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ORIGINAL RESEARCH

The incorporation of body composition assessments as part of routine clinical care in a tertiary hospital's dietetic department: a best practice implementation project

Wilkinson, Shelley A. BSc (Hons) (Psyc), GradDipNut&Diet, PhD, AdvAPD1,2; Jobber, Chloe J.D. MDietStud, APD1,3; Nave, Fiona Masters (Nut & Diet), APD1; van der Meij, Barbara S. PhD, APD1,3,4

Author Information
JBI Evidence Implementation: March 2022 - Volume 20 - Issue 1 - p 21-32
doi: 10.1097/XEB.0000000000000291

Abstract

What is known about the topic?

  • The international clinical nutrition community recognises the need for, and value of, body composition assessments (BCA) to assess nutritional status, including the identification of sarcopenia. However, despite available evidence of the benefits of BCA techniques its routine use in clinical practice is limited.
  • Previously reported barriers to BCA use are incomplete knowledge and awareness of BCA techniques, clinicians being unsure of how and when to measure body composition, poor availability of assessment tools, and a lack of time.
  • Our preparatory, local investigation reinforced that our department's dietitians felt unsure of their skills, when and how to systematically use BCA techniques. We also identified uncertainty about BCA's applicability and relevance in a clinical setting. However, we also identified many dietitians were optimistic about BCA's potential in enabling evidence-based practice and many noted their use would add to the strength of assessments, recommendations, and ability to detect malnutrition, and clinically relevant improvements within their delivery of medical nutrition therapy.

What does this article add?

  • Evidence-informed strategies, tailored to identified barriers and enablers, are effective in creating large shifts in clinician attitudes and behaviours around the BCA processes in our local setting.
  • As noted by other researchers, interventions aimed at facilitating clinician behaviour change need to acknowledge that fear and overwhelm is common, and structure activities, expectations and recognition to account for this while reinforcing the resultant benefits of the work.
  • Process evaluation, including fidelity assessment, is important in health service change to determine mechanisms of change and the beliefs behind them, as well as to direct future improvement cycles.

Introduction

Loss of muscle mass, quality and strength, also called ‘sarcopenia’,1–3 is associated with negative outcomes including reduced survival, worse clinical outcomes and impaired quality of life in many clinical populations including oncology, surgical, hepatology and older adults.1–3 The international clinical nutrition community recognizes the need for, and value of, body composition assessments (BCAs) to assess nutritional status, including the identification of sarcopenia. The Global Leadership Initiative on Malnutrition (GLIM) consensus paper recommends measuring body composition of patients and identifying loss of lean mass as one of the top five criteria to assist in diagnosing malnutrition,4 and according to the European Society of Clinical Nutrition and Metabolism, improved nutritional care can be achieved by incorporating BCA into standard care for certain patient groups, such as patients undergoing cancer treatment.5 Determining fat and lean body masses by direct measures, rather than relying on body weight and BMI, is important.3,6,7 The most common BCA techniques to assess this in clinical practice are bio-impedance analysis, computed tomography (CT) and dual-energy X-ray absorptiometry (DXA).3

Despite available evidence of the benefits of BCA techniques, its routine use in clinical practice is limited.2,3 General barriers identified are incomplete knowledge and awareness of BCA techniques, clinicians being unsure of how and when to measure body composition, poor availability of assessment tools and a lack of time.2,8 Following our dietetic department's ongoing knowledge translation process that routinely assesses and addresses evidence-practice gaps in line with implementation science methodologies, we identified the need for a department-wide strategy to incorporate BCA into routine dietetic care.9 To inform the evidence-informed process of implementation in our department, we previously investigated the current practices, competency and attitudes of clinical dietitians in regard to BCA within our department.

As noted by Swindle et al.,10 clinicians themselves are vital to implementation efforts. They call for practitioners to engage in implementation within their clinical practice using the implementation science knowledge base to improve the quality of everyday service delivery to targeted populations.10 It has been highlighted in a qualitative study with allied health practitioners that there exists a need for application of systematic approaches to research translation and research-informed decision-making.11 In response, to develop, implement and evaluate an approach to integrate body composition assessment as usual practice, we applied the Action Cycle of the Knowledge to Action (KTA) framework.9,12,13 The KTA's application follows an iterative approach; the steps of the Action Cycle can occur sequentially or concurrently and involve identification of the problem, assessing knowledge use or outcomes, and ensuring sustainability.9,12 In this project, assessment and intervention selection required use of the integrative Theoretical Domains Framework (TDF) and Behaviour Change Wheel (BCW).14,15 The TDF, which consists of 13 domains (Knowledge; Skills; Social/professional role and identity; Beliefs about capabilities; Optimism; Beliefs about consequences; Reinforcement; Intentions; Goals; Memory, attention and decision processes; Environmental context and resources; Social influences; Emotion) is a system for defining and sorting identified barriers, and the BCW is a system for guiding decision-making around designing behaviour change interventions based on the barriers through the alignment of its central COM-B hub (capability, opportunity, motivation–behaviour) with intervention and policy categories.14,15

We documented that the majority of dietitians rarely used BCA in a systematic way. Barriers and enablers existed in many of the same TDF domains. We identified that many dietitians felt unsure of their skills, when and how to systematically use BCA techniques, and some questioned their benefit for particular clinical areas and/or outside of research projects.9 However, many dietitians were optimistic about the potential that this process would provide to enabling evidence-based practice and noted that it would add to the strength of assessments, recommendations, and ability to detect malnutrition and clinically relevant improvements within their delivery of medical nutrition therapy.

