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

ABSTRACT

Interprofessional practice is increasingly cited as necessary in the delivery of high-quality nutrition and rehabilitation services. However, there is limited evidence available exploring the factors which influence interprofessional practice in subacute rehabilitation nutrition services. Our ethnographic study explored collaborative activities, influential factors and staff attitudes related to interprofessional practice in nutrition care. Fifty-eight hours of ethnographic field work were undertaken from September 2021—April 2022, across three subacute rehabilitation units, with a total of 165 patients, support persons and staff participating. Overall, 125 unique participants were observed and 77 were interviewed. We generated three themes through reflexive thematic analysis. First, the potential opportunities for interprofessional practice at mealtimes, as influenced by communication, role clarity and reciprocity. Second, hierarchy of nutrition roles and tasks impedes interprofessional practice, where the perceived lower importance of nutrition care to other clinical roles and physical therapies influences staff practice. Third, the mystery of nutrition care roles and systems in rehabilitation, which exposes gaps in the awareness of different team members regarding nutrition care roles and systems, hindering interprofessional practice. Our findings highlight the opportunity for embedded, innovative models of care and staff education to enhance interprofessional practice in nutrition and mealtimes.

KEYWORDS:

• dietetics
• ethnography
• interprofessional practice
• mealtimes
• nutrition
• rehabilitation

Introduction

Nutrition and mealtime care has traditionally been considered the realm of dietetics and nursing staff in inpatient hospital settings. Dietitians typically lead the creation and evaluation of nutrition care plans in collaboration with patients or support persons (i.e., family, carers and friends) (Swan et al., 2017). Mealtime care (such as assisting patients with eating and drinking) is considered by some as fundamental to nursing care (Feo & Kitson, 2016). The preparation and delivery of meals is the responsibility of food services and food service staff (Ottrey et al., 2018; Pashley et al., 2022). However, recent research has demonstrated the potential for delegated or interprofessional approaches to nutrition and mealtime care, which transcend traditionally held roles (Bell et al., 2021). These approaches champion the delegation of nutrition care actions by dietitians to others. For example, allied health assistants may assist patients with menu selection, or any member of the healthcare team (i.e., professions outside of nursing and dietetics) may provide supportive nutrition care activities, like mealtime encouragement (Bell et al., 2018, 2021). This supports the sentiment that “fundamentals of care are a core nursing responsibility, but are also ‘everybody’s business’ in a compassionate, person-centered health care system” (p.6) (Cahill et al., 2023). This is relevant across all inpatient healthcare settings, including rehabilitation.

Background

Rehabilitation is aimed at “optimizing a patient’s self-rated quality of life and degree of social integration through optimizing independence in activities, minimizing pain and distress, and optimizing the ability to adapt and respond to changes in circumstances” (p.579) (Wade, 2020). Rehabilitation practice is often promoted through the concept of interprofessional collaboration (Olufson et al., 2022; Sinclair et al., 2009; Wallace et al., 2022), with evidence suggesting that interprofessional collaboration may improve patient outcomes and healthcare practices (Reeves et al., 2017). Interprofessional collaboration sits on a practice continuum of teamwork, collaboration, coordination, and networking (Reeves et al., 2018), with different factors including clarity of goals, understanding of roles, level of shared identity, team commitment, interdependence, and integration of clinical activities influencing how interprofessional practice occurs (Reeves et al., 2010; Xyrichis et al., 2018). Hence, interprofessional collaboration is defined as different professionals regularly coming together to provide healthcare services, underpinned by shared accountability between individuals and defined roles (Reeves et al., 2010).

The way a team functions in healthcare, and thus how interprofessional practice occurs, is influenced by different factors within contextual, relational, procedural and organizational domains (Reeves et al., 2010). However, a recent systematic review found that agreement is lacking on the factors that influence interprofessional practice in long-term care facilities, such as rehabilitation (Doornebosch et al., 2022). Further research is needed to better understand the factors that influence interprofessional practice and the nature of the collaborative activities that take place.

