A nursing minimum dataset for documenting nutritional care for adults in primary healthcare: a scoping review protocol

Abstract

Review question/objective The primary objective of the scoping review is to identify all published nutritional screening instruments that have been validated in the adult population in primary healthcare settings and to report on their psychometric validity. The scoping review will also seek to include published evidence from the perspective of relevant experts in the field as to what is viewed as appropriate to assess in relation to nutritional care for adults in primary healthcare. Furthermore, published evidence of adult patients' and their relatives' views of nutritional assessment and documentation will also be sought for inclusion. Review question 1: What nutritional screening instruments have been validated for use for the adult population in primary healthcare settings? Review question 2: What is the psychometric validity of these nutritional screenings tools? Review question 3: What do nutritional experts, patients and their relatives find appropriate to assess in relation to the nutritional status of adults in primary healthcare? In this scoping review, the term “appropriate” refers to what patients, their relatives and experts consider as “suitable” or “meaningful” to assess in relation to the nutritional status of adults. Background Several studies describe the lack of important nutritional notes in patients' nursing records.1,2 In some studies, it was found that nurses routinely document (although with low rates of compliance, ranging from 22%-68%) details on nausea/vomiting, ability to eat/drink and diarrhea, while energy intake and body mass index are rarely documented.3 In other studies the trend is quite the opposite.4 Overall, the majority of the studies conclude that assessment and documentation of the patient's nutritional status are not routinely performed well as evidenced by a lack of structure in nursing documentation concerning nutritional care.1–6 Documentation should include information that ensures good quality and safe care of patients. However, detailed descriptions of what exactly should be documented regarding the patient's nutrition is often not given.3 A nursing documentation model called VIPS (an acronym for wellbeing, integrity, prevention and security) follows the structure of the nursing process and is widely used in Scandinavian countries.7,8 Despite the demands on documentation and the use of the VIPS model as well as other documentation models, nutritional issues are still sparsely documented. This overall generic framework for nursing documentation, such as VIPS, among other documentation models, does often not specify what nutrition data nurses have to collect and document.8 Using general terms like “nutrition”, “appetite”, “diet”, etc. does not guide nurses on how to make adequate and relevant observations about the patient's nutritional status. This can be linked to the low frequency of documentation, as the patient's nutritional problems simply remain unidentified by the nurses.9 In some studies, nutritional care is considered by some nurses to be without significant importance,10 while in other studies nurses themselves indicate that they do know that nutrition is important, but they have difficulties identifying what needs to be documented about patients' nutritional care, what is relevant and what is important.3,11,13 Overall, there seems to be both a lack of nutritional knowledge among nurses as well as a lack of a structured and systematic approach to the deal with assessment of nutritional status.14 The need for a Nursing Minimum Data Set (NMDS) in the nutritional area within primary healthcare is therefore obvious. In 2012 some of the authors of this review published an article in which a NMDS based on a scientific approach to identify core elements of nutritional care within the hospital setting was developed.15 The aim of a NMDS is to use the minimum number of items to best capture the nursing contribution to patient care. It is important to highlight that a NMDS is not another screening tool, but a collection of essential minimum nursing data which are of importance, e.g. on nutrition. A NMDS can be developed in several ways. Work conferences (based on expert opinions and experiences) are often used to develop specific or generic Minimum Data Sets.16 It has not been possible to identify a NMDS that has been developed by combining data from both a consensus based and a scientific based approach. This systematic scoping review can therefore hopefully contribute towards future initiatives to develop new approaches and methods for establishing NMDSs. This scoping review will be undertaken in accordance with the Joanna Briggs Institute's methodology for scoping reviews as described in the 2015 JBI Reviewers' Handbook17,18 and will use the following approaches: A systematic literature search of existing nutritional screening tools that are validated in primary health care will be conducted and these tools as well as their psychometric validity will be mapped and presented. This systematic literature search will also include qualitative/textual papers on nutritional experts' opinions on the assessment of the nutritional nursing care of adults in primary healthcare as well as the views of patients/and their relatives. After the mapping of these two areas it will be possible to develop a NMDS within the nutritional area. The NMDS is targeted toward informing nurses in primary healthcare of core elements in their daily documentation and observation, but could be equally