Objective/aims

This study evaluated the application of the processes undertaken following evidence-informed strategy development to overcome identified barriers and enablers in previous work.9 We present the three overarching interventions of upskilling (professional development strategy), modelling and reducing fear of change (Clinical Champion project), and embedding as usual practice (departmental integration).14,16 Further, we also present the results from our repeated departmental survey to re-assess adoption of, (perceived) competency in, and attitudes of clinical dietitians towards the utilization of BCA devices within our dietetics department.

Methods

The study was declared as Exempt from Review – Not Research according to the Human Research Ethics Committee of Mater Research Institute – UQ Human Research Ethics Committee (Project ID: EXMT/MML/58778).

Study design, setting and participants

This pre--post implementation project occurred in an 800-bed tertiary hospital in Brisbane, Australia between March 2017 and June 2020. The hospital provides services to private and public inpatients and outpatients, and includes a variety of patient populations. The Dietetics and Foodservices department consists of 20.55 full time equivalents (FTE)/26 dietitians. Within the department, there are three clinical groups: 1. Mothers, Women's & Babies; 2. Medical/Chronic and 3. Surgical/Acute. ‘Teams’ within each group were: 1. Maternity (preconception, antenatal, postnatal, diabetes in pregnancy) and neonatal; 2. Medical/Chronic (diabetes, eating disorders, ketogenic diets, medical, metabolic disorders, neurology, rehabilitation, renal, respiratory), and 3. Surgery/Acute (critical care, gastroenterology, oncology, surgical).

Intervention development and delivery

Barriers to BCA use within our department were identified in all TDF domains.9 Enablers included: Skills; Beliefs about consequences; Goals; Environmental context and resources; Social influences; Intentions; Optimism; Reinforcement.9 On the basis of a mapping process that linked evidence-informed strategies to the identified barriers and enablers strategies were broadly grouped as: 1. Professional development strategy, 2. Body composition assessment Clinical Champion project and 3. Departmental integration process.9 Details of each approach as planned are outlined in Table 1. We report what and how this was delivered in the Results.