Mealtimes may be an opportunity for interprofessional practice, given the numerous staff and professions involved, frequent duplication of tasks and sometimes lack of clear role delineation (Ottrey et al., 2019; Ross et al., 2011). We have identified that interprofessional practice can also influence the provision of person-centered nutrition and mealtime care in rehabilitation units (Olufson et al., 2023). Furthermore, research has highlighted the potential benefit of delegated or interprofessional approaches to nutrition and mealtime care in inpatient settings (Bell et al., 2018, 2021). Examples of this include models of care which foster sharing of nutrition care actions with other team members, such as patient support officers or physiotherapists supporting patients to get set up and out of bed to eat their meal, or allied health assistants initiating nutrition care plans and providing feeding assistance. However, there is limited literature available exploring what interprofessional practice looks like in action (e.g., collaborative activities) within the context of nutrition and mealtime care, nor how the opinions and behaviors of team members impact on nutrition and mealtime care in rehabilitation. This knowledge is needed to identify strengths and areas for improvement in practice.

Aims and objectives

The aim of this study was to explore interprofessional practice in the delivery of nutrition and mealtime care in the subacute rehabilitation setting, including the identification of collaborative staff activities and influential factors. Additionally, to better understand staff attitudes and behaviors toward nutrition and mealtime care in rehabilitation, and the influence on interprofessional practice.

Method

Study design

We chose an ethnographic study design to explore interprofessional practice in nutrition care through the behaviors, interactions, and insights of participants (Reeves et al., 2008). Our study was completed through an interpretivist research paradigm, with consideration of interprofessional practice theory to conceptualize the features and nature of practice (Reeves et al., 2017, 2018; Xyrichis et al., 2018). We embraced subjectivity, valuing the different experiences and views of participants, as well as appreciating the central role of HO in shaping data collection and analysis, and generating meaning from the data as relevant to the research questions (Brown & Duenas, 2020; Ryan, 2018). Ethnographic field work included different methods of data collection: observations, as well as opportunistic and scheduled interviews with staff, patients and support persons (i.e., family, friends or carers). The combination of observations and interviews enabled a rich and nuanced exploration of practices and perspectives.

Setting, recruitment and participants

We purposely selected three subacute, inpatient rehabilitation units across two sites with different food service systems, mealtime care arrangements and dietetic service models. This supported our exploration into how contextual differences may influence interprofessional practice in nutrition care. Table 1 provides a brief overview of the differences in food services arrangements across sites. Two units were co-located in one specialist facility, and all three units were part of the same metropolitan public health service. All units shared a purpose in supporting the rehabilitation of patients with a focus on improving functional ability, capacity, and independence post-illness or injury. Each unit had similar staff employed, including medical, nursing, dietetic, speech pathology, psychology, social work, physiotherapy, occupational therapy, administration and support staff (i.e., food service officers (FSOs), nutrition assistants (NAs), dietetic assistants (DAs) and patient support officers (PSOs)). We used a combination of purposive, convenience and snowball sampling to identify potential participants, with any patients, support persons and staff on the rehabilitation units eligible for study inclusion. In total, 165 participants were involved, including 113 staff.

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.

All potential participants were given the opportunity to opt-out of observations or decline interviews by contacting the primary investigator HO if they did not wish to be included in the study. To support this, flyers summarizing the research and providing HO’s contact details were displayed around the study units, offered to patients and support persons by support staff, and shared by managers to staff through internal channels. Furthermore, verbal or written consent was gained for opportunistic or scheduled interviews, respectively. Patients who lacked the capacity to provide consent were excluded from interviews but may have been included in observations. Unique identifiers were ascribed to each study participant to protect anonymity.

Data collection

Fifty-eight hours of field work were completed by HO across the units from September 2021-April 2022. This author was a doctoral researcher and a clinical dietitian concurrently employed at one of the study sites. For transparency, HO wore different identification badges to distinguish her roles and she confirmed her role when speaking to potential participants during field work. Based on her clinical experience and familiarity with the interprofessional practice literature, HO anticipated that : different professions would be involved in different elements of nutrition and mealtime care, to varying degrees; there would be elements of nutrition and mealtime care which would be working well, in addition to opportunities for improvement; and there would be differences in the way care is provided across settings, warranting observations across units, mealtimes and activities where nutrition care was delivered or discussed. Data were collected until HO, supported by discussions with the research team, felt that the research questions could be adequately answered by the information gathered (Braun & Clarke, 2019b).

