Opportunity, hierarchy, and awareness: an ethnographic exploration across rehabilitation units of interprofessional practice in nutrition and mealtime care

Figures & data

Table 1. Details of the food service arrangements supporting meal provision across sites.

Meal period	Co-located units	Standalone unit
Main meals	Breakfast: centralized tray-line plating in the off-unit kitchen with a trolley delivery service to the unit. Lunch and dinner: bulk decentralized service with a communal bistro dining service in the shared unit dining room. Meals plated in the dining room servery and patients encouraged to eat in the dining room. Meals also delivered to rooms.	Breakfast, lunch and dinner: Centralised tray-line plating in the off-unit kitchen with a trolley delivery service to the unit. Patients had the option to eat in their rooms or in a communal dining room.
Snacks	On-demand snacks ordered by patients (with staff support available) via a bedside digital self-selection system (implemented during data collection).	Tea-trolley food and beverage service.

Table 2. Examples of nutrition and mealtime care elements observed and interview questions.

Activities observed

Interview questions

Dietetic services (e.g., initial assessments and reviews of nutritional intake) provided by dietitians or NAs/DAs. Clinical care provided by speech pathologists. Ad-hoc clinical handover on the unit between staff (e.g., speech pathologists and nursing). Meal preparation group facilitated by occupational therapists. Case conference meetings with interprofessional team members. Weekday clinical huddle between dietitians and DAs. Meal orders taken by NAs, DAs or FSOs. FSOs delivering mid meals. PSOs transporting patients to and from mealtimes. Coordination and/or provision of mealtime assistance by FSOs, DAs, nursing staff or support persons.

Please describe your involvement in nutrition or mealtime care on this unit. Prompts: If not involved: Would you like to be involved? How? What stops you from being involved? What does interprofessional nutrition care mean to you? Can you provide any examples of interprofessional nutrition care on this unit? What currently supports or hinders interprofessional practice? What role, if any, does nutrition have in a patient’s rehabilitation?

NA: Nutrition Assistant; DA: Dietetic Assistant; FSO: Food Service Officer; PSO: Patient Support Officer.

Table 3. Examples of actions taken during the reflexive thematic analysis process×.

Phase	Actions
Familiarisation	The first author (HO) familiarized herself with the entire dataset by reading and listening to interview transcripts while capturing analytical and reflexive notes.
Coding	Data were imported into NVivo (QSR International Version 12) to streamline data management. Data extracts with shared meaning were inductively grouped together in a list of mostly semantic codes by HO, capturing surface level meanings of the data as informed by interprofessional practice literature. As familiarity with the data and coding progressed, latent codes were created by HO, reflecting meaning behind what was said or observed. Coding also occurred deductively in some instances, whereby data extracts were grouped together based on commonly cited elements of interprofessional practice identified from preexisting theory, such as communication and role clarity. A subset of interview transcripts and field notes were exported from NVivo and shared with the last author (TG) who coded these independently before discussing with HO. This was done to support HO’s consideration of different readings of the data. Coding involved two full passes through the entire dataset by HO.
Initial theme generation	HO reviewed each code and grouped codes together to capture patterns of shared meaning across the entire dataset and address the research aims. This was a recursive process in which various collections of codes were created, considered and discussed with the research team. HO created mind-maps to visualize the relationships between different codes and create, review and workshop these patterns. HO grouped codes into initial themes (with draft theme names and stories) based on the patterns across the dataset, as relevant to the research aims and in consideration of interprofessional practice literature. HO also created illustrations, flowcharts and mind-maps to consider the relationships between themes and how these themes best addressed the research aims.
Theme review and development	Initial themes were reviewed, developed, expanded and condensed by HO with reference back to the wider dataset and in discussion with the research team. HO continued to develop patterns and overlapping ideas in the data to enhance the initial themes, as well as making comparisons across sites and professional groups.
Theme refinement, naming and definition	Themes were “fleshed out” further by HO, expanding theme stories, re-naming themes and creating an order for the analytic narrative. The coded dataset and initial thematic maps were regularly revisited by HO during this phase.
Producing the report	Theme stories and names continued to evolve as HO created the analytic narrative to explore the research questions.

*These actions occurred recursively and not always in a stepwise fashion.

Table 4. Illustrative extracts from field work.