Table 1 - Outline of three departmental strategies planned to be implemented to embed body composition assessment as routine practice in a dietetic department
Strategy Details
Develop evidence-based resources (knowledge creation and integration)
 All teams to research relevant BCA for their clinical areas
 All teams to update Best Practice Investigation (BPI) documents
Develop user manuals with age-specific and gender-specific reference values as well as hygiene measures
 Relevant topics: handgrip strength (HGS), bio-impedance spectroscopy (BIS), mid upper arm circumference (MUAC) and other tape measure assessments
Develop body composition assessment form to transcribe patient results
1. Professional development strategy  To include general, disease and malnutrition characteristics, prompts for measurement circumstances (e.g. left/right side of body, emptied bladder, etc.) and spaces to record HGS, BIS, and MUAC assessments results
 Interpretation document to report and explain patient results
 Lanyard ‘cheat sheet’ with reference values and how to clean devices
Offer four professional development sessions in the year 2018. Topics to include:
 Results of the baseline department survey assessing clinician knowledge, confidence and current use of BCA
 Discussion of BCA implementation plan
 Practical tutorial on how to conduct BCA (including HGS, BIS, MUAC and tape measures)
 Case studies with BCA results, interpretation and changes over time
Orientate new staff members:
 Train each new staff member on how to find, book out, and use BCA devices. Where to locate user manuals and other relevant resources
Additional professional development sessions and refresher small group workshops scheduled ad hoc as needed.
2. Body composition assessment Clinical Call for and elect opinion leader (’Clinical Champion’ per team)
Champion project Undertake a 6-month BCA Clinical Champion project (March–September 2019). The steps to include:
 Map project plan, including identifying clinical areas in which BCA would be best implemented
 Present project plan to department and clinical areas
 Nominate Clinical Champions to be opinion leaders for smaller teams. This was optional and self-nominated.
 One-month trial of process
  Clinical Champion to identify best BCAs for their clinical area with reference ranges and appropriate patient group
  Guide Clinical Champions to develop workplace trial and template to input patient results
  Clinical Champions to identify achievable goal for frequency of BCAs being performed
 Three-month trial of procedures
  Month 1 – complete BCA on 1–2 patients per week and discuss process with team
  Month 2 – increase to regular BCA use for chosen patient cohort
  Month 3 – all eligible patients in particular patient cohort
  ‘Pulse’ evaluations of complex cases at daily team meeting
  Fortnightly team meetings to discuss and problem solve/debrief/upskill and share with the wider team
 At the end of month 3 to refine the process of implementation into workloads and map reporting structure and relevant KPIs [huddles and department strategic EBP (evidence based practice) and research meeting]
 Consecutive 6-month project (September 2019 to March 2020) to be undertaken to include
  Monthly reporting at department strategic and research meeting on key performance indicators (KPIs) in project plan
  Monthly peer meeting with BCA Clinical Champions and working group members
  ‘Pulse’ surveys of Clinical Champions to measure frequency of BCA in allocated areas, reporting in electronic medical chart system, and experiences of clinicians
  To document discussion points and frequently asked questions (FAQs) at Department and BCA Clinical Champions meetings for addressing and acknowledging, especially eliciting discussion around actual measures or ease of measuring outcomes and patient process
Daily consensus discussions between Clinical Champions and other team members (e.g. during clinical stand up meetings) -- after which findings are presented to allow objective assessment of BCA in clinical areas according to WARs.
3. Departmental integration process Strategic leadership
 To appoint/convene a steering committee
  Purpose: provide support, advocacy, and enablement for implementation of body composition into clinical care in Dietetics
  Activities: assist with strategic planning, advocacy, evaluation and refining of activities
  Meeting frequency: once a month
 To appoint/convene a working group
  Purpose: to develop and embed a department wide evidence-based BCA process to ensure/allow objective assessment of BCA in clinical areas according to WARs
  Activities: professional development, development of manuals, reference values and forms, maintenance and booking of devices, literature research, advocacy, coaching, professional development and orientation of new staff members
  Meeting frequency: once every 2 weeks
  Monthly e-mails on body comp topics will be sent by a member of the working group. Potential topics: the new GLIM guidelines, newspaper articles, quotes, reminders to assess xyz
To set BCA agenda item on monthly Department Strategic EBP and Research meeting
To purchase departmental resources: bioelectrical impedance spectroscopy, handgrip dynamometer, and mid upper arm circumference tape measures
To build learnings from strategy #2 into WARs as specific procedures (including private services), especially
  Who: Key patient group
  What: resource/technique and reference ranges
  Where: location (ward, clinic, other)
  When: clearly delineate which assessment and review appointments
  How: quick tips on technique; how to book; how to clean
  Why (should be in BPI): give short guide on what is ‘expected’
BPIs are evidence informed documents for each clinical area, written in the NCPT/ADIME (nutritional care process terminology ‘assessment, diagnosis, intervention, monitoring, and evaluation’) by each clinical team. WARs are outline procedures for each clinical area, informed by the BPIs and operationalised to the clinical setting and capabilities. BCA, body composition assessment; KPI, Key Performance Indicator, BPI, Best Practice Investigation; HGS, handgrip strength, BIS, bio-impedance spectroscopy, MUAC, mid upper arm circumference, WAR, work area resource.

Recruitment and measures

A survey designed and applied in 2018 to assess barriers and enablers to BCA within the local department of dietetics was redistributed for this study in March 20209 (Appendix I, https://links.lww.com/IJEBH/A65). All department dietitians were invited to complete the survey via an email link to an online survey portal (Survey Monkey). At the time the surveys were sent out, members of the BCA working group discussed the survey in the formal fortnightly department meeting and encouraged all team members to participate. To provide enough time for all team members to participate, the survey was open for 3 weeks with two reminders prior to the closing date.

Survey questions were designed to map against domains of the TDF.15 Questions covered knowledge and attitudes on, and confidence in BCA device use, frequency and predicted time taken to use the devices, views on how it would change dietetic practice, and which patient cohorts would benefit from BCA. These data were reported descriptively, illustrating trends graphically. Due to the small sample size, no statistical analyses were performed.

Results

Below we outline the process and fidelity of the delivery of the three evidence-informed strategies outlined in Table 1.

Upskilling (professional development strategy)

Evidence-based resources (knowledge creation and integration)

All departmental dietitians searched, critically appraised and presented the evidence for BCA relevant to their clinical teams in detail, and summarized at department meetings. Members of a working group (composed of two senior researchers, one clinical educator and one clinical dietitian: S.W., B.v.d.M., C.J., F.N.) developed BCA resources. These included gender-specific and age-specific reference values to be used to interpret assessments and reference guides on anthropometry in clinical dietetics (e.g. Griffith University Handbook of Clinical Dietetics – 4th edition, Dietetic Pocket Guide Adults, 2017). This information was then created into a swing-tag, which was designed to be hung from the clinician's ID lanyard for easy reference. All resources were saved in a shared electronic folder on the department network drive.