Overall, 125 participants were observed, including 95 staff, with observations focusing on events and interactions that occur as part of usual care (see Table 2). Observations were completed on different days and times of the week to capture a diverse sample of participants and activities. HO applied a recognized framework to support the writing and reconstruction of field notes (Spradley, 1980). Handwritten notes were reconstructed in Microsoft® Word as soon as possible following field work to enhance accuracy. From this, 100 pages (34208 words) of typed field notes were produced, including HO’s reflexive notes. These reflexive notes captured HO’s feelings and impressions about what she had heard and observed, as well as areas for further investigation.

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.

A combination of opportunistic and scheduled interviews were undertaken with 77 unique participants, including 49 staff. Each interview was tailored to the participant, with referring to an interview guide as needed (see Table 2). Opportunistic interviews were often ad-hoc, taking place face-to-face during or immediately after observations. Scheduled interviews were planned and most occurred face-to-face in a private space (e.g., meeting room) or via Microsoft® Teams (in accordance with local COVID-19 directives). Follow-up interviews occurred with 12 participants, initiated either by the participant or by HO. These follow-up interviews allowed further elaboration on points raised in a prior interview or during observations. Both opportunistic and scheduled interviews were audio recorded with consent. Automated transcription of the audio recordings were verified as soon as possible following the interview. HO achieved this by listening back to the recording and reading through each transcript, as well as making reflexive notes to discuss with the research team.

Data analysis

The data recorded in interview transcripts and field notes were analyzed through reflexive thematic analysis (referred to herein as reflexive TA) (Braun & Clarke, 2021). This supported a flexible approach to analysis, and valued the subjectivity of HO in driving the analysis, coherent with the interpretivist paradigm of this research (Braun & Clarke, 2019a). We applied the six phases of reflexive TA – familiarization; coding; initial theme generation; theme review and development; theme refinement, naming and definition; and producing the report (Braun & Clarke, 2021) – in an iterative and recursive way (i.e., moving backward and forward through the six phases repeatedly) (see Table 3). Reflexive TA was led by HO and began during field work. Coding and initial theme generation occurred both inductively and deductively using software such as NVivo (QSR International Version 12) and Microsoft® Word, or by hand to create thematic maps and flowcharts (see Table 3 for further details). While insights from patients and support persons were considered as part of the entire dataset, we have focused on the perspectives and behaviors of staff to best answer our research questions for this study.

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.

Ethical considerations

We gained ethical approval from the health service ethics committee (HREC/2021/QRBW/75477) with ratification from the university ethics committee (2021/HE001190). Support was also obtained for this research from directors/managers of medicine, nursing and allied health across the study sites.

Rigor

Commitment to enhancing the credibility of our findings was supported by prolonged engagement in the field, coupled with the use of two different methods of data collection (i.e., observation and interviews). The rigor of data analysis was supported by the iterative and in-depth process of reflexive TA. Aligned with HO’s interpretivist view, and supporting the consideration of different orientations to the data, regular discussions were held with the research team during data collection and analysis. Additionally, the last author, an experienced qualitative researcher, independently coded a subset of the data before discussing this with HO. Reflexivity and transparency were enhanced by recording reflexive notes during field work and examining these with the research team. The Standards for Reporting Qualitative Research were used to support the comprehensive reporting of this study (O’Brien et al., 2014).

Results

We generated three themes to explore interprofessional practice in nutrition and mealtime care: Theme 1, the potential opportunities for interprofessional practice at mealtimes; Theme 2, hierarchy of nutrition roles and tasks impedes interprofessional practice; and Theme 3, the mystery of nutrition care roles and systems in rehabilitation. Illustrative extracts for each theme are displayed in Table 4.

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.