valuable to other healthcare professionals who are involved in the assessment and observation of the nutritional status of adults in primary care, such as healthcare helpers and general practitioners. An initial search of the literature in The Cochrane Library, JBI Database of Systematic Reviews and Implementation Reports, TRIP database and Prospero has identified that no other scoping reviews have been undertaken on this topic. Definitions: Nursing Minimum Data Set A NMDS is comprised of “essential nursing data” which are defined as “those specific items of information that are needed on a regular basis by the majority of nurses across all settings in the delivery of care”.19(p102) Uniform definitions and categories are used to describe these items of information, and the aim is to meet the information needs of various data users in healthcare systems.20 Nutritional nursing care Nutritional care is a concept including different aspects that needs to be handled in a seamless way. The patient is entitled to the right kind of individual nutritional support at the right time and in the right place. Successful nutritional care is dependent on careful management.21 Nutrition is a strong and integral part of nursing care,22 and can be referred to as “nutritional nursing care”.3 Psychometric validity The two main issues in psychometric validation are that the tool measures what it is intended to measure and that the tool measures the same way each time it is used. These concepts are known as validity and reliability respectively.23 In this review only the psychometric validity of nutritional screening instruments will be explored. There are several types of validity - below the types of validity that will be presented are described: Face validity refers to the test looking like it should be measuring what it is intended to measure. A tool is likely to have little credibility if it does not possess this characteristic.23 Content validity involves the tool possessing sufficient breadth as to ensure all relevant aspects of the construct under investigation are included and that aspects irrelevant to the constructs are not included.23 Construct validity refers to whether scales purported to measure an attribute measure the actual attribute. Pearson's correlation coefficient is used to test for construct validity. Generally, a test will have good construct validity if it correlates well with other tools that also measure that construct (i.e. convergent validity) and correlates less well with tools that do not measure the same construct (i.e. discriminant validity). Construct validity is generally considered good if correlations related to convergent validity exceed those related to discriminant validity. Factor analysis is also a statistical technique involved in the establishment of construct validity. A set of items in a tool usually combines to provide a measurement of a particular construct. Factor analysis is used to determine which items are associated with the measurement of a construct. Evidence for a construct being valid is provided if the same items are associated with the same construct across a number of different samples, conditions, etc. When this occurs, the tool is said to have a stable factor structure.23 Criterion validity (predictive validity and concurrent validity) discriminates between groups known to differ with respect to attributes being measured. The tests generally used to assess criterion validity are tests of differences between groups such as analysis of variance and the Kruskal-Wallis test. Criterion validity is often divided into “concurrent” and “predictive” subtypes of validity. This term is reserved for demonstrations relating a measure to other concrete criteria assessed simultaneously and refers to the degree to which any measure can predict future or independent past events.23 Primary health care Primary health care refers to a broad range of health services most often delivered in community-based settings. Primary health care services seek to intervene early to maximize health and wellbeing outcomes and prevent or slow the progression of ill health.24 Primary health care encompasses both “home care” and “nursing home”.24 Home care, also referred to as domiciliary care, social care or in-home care, is supportive care provided in the home. Care may be provided by licensed healthcare professionals who provide medical care or by professional caregivers who provide daily care to help to ensure the daily activities are met. Home Health services help adults, seniors and pediatric clients who are recovering after a hospital or facility stay, or need additional support to remain safely at home and avoid unnecessary hospitalization. This care is provided by registered nurses (RNs), licensed practical nurses (LPNs), physical therapists (PTs), occupational therapists (OTs), speech language pathologists (SLPs), home health aides (HHAs) and medical social workers (MSWs).24 A nursing home, convalescent home, skilled nursing facility (SNF), care home, rest home or intermediate care facility provides a type of residential care. It is a place of residence for people who require, as determined by a local hospital social worker and their nursing facility provider, continualnursing care and have significant difficulty coping with the requiredactivities of daily living.24 Inclusion criteria Types of participants For Question 1 and 2, this scoping review will seek to include studies with participants who are adults (aged 18 years and over) of any sex, culture, diagnoses and ethnicity. For Question 3, studies will be sought that report on the