User manuals

On the basis of BCA device manuals, reference guides and local practice, user manuals were developed for mid upper arm circumference (MUAC), handgrip strength, bio-impedance spectroscopy (BIS) and waist circumference. The manuals included a step-by-step instruction on how to prepare and perform the assessment, gender-reference and age-reference values as well as local hygiene measures. The user manuals were reviewed by all working group members. During professional development sessions, feedback from other staff members was sought and user manuals were adapted accordingly.

From departmental feedback, a BCA resource sheet was developed to assist with interpretation and discussing of BCA results with patients. This table included the BCA result, 50th centile of the reference range, what it means if you are above or below the reference range, and a brief explanation of what it all means. The bottom of the form provided a brief explanation on the meaning of centiles and why the 50th was chosen as a reference value (Appendix II, https://links.lww.com/IJEBH/A65).

Body composition assessment form

A form for individual BCA was developed and included general patient, disease and malnutrition characteristics, checkmarks for measurement circumstances (e.g. left/right side of body, emptied bladder) and spaces to record MUAC, handgrip strength and BIS assessments.

Professional development sessions

Thirty-minute BIS workshops for small groups were offered. Members of the working group demonstrated how to operate a device and introduced the user manual. Every staff member attending the training session conducted an assessment according to the user manual. Feedback on user manuals and the assessment form was sought from staff members, and changes were made accordingly.

Thirty-minute interactive professional development sessions were offered every 3–4 months. Topics included:

  • (1) Rationale and aims for BCA
  • (2) Results of the department survey
  • (3) BCA implementation plan
  • (4) Workshop handgrip strength, waist circumference, MUAC, bio-impedance spectroscopy
  • (5) Case study – BCA results of stem cell transplant patient during 2 weeks admission to hospital
  • (6) Techniques for body composition assessment in clinical practice, by Professor Carrie Earthman (University of Minnesota Twin Cities, Minneapolis USA)

As part of professional development, a handgrip strength competition was run in the team. In this way, all team members learnt how to use the handgrip dynamometer by competing to see who had the highest handgrip strength using a nonthreatening learning activity.

Orientation for new staff

A system was developed for orientation of new staff members. As part of standard orientation, a new staff member received basic training from a working group member. In total, four new staff members received this training.

Clinical Champion Project

The Clinical Champion project was planned for March 2019 to September 2019. At the end of months 3 and 6, it was identified that most Clinical Champions did not meet the intended number of BCA in their area because of workload changes and absences because of holidays and illness. Therefore, the Clinical Champion project was extended to March 2020 (running for 12 months).

Seven Clinical Champions were appointed across Renal, Respiratory, Gastroenterology, Cancer and Critical Care workloads. During the first month, Clinical Champions explored the evidence and identified in which patient groups/clinical areas BCA would be indicated and appropriate. Working group members guided Clinical Champions to develop workplace trials and how to input patient results.

Findings of the pulse surveys are depicted in Fig. 1a--d. Results show that from the start, the majority of Clinical Champions felt they had the skills to perform BCA and completed BCA on their patients within their daily clinical workload. They also felt that BCA were useful to improve patient assessment/care. Only 33% felt supported to conduct BCA at the start, which increased to 100% (5/5) at follow-up pulse surveys. Overall, Clinical Champions reported that it was hard to increase numbers of BCA performed daily. Therefore, in Clinical Champion project meetings, the aimed number of BCAs to be performed was revised to a number negotiated with all Clinical Champions and the Working Group. Champions also shared BCA findings in team meetings and other Champions and working group members contributed to problem solve and upskill Champions and peer dietitians.

F1
Figure 1:
(a--d) Responses from Clinical Champions regarding their perceived skills, support, frequency of completion, and usefulness of Body Composition Assessment. (a) Clinical Champions’ responses to feeling that they have the skills to perform accurate body composition assessments on patients. (b) Clinical Champions’ responses to feeling supported to complete body composition assessments on patients. (c) Clinical Champions’ responses regarding frequency of completing body composition assessments on patients within their daily clinical workload. (d) Clinical Champions, responses regarding the usefulness of body composition assessments in improving patient care/assessment.

During the second 3-month period, BCA working group members focused on monthly reporting of progress and reflections to the department (strategic and EBP meetings) and monthly peer meetings with Clinical Champions and working group members. Discussion points included measurement circumstances, interpretation of findings, troubleshooting whenever devices were not working, how to explain and report BCA to medical staff or patients, and when to repeat a BCA. In addition to the pulse surveys being sent via email, during the ‘pulse’ week, the working group members verbally encouraged Clinical Champions to complete the survey.

Departmental Integration Process

Strategic leadership

A steering committee was convened that consisted of the department's two senior research dietitians (S.W. and B.v.d.M.) and one dietetics team leader (F.N.) and met on a monthly basis to oversee the governance of the project, to enact managerial and research decisions and activities to facilitate the project outcomes. A working party was also convened, led by a senior research dietitian (B.v.d.M.) with two senior clinicians (S.W. and F.N.). They met fortnightly for 6 months and then monthly for an additional 6 months. Their role was enacting and organising the professional development and Clinical Champion project activities within the department.