Theme 1: The potential opportunities for interprofessional practice at mealtimes

Mealtimes were cited by staff across management, clinical and operational roles as a potential opportunity for interprofessional practice in rehabilitation units, with some of these opportunities actioned and others unrealized. It was suggested by many staff across sites that interprofessional practice was an enabler to supportive mealtime arrangements, whereby patients are supported to sit out of bed for meals and are offered ample, timely assistance to eat. Interprofessional practice of this nature was seen to be supported by embedded models of care. For example, the communal dining model for lunch and dinner service within the two co-located units. This model aimed to involve staff from diverse professions at mealtimes and had been enabled by interprofessional education sessions and simulations prior to the hospital opening. Despite this education, interprofessional practice was mainly seen between PSOs, DAs, and FSOs, and sometimes nursing, with limited involvement of other staff. Interprofessional teamwork was demonstrated by DAs and FSOs in the communal dining room through constant communication, a strong relationship and clear understanding of each other’s roles, which contributed to the seemingly effortless provision of meals and mealtime support. Additionally, PSOs and DAs collaborated to support the efficient transport of patients to and from the dining room (extract 1). This was achieved by DA-led communication of which patients needed assistance to get to the dining room. Nursing staff described their role in the communal dining model as primarily focused on safety and supervision alongside the DAs. However, nursing staff were at times seen to also help patients eat or move to and from the dining room.

Mealtime assistance was an activity shared by nurses, assistants in nursing (AINs) and DAs within the two co-located units. Nurses reported valuing the help of DAs and AINs to provide mealtime support, particularly at breakfast when meals were served to patient rooms only; however, this came with its challenges when interprofessional communication was lacking (extract 2). Additionally, one nurse mentioned that nursing non-meal roles and task allocations could be better defined across the night and morning shifts to better assist in setting patients up for breakfast.

Staff across sites recalled different initiatives aimed at enhancing interprofessional practice at mealtimes. Most of these appeared to have been reliant on key staff champions and had not been sustained. Staff within the standalone unit cited an example whereby physiotherapists started their workday early to assist with setting up patients for breakfast. While this was successful for a period, it was discontinued, with reported reasons including a change in management (decreased advocacy), staff being unable or unwilling to change their working hours, and a lack of interprofessional collaboration with nursing staff.

Similarly, the notion of reciprocity as an enabler to interprofessional practice was also noted by some members of staff from dietetics, nursing, and physiotherapy. They implied that without reciprocity, interprofessional practice in nutrition and mealtime care was viewed as extra work (extract 3). Staff from speech pathology and dietetics also suggested that reciprocity can be more challenging to facilitate in smaller disciplines (e.g., dietetics) that may be perceived as being too busy completing their own clinical work for interprofessional practice. Regardless, many clinical staff members agreed that interprofessional practice at mealtimes in particular needed to be a two-way street. It was reported that if other professions were to ‘fit’ nutrition or mealtime care into their responsibilities, then dietitians needed to reciprocate and be involved in the services of other professions.

Within the standalone unit, various team members reported previous collaboration during a “mid-meals in the gym” initiative. Through this, NAs provided mid-meals to patients, with a break in therapy for patients to consume food and beverages. Staff from dietetics, physiotherapy and occupational therapy spoke fondly of this initiative and how it supported patients to meet their nutrition and hydration needs. Many staff expressed eagerness for this initiative to recommence; however, staff labor costs were identified as a barrier.

Whilst mealtimes were identified as an opportunity for enhanced care through interprofessional practice, barriers to staff mealtime involvement were identified across sites. Historical “rules” discouraging staff presence on the unit during lunch, and routines including staff taking their lunch break at the same time as patients and staff using patient mealtimes to catch up on clinical documentation were identified as hindering interprofessional practice. Thus, these factors were potential reasons that opportunities for interprofessional practice at mealtimes had not been fully realized. Additional barriers reported and observed included clinical staff not being confident in, nor believing they should be involved in mealtimes and the notion that staff were too busy to attend mealtimes.

The reports and actions of dietitians offered insights into their understanding of mealtimes and their mealtime roles. Dietitians working within the co-located units were familiar with the communal dining model of care, confidently reciting how it enabled person-centered nutrition care. They expressed a desire to be more present at mealtimes, however staffing and other clinical priorities were barriers. Interestingly at the standalone unit, dietitians were largely unfamiliar with mealtime processes, with this considered the domain of nursing staff. While dietitians at this site did not view involvement in mealtimes as part of their role (extract 4), they, along with managers and nursing staff, welcomed help from other team members to support mealtime care.