Theme	Extract Number	Extract
Mealtimes as an opportunity for interprofessional practice	1	Field note*: Middle aged male PSO wheels an older patient sitting in a wheelchair into the dining room and sets him up at the table ready for lunch. DA1 then comes over and places a bib on this patient who must need it. This process seems like a well-oiled machine!
	2	Nurse 19: Sometimes it’s a bit blurred. … we might think that this dietitian assistant [is helping] this particular patient, but then they might not be, [and you] come back to the patient and be like, oh shoot they haven’t been fed, and then you gotta squeeze in help [for] that patient when you might not have time.
	3	Physiotherapist 5: [Speaking about when physiotherapists have started work earlier to help set up patient’s for breakfast] … we try and engage the nurses, but they don’t give us enough input to make it advantageous for us to continue, because it takes time out of our day to spend 45 minutes helping patients out of bed to the dining room, without getting any help back.
	4	Dietitian 3: … [mealtimes are] a nursing duty, and it’s not something that was handed over to me that we [dietitians] assist at mealtimes…
Hierarchy of nutrition roles and tasks impedes interprofessional practice	5	Nurse 22: I think it [nutrition] is overlooked as part of their [the patient’s] rehab journey. … These patients need a lot of energy to be doing their day-to-day therapies.
	6	Allied Health Leader 3: [Talking about nutrition:] We [staff] undersell this so much. … I wish it wasn’t seen as an aid. I wish it was seen as one of the cornerstones to enabling therapy.
	7	Dietetic Assistant 1: I think sometimes nutrition and food are dismissed [by staff] until they become an issue…
	8	Social Worker 1: Potentially patient priority over their physical therapy rather than us [dietetics and social work hinders their nutrition care]. I think sometimes patients tend to look at their physiotherapy or their occupational therapy—’cause they can see their hand needs help, or that they need to be able to walk—so they really focus on that … but then maybe that education around linking that with good nutrition helps.
	9	Field note*: I noticed that the nurse sits to the side of the dining room on their computer/making calls, at times will get up and talk to patients. I chat to DA4 about this observation who informs me that it’s normal for the nurse present to sit to the side of the dining room. However, DA4 also reported that if she needed help (e.g., with feeding assistance for patients) she would ask the nurse for this.
	10	Occupational Therapist 1: …if patients have swallowing impairments and then they’re really fatigued at the end of the day, all we’ve done is therapy … we need to set those therapy schedules [to] have a break before lunch. … [Creating the plan] would be a whole team effort. …It would generally come up in case conference, “Hey, we need to make a therapy schedule,” and then someone would probably nominate to put it together [and would ask] can everyone [staff] put in their times.
	11	Physiotherapist 4: …It’s also probably just the nature of the profession. It’s [dietetics] not a physical type [of] therapy where you would do [a] joint session like with speech [pathology] or OT more traditionally.
	12	Field note*: Following the end of their morning huddle there is an influx of nurses onto the ward. RN11 walks past DA10. DA10 stops RN11 to inform her that the meal at the nurse’s station (where it’s been sitting for 30 mins now) is the breakfast for the patient in bed 443 but they require supervision with eating. DA10 asks RN11 what she wants her to do with the tray? The RN looks frustrated and abruptly states, “Well I can’t do it because I’m doing obs!” DA10 politely replies, “I can’t do it either as I’ve got to keep setting up the other patients.”
The mystery of nutrition care roles and systems in rehabilitation	13	Occupational Therapist 5: [Talking about involvement in nutrition care:] I feel like it would be better if I had a better understanding of exactly what the role [dietetics] includes and whether we could contribute and help that. There’s a lot of systems… and a lot of the role that I don’t understand.
	14	Speech Pathologist 2: [Talking about nutrition and mealtimes:] That idea of that it’s everyone’s job… we’re not there yet. … There is key staff and nurses who are really onto it, but the team as a whole probably aren’t super aware of the [nutritional] requirements of this population.
	15	Physiotherapist 4: I don’t seem to have had as many of those discussions [about nutrition] here as I have at other places, and whether that is just because it’s such a well-run service that people don’t complain… or maybe I’ve just been sort of more in my own physio bubble, just wrapping my head around that [working in a new service].

*Dates and times have been removed for anonymity.

PSO: Patient Support Officer; DA: Dietetic Assistant; OT: Occupational Therapy; RN: Registered Nurse.