Agenda items, resources and departmental procedures

Successful actions enacted as part of the third departmental integration strategy included facilitating the purchase of departmental resources (BIS, handgrip dynamometer and mid upper arm circumference tape measures) and adding BCA as an agenda item on monthly Department Strategic EBP & Research meetings. The Steering Committee also advised on a department-wide activity to be completed by the end of 2020, which would incorporate the learnings from the second strategy, the Clinical Champions project. This activity involves routinizing specific BCA procedures into all clinical Work Area Resources (WARs; the procedure manual for each clinical area). This was to outline: Who: Key patient group to perform BCA; What: resource/technique and reference ranges; Where: location (ward, clinic, other); When: clearly delineate which assessment and review appointments; How: quick tips on technique; how to book; how to clean; Why (should be in BPI): give short guide on what is ‘expected’.

Findings from surveying department dietitians post intervention

Demographics and response rate

Twenty-two out of 26 dietitians (84.6%) completed the baseline survey, compared with 13 out of 21 (61.9%) (22/26) for the second survey in 2020. Seven (of the 13) dietitians completed the survey in 2018. There was a slight decrease in those completing the 2020 survey working for fewer years (0–2 years, 2018: 13.6%, 2020: 7.7%), and increase in those working 3–5 years (2018: 9.9%, 2020: 15.4%). Those with 6 to 10 and more than 10 years’ experience remained similar (2018: 45.5%, 2020: 46.2%; 31.8 vs. 30.8%, respectively).

Training, knowledge and usage changes

From the first to the second survey, there was a 30% increase (54.6--84.6%) in respondents reporting receiving previous training in BCA. Increases in training for BCA techniques were reported for: BIS machine (33.3--41.7%), stable for MUAC (75%); DXA (8.3%) and a decrease in skinfold thickness (use of callipers) (75--33.3%) and BIS scale (41.7--33.3%). Increases in knowledge of location in the department of BCA devices were reported for measuring tapes (85--100%); dynamometer (75--100%), and BIS machine (90--100%). A decrease was observed for skinfold callipers (75.0 to 23.0%) and the BIS scale (45.0 to 15.4%). The dietitians also reported an increase in confidence in using various BCA techniques; increases in reports of being confident/extremely confident were observed for: MUAC (85--100%); tape measure use (e.g. for waist circumference) (75--90.3%); using the dynamometer (50--69.2%); and using skinfold callipers (5--15.0%).

When surveyed in 2018 on how often the BCA techniques were used with patients, the dietitians reported nil daily, weekly, or monthly use of MUAC, dynamometer, or BIS, except for exceptional cases (25, 5, 10%, respectively). Tape measures were used weekly (5%), monthly (15%), and for exceptional cases (not specified). In 2020, the dietitians reported an increase in use of: MUAC (daily 7.7%; weekly 15.4%; monthly 7.7%; exceptional circumstances 30.8%); dynamometer (monthly 7.7%; exceptional cases 38.5%); callipers (monthly 7.7%); tape measures (e.g. waist circumference) (daily 7.7%; weekly 23.1%; monthly 23.1%; exceptional cases 38.5%).

Barriers and enablers

Table 2 illustrates the change in the dietitians’ ratings of their perceived barriers and enablers relating to all TDF domains. Marked reductions in barriers being reported, increases in enablers and positive attitudes towards techniques, as well as a proportion of barriers being reported as ‘not applicable’ in the 2020 survey were noted. At least a quarter of the respondents reported barriers in the following TDF domains as ‘not applicable’: Environmental Context and Resources (66.7%); Social Influences (66.7%); Beliefs about Consequences (45.5%); Social/Professional Role and Identity (40.0%); Beliefs about Capabilities (25.0%); Memory, Attention and Decision Processes (25.0%); and Emotions (25.0%).