Theme 2: Hierarchy of nutrition roles and tasks impedes interprofessional practice

The perceived importance of nutrition and food services in relation to other professions and activities was found to affect how staff viewed and instigated interprofessional practice. While one nurse leader suggested the inclusion of eating in their functional assessment demonstrated the importance of nutrition, staff across professions indicated (both explicitly and implicitly) that nutrition was considered merely an “aid” to therapy (extracts 5 and 6). It was also reported that some staff were unaware of or neglected to make the potential link between nutrition and rehabilitation progress or outcomes. Dietitians explained that emphasizing this link within team meetings was a core part of their role. Interestingly, some staff also commented that taking part in the study interviews prompted them to consider the intersection of nutrition and their professional role, which they had seldom done previously. It was also suggested by staff from nursing, medicine, physiotherapy and psychology that only when nutrition was a problem was it viewed as important (e.g., if inadequate nutritional intake resulted in weight loss or impacted therapy participation). This was corroborated by reports from dietetics staff when reflecting on team awareness and involvement in nutrition care (extract 7).

Managers, dietitians and DAs suggested that nutrition was considered less important to staff and patients than other therapies and activities because it was not a physical therapy, with a similar sentiment echoed by one social worker (extract 8). This was also observed and reported through the actions of some staff across sites, such as clinical staff interrupting or talking over support staff as they distributed meals, took meal selections and completed nutrition screening with patients, or nurses sitting to the side of the dining room on their mobile phone or completing clinical documentation rather than being actively involved in mealtime care activities (extract 9). Further examples included physical therapy occurring over lunch time, mealtimes being interrupted or cut short for showers, and nurses doing bedside handover obstructing the path of FSOs as they delivered meals. However, staff in the two co-located units also recalled positive instances of interprofessional coordination with the team, such as when they identified the need to schedule patient therapy around lunch and then worked together to achieve this (extract 10).

Given the lower perceived priority of nutrition, some staff suggested that dietitians need to incorporate nutrition messaging into existing therapy sessions or groups, which was not routinely occurring at either site. While joint therapy sessions were reported to occur regularly across other professions (e.g., speech pathology and occupational therapy or occupational therapy and physiotherapy sessions), dietitians rarely completed sessions with other staff, with some suggesting this was due to the “nature” of nutrition care (extract 11).

Despite this, speech pathologists were found to place a high value on nutrition care and collaborating closely with dietetics staff. While speech pathologists and dietitians were not reported or seen to regularly undertake sessions together, other examples of interprofessional collaboration or teamwork were frequently described or observed across sites. This included collaborative, out-of-session dietitian and speech pathologist practice to create care plans in line with a patient’s expressed wishes (e.g., to be on a less texture modified diet), as well as speech pathologists reiterating dietetic messages with patients (and vice versa for dietitians with speech pathology messages). Speech pathologists were also reported and seen to give discharge information to support persons or provide handover in case conference on behalf of the dietitian when they were unable to attend.

Competing priorities for nursing staff at mealtimes meant that despite being aware of its importance, mealtime support was the first thing to drop off their radar when busy. This was most evident at breakfast time, where competing priorities included needing to get patients up and ready for physical therapy, nursing handover between the night and morning shift staff, medication rounds and medical observations (extract 12). It was suggested by one nurse that therapists could better coordinate with them, identifying those patients who need more time at breakfast and scheduling their therapy for later in the morning. This coordination was not observed across either site.

Theme 3: The mystery of nutrition care roles and systems in rehabilitation

Despite understanding nutrition to be core business for dietitians, staff across sites from physiotherapy, occupational therapy, psychology and nursing stated that a key barrier to their involvement in nutrition care was their lack of understanding of nutrition staff roles (i.e., dietitians or nutrition/dietetic assistants: extract 13). This was echoed by staff from speech pathology, dietetics and physiotherapy, who posited that many team members were not aware of how systems within their workplace influenced nutrition (e.g., how patients get their food), nor the nutritional needs of patients in rehabilitation (extract 14).