views and opinions of nutritional experts as well as the views of patients (defined above) and their relatives. Nutritional experts in this scoping review are defined as: persons with knowledge within the nutritional area. It is not limited to a those with formal education such as registered dieticians/nutritionists or nutritional therapists. It also encompasses persons who have undertaken research in the nutritional area. A nutritional expert is not one with formal education and includes therefore a large range of people with knowledge within the nutritional area. Relatives in this scoping review are defined as: persons who are connected to patients either through blood or marriage. Concept For Question 1 and 2, studies that report on any nutritional screening tools validated (regardless of the type of validation) in the adult population in primary healthcare will be sought for inclusion. For Question 2, only studies that report on the psychometric validity of the nutritional screening tools will be considered for inclusion. For Question 3, the concept of interest is the views and opinions of eligible participants regarding the appropriateness of nutritional assessment. This includes studies of patients and/or their relatives' views of assessment of the nutritional status of adult in primary healthcare on both an individual and/or group basis. Consensus statements, reports, interviews, etc. from nutritional experts on the same concept of interest will also be included. Types of outcomes The quantitative component of this review will consider studies that include the following outcome measures: For the review of nutritional screening instruments, outcomes of interest include: 1) the psychometric validity of tools; and 2) the content of the nutritional screening tools used to assess the nutritional needs of adults in primary health care. Context Studies to be included must be conducted in primary healthcare settings. This includes studies both home care and nursing home facilities. Types of studies This scoping review will consider quantitative and qualitative studies of any design or methodology, and text and opinion sources. Quantitative studies may include, but will not be limited to, experimental and observational study design, including randomized controlled trials, non-randomized controlled trials, quasi-experimental, before and after studies, cohort studies, case control studies and cross sectional studies. Qualitative studies may include, but will not be limited to, phenomenology, grounded theory, ethnography, action research and feminist research. Text and opinion papers may include, but will not be limited to, consensus papers, discussion papers, position papers and other texts. Search strategy The search strategy aims to find both published and unpublished studies. A three-step search strategy will be utilized in this review. Initial search terms have been chosen in discussion with a research librarian with the aim of identifying the maximum number of articles. An initial limited search of MEDLINE and CINAHL will be undertaken followed by an analysis of the text words contained in the title and abstract, and of the index terms used to describe the article. A second search using all identified keywords and index terms will then be undertaken across all included databases. Thirdly, the reference list of all identified reports and articles will be searched for additional studies. Studies published in English, German, Danish, Swedish, and Norwegian will be considered for inclusion in this review as members of the review team have expertise in each of these languages. Databases will be searched from their inception to April 2015. The databases to be searched include: PubMed, CINAHL, Embase, Scopus, Swemed+, Mednar, CDC, MEDION, Health technology assessment database, Turning research into practice, NTIS, ProQuest Dissertations and Theses, Google Scholar, Current Contents Additional searching for published and unpublished literature will include: Hand searching reference lists, bibliographies of included articles, international and government affiliated websites with areas dedicated to nutrition within primary health care Initial keywords/search terms to be used will be: nutrition, screening, nutritional screening, instrument, nutritional assessment, malnutrition, assessment, tool, diagnostic, diagnostic test, adult, primary care, Nursing Minimum Data Set, Minimum Data Set, appropriateness, adult, primary care, consensus, work conference nutritional care, assessment, nutritional expert opinion Data extraction For Question 1, data will be extracted from included papers pertaining to the type of nutritional screening instrument discussed. Details that will be extracted may include:TableFor Question 2, data will be extracted from included papers pertaining to the psychometric validity of nutritional screenings tools. Details that will be extracted may include:TableFor Question 3, data will be extracted pertaining to the views of nutritional expert, patients/and their relatives regarding what they find appropriate to assess regarding the nutritional status of adults in primary health care contexts. Details that will be extracted may include:TablePresenting the data Data extracted from each of the studies will be mapped and presented in a form that logically reflects the objectives of this scoping review. The data from the studies will be presented in terms of overall concept/components that can be related to nutritional assessment in primary health care. Conflicts of interest The authors have no conflict of interest to declare. Acknowledgements None.