Table 2 - Changes in percentage of responses to questions framed in each theoretical domains framework domains from 2018 to 2020
TDF domain Question Percentage agreement with question
2018 2020
Knowledge I don’t know what measurements to perform 68.8 23.1
I don’t know when to perform the measurements (i.e. at first assessment only, intervals, frequency) 68.8 46.2
I don’t know which patient group I could practise these measurements on 75.0 23.1
I don’t know how to interpret these measurements 62.5 15.4
Not applicable 0.0 15.4
Skills I don’t know how to use a tape measure 11.1 0.0
I don’t know how to use a Bioelectrical Impedance Spectroscopy machine 55.6 15.4
I don’t know how to use the hand grip dynamometry 50.0 15.4
I don’t know how to use skin-fold callipers 66.7 76.9
Not applicable 0.0 7.7
Social/professional role and identity I do not think these measurements are appropriate for my area of work 66.7 8.3
I think these measures are more appropriate for research 66.7 16.7
The measurements are not required for dietetic assessment 0.0 0.0
Not applicable 40.0 41.7
Beliefs about capabilities I do not have time to perform these measurements 25.0 25.0
I think these measurements would be hard for me to learn 0.0 0.0
I don’t think I could perform these measures accurately 37.5 16.7
These measurements are not in my daily routine 81.3 41.7
Not applicable 0.0 25.0
Beliefs about consequences We do not have procedures or forms to report these measurements 70.0 45.5
I don’t think these measurements would benefit my practice/tell me anything new/useful 30.0 0.0
Not applicable 0.0 36.4
Goals I would like to apply measurement of body composition to my practice 85.0 76.9
I would like to learn more about body composition assessment 80.0 46.2
Not applicable 0.0 7.7
Memory, attention, and decision processes It is too much of a hassle to find a reference value and report the results 53.9 25.0
I forget about doing or scheduling a measurement 30.8 66.7
Body composition assessment does not fit into my schedule (it takes up too much time) 46.2 16.7
Not applicable 0.0 25.0
Environmental context and resources I don’t trust myself not to break the devices 13.3 0.0
I know where these devices are kept but I don’t know how to get them to the ward 26.7 0.0
I don’t know how to book these devices 80.0 16.7
I don’t know where these devices are kept 40.0 16.7
I don’t have access to the devices I need to perform body composition assessment 26.7 0.0
Not applicable 0.0 66.7
Social influences I think these measurements are a burden to patients 7.7 8.3
My peers do not perform these measurements, so why should I? 30.8 0.0
Not applicable 0.0 66.7
Intentions I never think of doing these measurements when I see or evaluate a patient 38.9 23.1
I would like to add these measurements to my daily routine 61.1 69.2
Not applicable 0.0 15.4
Emotion I feel stressed about the time required to do these 42.9 25.0
I feel guilty about not performing body composition assessments 7.1 41.7
I do not need more challenges 0.0 0.0
I already have enough on my plate 7.1 16.7
Not applicable 0.0 25.0
Optimism I think these measurements would make my practice more interesting 73.7 92.3
I think these measurements would improve my practice 52.6 53.9
I think it is not feasible to implement these measurements in my practice 15.8 0.0
I do not see the added value of such measurements 10.5 7.7
Not applicable 0.0 0.0
Reinforcement The help of the body comp lab group would make it possible to implement measurements 77.8 75.0
Having more training available to me would prompt me to do the measurements 66.7 50.0
There's nothing that prompts me to do the measurements 22.0 33.3
Not applicable 0.0 8.3
Behavioural regulation I would need to change my practice regarding assessing nutritional status 55.6 23.1
I would need to change my practice 38.9 46.2
I’m happy with the way that I assess patients’ nutritional status 22.2 38.5
Not applicable 0.0 0.0

Staff's knowledge improved in knowing appropriate patient groups and how to interpret measurements, as well as when to perform measurements (to a lesser extent). Improvements in skills (ability to use BCA devices) were reported for all but skinfold callipers. Many more dietitians felt the BCA measures were appropriate for use in (their) clinical work. They also felt less of a barrier existed to the measures being in their daily routine and that they could perform them accurately. However, a similar proportion still felt they did not have time to perform the measurements. The dietitians felt undertaking BCA would benefit their practice and had resource to report on those measures. There was a slight reduction in the proportion wanting to learn more about BCA and applying BCA into their practice. Despite a slight increase in the proportion of dietitians reporting that they forget to do or schedule measurements, a reduction was observed in the proportion of dietitians reporting it does not fit in to their schedule or is a hassle to find reference values and report on the results. A marked reduction was observed regarding dietitians being aware of locating, booking and using the devices in clinical practice. However, a small proportion still felt these measures were a burden to patients. There was an increase in the proportion of dietitians who wanted to add BCAs to their daily routine and would be more likely to remember to undertake these measurements. Conflicting responses were noted relating to dietitians’ emotions, with a slight increase in the feeling they had ‘enough on their plate’ and feeling guilty about not performing these assessments but they did report feeling less stressed about the time required to do them. Dietitians also overwhelmingly reported feeling these measurements would make their practice more interesting, would improve their practice, and could implement them into their routine. Only slight reductions were observed in respondents believing nothing prompted them to undertake measurements and that extra training or a ‘body comp lab group’ would not assist this. Finally, dietitians agreed they were both happy with how they measured nutritional status and did not feel they would need to change their practice in how they performed this process.