Moreover, a lack of understanding regarding nutrition roles sometimes resulted in a double up of tasks. In the two co-located units, food and beverage consumption (of all meals and snacks provided by food services) was recorded by FSOs in a digital menu management system. However, both medical staff and nursing managers commented on how nurses completed food charts in the electronic medical record, suggesting these staff members were either unaware or had forgotten this element of the nutrition care system.

It was often suggested that a lack of understanding was the result of working within profession-specific “silos”. Staff across sites attributed this to busy caseloads or being new to their role and workplace (extract 15). Adjusting to the complexities of a new team and workplace also reportedly impacted the ability of dietitians to proactively instigate interprofessional collaboration or teamwork (e.g., through dietitian input into occupational therapy cooking groups) within the co-located units. Shared work environments where clinical staff from different professional backgrounds sat together at lunch times or in workspaces were cited across sites as enhancing understanding of the roles of different team members.

Nutrition education was identified as important for improving staff knowledge about nutrition roles and systems. Staff nutrition education was reported at the standalone unit, where positive feedback had been received from dietitian-led nursing education sessions focused on malnutrition. A dietitian at this site reported plans to extend this training to NAs and FSOs, as well as providing these staff with education on healthy eating principles, to enhance their ability to support nutrition care for patients with diverse nutritional needs. Nutrition education for staff was not occurring across the two co-located units, despite previously happening during workplace orientation. This appeared to have dropped off the dietetics agenda due to other clinical priorities associated with opening new units and onboarding new staff, as well as possibly being influenced by COVID-19-related directives. One dietitian and another DA suggested that reintroducing staff education sessions may help to enhance nutrition awareness and understanding. Encouragingly, students at this site had the opportunity to participate in interprofessional practice education workshops that focused on spotlighting opportunities for interprofessional collaboration in a communal dining model.

Discussion

The findings of our ethnographic study advance existing understanding of collaborative interprofessional activities and influential factors in nutrition and mealtime care across subacute rehabilitation units. We identified examples of routine interprofessional collaboration and teamwork among some staffing groups in the provision of mealtime care in an embedded communal dining model, as well as instances of regular interprofessional collaboration in clinical practice between dietitians and speech pathologists. We also found that the perceived hierarchy surrounding nutrition care activities and staff, as well as a lack of understanding regarding the intricacies of nutrition staff roles and nutrition care systems influenced how staff perceived, initiated and applied interprofessional practice. Thus, organizational focus on enhancing staff understanding of nutrition care systems and clarifying the roles and responsibilities of those involved in nutrition and mealtime care is needed to enable interprofessional practice. Staff also identified various opportunities through which interprofessional practice can be better harnessed, highlighting areas for service improvement activities and future research. These included the collaborative creation of therapy schedules that consider holistic patient needs, joint allied health sessions including dietitians (e.g., dietitian involvement in cooking groups), as well as increased involvement of other staff (e.g., from nursing, physiotherapy, support services) in setting patients up for mealtimes through a coordinated and collaborative approach.

Competing priorities were seen and cited as barriers to staff involvement in nutrition and mealtime care across sites. These included the general busyness of clinical workloads, medication rounds, personal care, medical observations and clinical handover. Competing priorities at mealtimes is a longstanding challenge in healthcare systems, as identified by Ross et al. (Ross et al., 2011) in focus groups with acute care staff over 10 years ago, as well as others more recently (Jong et al., 2021; Marshall et al., 2019). This demonstrates the ongoing complexity of addressing this problem in practice as repeatedly highlighted in our research.

Through our study, we identified that an embedded communal dining model was an enabler for interprofessional mealtime practice involving DAs, FSOs and PSOs, and sometimes nursing staff. However, staff identified further opportunities to advance wider team involvement within this model. While previous initiatives involving different interprofessional team members in nutrition care were cited, these had not been sustained for various reasons, including decreased advocacy and a lack of interprofessional collaboration. Our findings echo the research of others, which draws attention to the importance of embedding change into practice to enhance sustainability (Laur et al., 2017).

