Introduction
The present problem is that nutrition and hydration are not considered priority nursing interventions and are performed in a suboptimal manner as shown in many studies (Begum & Johnson 2010; Godfrey et al 2012; Ross et al. 2011). Food and feeding times are institutionalized and fail to consider the preferences of the patient and other needs that may be linked with dining. In order to learn the most appropriate interventions in providing patients with nutrition and hydration, there is a need to perform a literature search and determine whether this topic has already been extensively studied or if further research is needed. The retrieval of relevant material is facilitated by the use of the PICO method, an acronym for patient, intervention, comparison and outcome, which ensures that the literature search turns out articles that directly provide answers to the chosen problem, thus ensuring efficiency and high quality secondary data (Waljee, Larson & Chung 2012).
The PICO was conceptualized by practitioners at Oxford University (van Etten-Jamaludin & Deurenberg 2009). To date, there is limited evidence as to the effectiveness of searching using this method but it has gained wide popularity in the health sciences as a method of facilitating better queries (Hoogendam et al. 2012). In using the PICO strategy, the problem needs to be restated into the appropriate format. For this problem, the patient would be adult patients in acute and long-term care settings. They could be young, middle-aged and older adults in such settings as the medical-surgical unit, neurology ward and nursing care homes.
The intervention would be nutrition and hydration via the oral route, hence excluding artificial nutrition and hydration (ANH) that is given to unconscious patients and those whose medical condition render them unable to tolerate per orem feedings. The previous literature review points out that individualised, as opposed to institutionalised, nutrition and hydration practices results in better outcomes. Thus, comparison would be between the conventional institutionalised interventions and individualised interventions as the alternative. Outcomes include adequately meeting the nutrition and hydration needs as evidenced by weight, recommended intake, BMI, hydration indicators as well as associated social, emotional and cultural needs associated with eating and drinking.
The PICO question would be “Can individualised oral nutrition and hydration interventions among older adults in acute and long-term care settings lead to better physiologic, social, emotional and cultural outcomes?” Answering the above clinical question is important in improving current clinical practice for several reasons. Firstly, nutrition and hydration are basic needs of patients that need to be fulfilled in order to promote healing and a return to previous function levels or ensure the highest level of health possible. Secondly, the advent of evidence-based practice dictates that nursing care should continually change as standards of quality change. Such standards are founded on safety, efficacy, efficiency and cost-effectiveness. Thirdly, practice change cannot take place without sufficient research supporting alternative best practices. In-hospital reviews and research permits improvements that are suited to the particular organization’s context.
The PICO method involves several steps beginning with the formulation of an appropriate clinical research question. The next steps are to determine the inclusion and exclusion criteria in order to further limit the search and then formulate a suitable search strategy. Each of the components of the question will be searched separately and in combination to yield studies that are directly related to the question. These will be subjected to review and appraisal in order to finally answer the clinical question.
Inclusion and Exclusion Criteria
The inclusion and exclusion criteria form the basis for choosing a study for review in the effort of answering the clinical question. Considering the characteristics of the patient, studies that involve adult participants in acute and long-term care will be included. Since there is no perceived difference between genders, male and female participants are acceptable. To determine cultural outcomes, all participants regardless of ethnicity will be considered. Paediatric patients cannot be included since children would have different needs related to nutrition and hydration. For instance, they may not be able to perceive the social, cultural and emotional needs associated with eating and drinking that adults consider as outcomes of care. Especially for very young children, nutrition and hydration basically fulfil hunger and thirst which are purely physiologic needs.
Further, participants who have retained the capacity for oral nutrition and hydration will be included. For this type of intervention, there are institutional protocols such as the extent to which dietary and aesthetic preferences are considered and how food and fluids are administered by nursing staff. Although artificial means such as through tube feedings or the parenteral route are also nutrition and hydration interventions, they are excluded because this type of care is governed by a different set of protocols which include legal and ethical considerations as well as who makes the decisions and when such an intervention should be initiated. ANH is considered a medical treatment requiring doctor’s orders and outcomes are often narrower to include recommended intake, weight and BMI only. Patients in acute care and long-term care are included although ICU and palliative care patients are excluded for the reason that ANH is usually the primary intervention provided them.