Discussion

This article demonstrated a successful adoption and execution of an implementation strategy to incorporate BCA into departmental processes. Two of the three elements were incorporated as planned (professional development and strategic integration), with one element (Clinical Champions) modified through iterative processes. The success in the strategies was reflected in the change over time in many of the survey results, particularly the considerable proportion of ‘not applicable’ responses given for many barriers in 2020. The largest (positive) shifts in perception were around adequate resourcing and the positive influence of peers and how dietitians saw themselves as ‘clinicians who used BCA’ and held positive beliefs about BCA's clinical usefulness. A smaller shift in dietitians’ personal beliefs was observed in their capabilities to perform BCAs and remembering to integrate these into their practice, as well as a reduction in the emotions (felt) around the process. As could be expected, the Clinical Champions felt confident and believed in the process from the outset. Positively, the planned structured process of integration into their workloads also resulted in them reporting over time to feel more supported in the process; however, we overestimated the numbers of BCAs that could be performed by Clinical Champions during 6 months.

Large, positive changes in the responses to perceived barriers and enablers were identified across all TDF domains. Improvements were seen across skills, knowledge, resources, emotions and planning strategies. It appears the targeted suite of strategies has been effective at addressing concerns identified at baseline. However, slight negative changes were identified in a few domains. A commonly cited barrier (to BCA)9 and evidence-based practice more broadly related to dietitians identifying that they had no time (Belief about capabilities). Despite other positive shifts around comments relating to ‘I feel stressed about the time to do BCA’ (fewer agreed to this in 2020), ‘I would like to add this to my daily routine’, and (fewer) ‘this is not feasible’, a higher rating given to ‘I have enough on my plate’, ‘I forget to schedule this’, and ‘Nothing prompts me’ might reflect a wider feeling of busyness in workloads and/or a lack of agency for clinicians to adapt their own practices within their clinical areas.

An evidence-based approach to address this would involve examining the TDF domains in which these concerns were raised and noting the COM-B model (centre of the BCW) items with which they align to allow planning of further interventions and clinician support. Belief about capabilities was the domain relating to ‘don’t have time’ and this aligns with (Reflective) Motivation. ‘I forget to schedule’ was in the domain of Memory, attention and decision processes which aligns with (Psychological) capability. Finally, ‘I have enough on my plate’ and ‘I feel guilty about NOT doing BCAs’ were in the domain of Emotion, which aligns with (Automatic) Motivation.9 This aligns closely with research undertaken examining barriers and enablers to allied health undertaking research in practice.17 To facilitate this process, their findings suggested the need to structure programs that acknowledge that fear and overwhelm is common, and structure activities, expectations and recognition to account for this while reinforcing the resultant benefits of the work.17

Drawing from the literature (e.g. Colquhoun et al.16), strategies that align with these TDF domains/COM-B barriers include: (Reflective) -- Motivation: Persuasion, Incentivization, Coercion; (Psychological) -- Capability: Education, Training, Enablement and (Automatic) -- Motivation: Persuasion, Incentivization, Coercion, Education. Greater detail regarding components for operationalization can be found in the literature,16 but broadly the literature supports a continuation and broadening of the Clinical Champions strategy to cycle additional cohorts of dietitians through the peer-supported, structured program. This should be supported by department-wide ongoing skills-based training regarding performing all types of BCAs, interpreting and discussing measurements, and incorporating the procedures identified in the BPIs into each area's WAR. This should be further supported by ongoing department-wide support and discussion of BCA processes at team meetings, led by the steering committee and working group.

A strength of this study includes the application of implementation science methodology and frameworks (KTA, TDF, BCW)12,14,15 as well as evidence-informed strategies to map and inform our adoption process.16 This allowed a tailoring solution to local barriers; the foundational tenet to the implementation science approach.18,19 Despite the reality of staff turnover in a large department, with not all staff completing the survey at both time points, it appears the adopted strategies were embedded into usual practice to change orientation content, departmental expectations and culture as well as available resources. Other limitations include the dietitians’ answers potentially reflecting social desirability despite being anonymous and an acknowledgement that the results reflect perceived rather than actual behaviours. However, a change in clinical practice was observed in the smaller cohort of the Clinical Champions and it is likely that as this strategy is widened to more clinicians, the supported, stepped process would continue to result in true practice change.

Conclusion: implications for research and practice

Our department will continue to plan activities to embed BCA into standard practice dietetic practice. This will involve ongoing steering committee and working group meetings, a yearly repeat of the department-wide survey, and continuously addressing emerging and known barriers.19

The evidence-informed implementation strategy successfully integrated BCA into departmental processes highlighting direction for future iterative service changes. Although attitudes and behaviours were positively influenced, more work is required to maintain these results. This will be facilitated by continual assessment of barriers and success of integration into routine workloads. In addition to an ongoing focus on skills, knowledge and adequate resources, a targeted approach to addressing strategies that relate to emotions that underpin practice change (guilt, confidence, self-efficacy) will be required.

Acknowledgements

Ethics approval and consent to participate: The study was declared as Exempt from Review – Not Research according to the Human Research Ethics Committee of Mater Research Institute – UQ Human Research Ethics Committee (Project ID: EXMT/MML/58778). Participants were informed that completion of the surveys implied consent. Completion was voluntary.