We found that historical “rules” and routines inhibiting staff presence on the unit during lunch time were a deterrent to interprofessional practice. This contributes to existing evidence which encourages a move toward mealtime models that focus on support and assistance (i.e., helping and encouraging patients at meals), rather than protection (i.e., preventing interruptions) (Young et al., 2013). This was further supported by staff in our study calling for diverse team members to be more involved in mealtimes, especially in setting patients up for eating. Other rehabilitation staff have also suggested a team approach as the most efficient way to support patients to attend a communal dining room (Jong et al., 2021). We observed a successfully implemented method where PSOs and DAs collaborated closely to support patients to attend the communal dining room following therapy.

Hierarchy was seen to influence interprofessional collaboration, especially at mealtimes, as others have previously identified (Gergerich et al., 2019; Lingard et al., 2012). However, rather than continuing attempts to flatten these hierarchies, our findings indicate that these could instead be accepted in some instances. For example, the overriding priority for nurses to complete medical observations, two-person medication checks and provide patient medications on time during breakfast service. Instead of forcing change in dogma and routine, alternatives could be explored to ensure that patients’ needs are met, by reimagining traditional models of care to enable clinical and support staff to work to their full professional capacity, as in line with emerging evidence (Bell et al., 2021). This may include FSOs opening food packaging for patients, DAs or NAs providing feeding assistance, nurses completing medication or observation rounds followed by encouraging and checking that the patients’ mealtime needs are being met, or physiotherapists aiding patients to set up for mealtimes (e.g. attend the communal dining room) as part of therapy. It is essential that this occurs alongside investigation and consideration of local contextual factors to best inform and embed models of care to enable change.

We identified a lack of awareness regarding nutrition care roles, processes or services, as has been identified by others as a barrier to involvement in nutrition care on medical units (Laur et al., 2017; Marshall et al., 2019; Ross et al., 2011). Some staff in our study suggested that targeted education sessions on how different professions can contribute to nutrition care and how the nutrition care systems within their workplace operate may be beneficial in raising nutrition awareness. The importance of staff nutrition education (initial and continuing) has been previously highlighted by Tappenden et al. (Tappenden et al., 2013) who suggested that education is essential in tackling malnutrition, especially for nursing and medical staff who may have received little nutrition education during their training.

Interestingly, some dietitians included in our study did not see mealtimes as part of their role and had limited understanding of what happened at mealtimes in their workplace. They instead viewed mealtimes as a core responsibility of nursing staff, which is consistent with other literature citing eating and drinking as a fundamental of nursing care in acute settings (Feo & Kitson, 2016). Our finding may also reflect the decreased focus on food service work in dietetic practice, as highlighted by Wright et al. (Wright, 2017). Overall, this emphasizes the need to foster further involvement and engagement of dietitians in food services. It is essential that dietitians employed in inpatient settings understand the food service systems they must work with (including mealtime models of care), given that these systems determine how patients choose and receive their meals, potentially influencing clinical dietetic recommendations (i.e., a dietitian’s treatment) (The British Dietetic Association Food Services Specialist Group, 2019; Dietitians Australia Food Service Interest Group, 2022). This knowledge is vital, not only for the creation of holistic nutrition care plans, but to empower dietitians to be champions of all aspects of rehabilitation nutrition care (e.g., medical nutrition therapy, mealtimes and food services), and thus, their proclivity to lead by example and share this knowledge with other staff, patients and support persons.

Supporting a move toward interprofessional practice in nutrition and mealtime care is complex. It may require systems approaches to target various layers of the healthcare process, addressing local contextual barriers. Further research considering behavior change, systems or complexity theories may be useful to evaluate strategies aimed at optimizing interprofessional practice in nutrition and mealtime care. Opportunities exist for future research and quality improvement projects focused on interprofessional staff education regarding nutrition care roles and systems, the collaborative creation of rehabilitation therapy schedules addressing holistic patient needs, as well as implementing models of care that support team members to work to their full professional capacity with attention to the needs of patients at the center.

