educational intervention.
Patient and Carer Questionnaire Responses used in educational tool Giving a full but caring explanation to the family. Taking an active part in managing the therapy at home and being available to sort out problems. Infection prevention, reflux, pump problems etc. No emotional support. Don t know, I just accept it as I will never eat or drink again. More checks on swallow. To feel the professionals in the community know something about feeding and not just to be fobbed off when looking for help. Emotional support particularly at the beginning when the realisation about such a life changing issue dawns. A detailed list of who to contact in the event of a particular problem.
Home Enteral Tube Feeding Training for Health Care Professionals Sharon Madigan Community Dietitian
Aim of the Educational Intervention To compare the efficacy of a communitybased detailing intervention on the change of pre- and post-intervention questionnaire scores of a sample of primary care health professionals (GPs and nurses) using a cluster randomised trial with waiting list control.
Development of Intervention Training Developed from interviews with health care professionals and feedback from the patient questionnaires. Needed to be : Delivered at practice level Quick (35mins to 1 hour max) Cover problem areas for health professionals and patients. Allow professionals to observe and handle the tubes and plastics involved in enteral feeding. Pre post questionnaires with 9 questions 7 knowledge based 2 scenarios (shown to affect practice)
Development of Intervention Training Presentation style with 18 slides. Areas covered include: Indications for tube feeding Routes of tube feeding Specific problems and trouble shooting problems Summary of comments from patient / carer questionnaire Facilitated the observation and handling of tube feeding equipment Handout pack given including: Copies of overheads BAPEN Poster on medicines Case study Trouble shooting suggestions
Intervention A short (<1 hour), work based training programme delivered when patients were discharged into primary care addressing issues in enteral feeding. Developed and piloted in an earlier phase of the study Based on the principles of academic detailing Using small group learning. The same intervention was also offered to the control group after both questionnaires were completed. Main outcome measures: Change in knowledge scores from pre- and post-intervention and after the intervention six months later.
Educational Intervention: Method Cluster RCT Nursing Teams identified as clusters. Geographical stratification. Waiting list control; Both arms of the study ultimately received the intervention: it was the timing of the pre and post questionnaires that differed. Data analysed using SPSS taking into consideration the clustering effect.
Results 22 clusters with 234 individual health professionals 11 intervention (n= 122); 11 control (n= 112). At baseline the knowledge scores were: GPs : 2.3 correct District Nurses : 3.0 correct Nursing Home Nurses : 3.1 correct
Results Change in questionnaire scores by professional group Change Score No Mean SD SEM p GPs Treatment 20 4.25 1.97 0.44 <0.001 Control 44 0.52 1.07 0.16 District Nurses Treatment 65 4.20 1.86 0.23 <0.001 Control 48 0.38 0.89 0.26 Private Nursing Home Nurses Treatment 36 3.19 1.69 0.28 <0.001 Control 20 0.45 1.39 0.31 SD = Standard Deviation; SEM = Standard error of mean; Differences between pre and post test were measured using an independent t-test
Results: Six months After six months the intervention group were sent the post intervention questionnaire (n=122). The overall response rate was 35% (n= 43). Six questionnaires were not completed giving a completed response rate of 30%. The mean score changes at six months dropped from the post intervention scores: GPs : -1.6 District Nurses : -1.9 Nursing Home Nurses : -1.6
Conclusion A short, work-based targeted educational intervention resulted in improvements in knowledge scores. Unsure if it helps with practice Further training may be required after each patient is discharged to maintain this effect but this response rate is to small to generalise these findings. One strength of this study is the pragmatic design of the intervention delivered within the place of work over a short time. This study provides some evidence for providers of postgraduate education as to how best deliver education to GPs and nurses in primary care about this topic area.
Acknowledgements National Primary Care Awards and the Research and Development Office, Northern Ireland for funding the project. Clinical Research Support Centre Community Nutrition and Dietetics Service (then North and West Belfast HSST). Participants in study Study Supervisors