Consent for publication: authors provide consent.

Availability of data and materials: these can be made available on reasonable request.

Funding: S.A.W. was supported by a Queensland Government Department of Health- Health Research Fellowship. Nil funding was received to complete the study included in this manuscript.

Authors’ contributions: All authors have participated sufficiently in the article to take public responsibility for the content. S.A.W., conceptualization; data curation; formal analysis; investigation; methodology; roles/writing -- original draft; writing - review & editing; supervision. C.J.D.J., data curation; investigation; project administration; roles/writing -- original draft; writing -- review & editing. F.N., investigation; project administration; supervision; writing -- review and editing. B.v.d.M., conceptualization; data curation; formal analysis; investigation; resources; roles/writing -- original draft; writing -- review and editing; supervision.

Conflicts of interest

The authors report no conflicts of interest.

References

1. Martin L, Gioulbasanis I, Senesse P, Baracos V. Cancer-associated malnutrition and CT-defined sarcopenia and myosteatosis are endemic in overweight and obese patients. JPEN J Parenter Enteral Nutr 2020; 44:227–238.
2. Deutz NEP, Ashurst I, Ballesteros MD, et al. The underappreciated role of low muscle mass in the management of malnutrition. J Am Med Directors Assoc 2019; 20:22–27.
3. Earthman CP. Body composition tools for assessment of adult malnutrition at the bedside: a tutorial on research considerations and clinical applications. JPEN J Parenter Enteral Nutr 2015; 39:787–822.
4. Cederholm T, Jensen GL, Correia M, et al. GLIM criteria for the diagnosis of malnutrition - a consensus report from the global clinical nutrition community. Clin Nutr 2019; 38:1–9.
5. Arends J, Bachmann P, Baracos V, et al. ESPEN guidelines on nutrition in cancer patients. Clin Nutr 2017; 36:11–48.
6. Kyle UG, Morabia A, Slosman DO, et al. Contribution of body composition to nutritional assessment at hospital admission in 995 patients: a controlled population study. Br J Nutr 2001; 86:725–731.
7. Thibault R, Pichard C. The evaluation of body composition: a useful tool for clinical practice. Ann Nutr Metab 2012; 60:6–16.
8. Reijnierse E, de van der Schueren M, Trappenburg M, et al. Lack of knowledge and availability of diagnostic equipment could hinder the diagnosis of sarcopenia and its management. PLoS One 2017; 12:e0185837.
9. Jobber C, Wilkinson S, Hughes E, et al. Using the theoretical domains framework to inform strategies to support dietitians undertaking body composition assessments in routine clinical care. BMC Health Serv Res 2020; 21:518.
10. Swindle T, Curran G, Johnson S. Implementation science and nutrition education and behavior: opportunities for integration. J Nutr Educ Behav 2019; 51:763–774.
11. Wenzel L-A, White J, Sarkies M, et al. How do health professionals prioritize clinical areas for implementation of evidence into practice? A cross-sectional qualitative study. JBI Evid Implement 2020; 18:288–296.
12. Straus S, Tetroe J, Graham I. Knowledge translation in health care, moving from evidence to practice. Oxford: Wiley-Blackwell/BMJ Books; 2009.
13. Kent B. Implementing research findings into practice. Int J Evid Based Healthc 2019; 17:s18–s21.
14. Michie S, van Stralen M, West R. The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implement Sci 2011; 6:42.
15. Francis JJ, O’Connor D, Curran J. Theories of behaviour change synthesised into a set of theoretical groupings: introducing a thematic series on the theoretical domains framework. Implement Sci 2012; 7:35.
16. Colquhoun H, Leeman J, Michie S, et al. Towards a common terminology: a simplified framework of interventions to promote and integrate evidence into health practices, systems, and policies. Implement Sci 2014; 9:51.
17. Wenke R, Noble C, Weir K, Mickan S. What influences allied health clinician participation in research in the public hospital setting: a qualitative theory-informed approach. BMJ Open 2020; 10:e036183.
18. Baker R, Camosso-Stefinovic J, Gillies C, et al. Tailored interventions to address determinants of practice. Cochrane Database Syst Rev 2015; (4):CD005470.
19. Porritt K, McArthur A, Lockwood C, Munn Z. JBI handbook for evidence implementation: JBI; 2020 [cited July 2021]. Available at: https://implementationmanual.jbi.global. https://doi.org/10.46658/JBIMEI-20-01. [Accessed 14 July 2021].
Keywords:

behaviour change; body composition assessment; implementation science; sarcopenia

Supplemental Digital Content

JBI Evidence Implementation 2021 JBI. Unauthorized reproduction of this article is prohibited.

A video commentary on implementation project titled: How do health professionals prioritise clinical areas for implementation of evidence into practice? The commentary is provided by Andrea Rochon RN, MNSc, Research Assistant, Queen's University, Ontario, Canada