Limitations

There are limitations to consider alongside our findings. We collected data during the COVID-19 pandemic, where associated lockdowns periodically impacted operations within the health service and the study units. While it was outside of the scope of our study to explore the impact of COVID-19 on interprofessional practice, there may have been changes to usual care practices that do not reflect a pre- or post-pandemic environment. However, staff were able to identify changes to practice associated with COVID-19, which we considered in our analysis. We collected data from three subacute rehabilitation units located within the same health service, potentially limiting the transferability of our findings to other settings. However, reassuringly there are similarities between our findings and those in the published literature (Jong et al., 2021; Ross et al., 2011). The assessment of local contextual barriers and enablers may be needed in the translation of our findings into other practice settings.

Conclusion

Our ethnographic study identified various enablers to interprofessional collaboration in nutrition and mealtime care in subacute rehabilitation units, such as embedded models of care and strong professional relationships that foster a clear understanding of each other’s roles. We found that a lack of awareness regarding the nuances of nutrition care roles and systems, as well as the perceived hierarchy of these in relation to other professions or tasks impeded interprofessional practice. Rehabilitation services should look to engage diverse team members (i.e., beyond dietitians and nurses) in nutrition and mealtime activities by reimagining traditional models of care to support interprofessional practice. This may be enhanced by identifying how each staff group can best contribute when operating at their full capability, and implementing service initiatives or models of care to support this. Strengthening interprofessional education may further encourage interprofessional practice and provide opportunities to learn and practise nutrition care activities.

Author contributions

All authors contributed to the conception and design of this study. HTO led data collection and analysis, as well as the drafting, revision and finalization of the manuscript. TLG provided supervision throughout the data collection and analysis process, as well as input into coding and led the review and editing of the manuscript. EO and AMY both provided supervision during the data collection and analysis process, as well as reviewing and editing the manuscript. All authors have critically reviewed the content of this manuscript and approved the version submitted for publication.

Acknowledgments

Thank you to all patients, support persons and staff who participated in this research. The authors would also like to thank Karina O’Leary for her critical review of the draft manuscript. This study was completed as part of doctoral research for HO and was supported by an Australian Government Research Training Program (RTP) Scholarship.

Disclosure statement

No potential conflict of interest was reported by the authors.

Additional information

Funding

The work was supported by the Australian Government .

Notes on contributors

Hannah Olufson

Hannah Olufson is a PhD candidate at the University of Queensland and an Accredited Practising Dietitian at the Surgical, Treatment & Rehabilitation Service in Brisbane, Australia. Hannah’s PhD research explores person-centred care and interprofessional practice in nutrition and mealtime care across rehabilitation units. Her research will inform the creation of a conceptual model which can be used to guide, evaluate and enhance current practice. Hannah is also passionate about embedding the collection and action of consumer feedback into practice, as well as building the capacity of dietetics and food services staff to undertake research and service improvement projects.

Ella Ottrey

Ella Ottrey is a Senior Research Fellow at the Monash Centre for Scholarship in Health Education, undertaking health professions education research. She has 10 years of experience as an Accredited Practising Dietitian working within the Victorian public healthcare system. She completed her PhD in 2019, which explored mealtime practice and environment in subacute care. Ella’s research expertise and interests include preparedness for practice, transitions into practice, and healthcare workforce development using interpretivist approaches.

Adrienne Young

Adrienne Young is an Advanced Accredited Practising Dietitian and research coordinator for the Dietetics & Food Services department at the Royal Brisbane and Women’s Hospital, as well as a Senior Research Fellow at the University of Queensland, Centre for Health Services Research. Her research over the past 10 years has focused on improving nutritional care of older people in hospital, with recent work also focused on capacity building for research and knowledge translation amongst allied health professionals and co-design nutrition care improvements with older people and caregivers.

Theresa Green

Theresa Green has over 30 years post registration nursing experience in clinical neuroscience nursing practice, management, education, research, and academia across a variety of settings (acute & rehabilitation care). She completed her doctoral and post-doctoral studies in Canada in stroke recovery and community reintegration; she has presented and published ongoing research findings nationally and internationally. Theresa’s neuroscience-related and clinically focused research interests centre on quality patient care, evidence-based practice and the fields of implementation and improvement science.