In terms of intervention, studies will be limited to those that relate to oral nutrition and hydration interventions provided by nurses and other health care professionals such as dieticians and physicians. The latter are included since the intervention can also be performed by these health professionals. Interventions encompass the preparation and giving of food and fluids, encouraging and monitoring for intake, assisted feeding practices, the involvement of family members, as well as cultural and individual considerations. It also includes the level of priority given to these interventions and whose responsibility it is in the facility to perform them. In brief, the search is limited to interventions per se as the step that follows assessment in the nursing process. For this reason, research focusing solely on nutrition and hydration assessment will be excluded as this nursing action has a different set of outcomes compared to just interventions. For instance, assessment outcomes may include accuracy, timeliness and appropriateness while intervention outcomes mainly relate to the measurable impact of the nursing action on the patient.
Regarding comparison, studies reveal that institutionalised nutrition and hydration practices contribute to reducing intake among patients, a negative outcome that the intervention is supposed to prevent. In addition, conventional practices fail to meet nontangible needs associated with taking in food and fluids, as per patient reports, because of meals being decided upon by the dietetics department and controlled by predetermined time limits and places (Godfrey et al 2012). Nurses’ perceptions of what food and drink mean to patients and also their responsibilities regarding these needs contribute to inadequate and unsatisfactory care. On the other hand, professional organizations are now calling for individualised nutrition and hydration interventions which take into account not only physiologic needs but the whole range of needs that only the individual patient can define. An individualised approach is deemed to have the capacity to increase food and fluid intake as well as quality of life and satisfaction with care.
Focusing on a specific intervention such as individualised nutrition and hydration rather than a general class of interventions contributes to an efficient literature search (Waljee, Larson & Chung 2012). The evidence base for this intervention has to be established and is the reason why a search of literature is being conducted. Thus, studies comparing the outcomes of conventional or institutionalised nutrition and hydration will be included. At the same time, studies providing evidence of either intervention, or without comparison between the two, will also be considered as these also assist in identifying the evidence for each.
Finally, the interventions can be nurse led or facility led and it can be a single intervention or in conjunction with other organisational system and process changes. Randomised controlled trials (RCTs), controlled clinical trials (CCTs), meta-analyses, systematic reviews, qualitative studies, retrospective studies and descriptive studies documenting the patient outcomes of either or both institutionalised and individualised nutrition and hydration approaches will be included as they provide data on how safe, effective, cost-efficient or holistic the intervention is or which of the two is more superior in all of these respects. However, RCTs are the best type of research to answer questions pertaining to interventions or therapy (McGrath, Brown & Samra 2012). Studies will also be limited to those published in English from the year 2000 to present in order to ensure that these are understandable and more or less recent considering that the focus on alternative practices to nutrition and hydration has only been given recently.
Search Strategy
The Cochrane Library is one electronic database that can be searched for high quality studies. It contains a collection of systematic reviews considered to be the strongest level of evidence as it evaluates the results of various trials and studies on a given intervention (About the Cochrane Library 2013). Systematic reviews are characterised by precision and greater generalizability (Salmond 2013). It includes those published in nursing journals or conducted by nurses and other health professionals as well. Another is CINAHL, a database of 3,000 journals with scholarly material generated by nursing and allied health disciplines (CINAHL 2012). The quality of information offered and its coverage not only of nursing research but also the work of non-nursing health professionals make these databases ideal for searching studies relevant to the clinical question.
Key words or concepts that can be used to retrieve appropriate material pertain to patient, intervention, comparison and outcomes. Regarding patient, the words “adult,” “acute care,” “long-term care,” “care home,” “hospital,” and “nursing home” can be used. These words encompass the clinical setting and type of patient being considered. Regarding intervention, the words “individualised,” “personalised,” “nutrition,” “hydration,” “feeding,” “assisted feeding,” “food,” “drink,” “beverage,” “diet,” “oral,” “nursing intervention,” “nursing care,” “guidelines,” “protocols,” “conventional,” and “institutionalised.” Spelling variations are also included namely “individualized,” “institutionalized,” and “personalized.” For outcomes, “body mass index,” “BMI,” “weight,” “energy,” “healing,” “recovery,” “wellness,” “quality of life,” “satisfaction,” “hydration,” “aesthetic,” “holistic,” “culture,” and “social” are the search terms identified. In the above search terms, synonyms such as nursing intervention and nursing care or drink and beverage have also been taken into account (McGrath, Brown & Samra 2012).
These key words and concepts identify the appropriate publications as they represent the inclusion criteria for patient, intervention, comparison and outcomes as stated in the clinical question which are the limits that narrow down the selection of articles. Using key words from the PICO question is a time-saving strategy while at the same time increasing the strength of the search for literature (Grant, Stuhlmacher & Bonte-Eley 2012). The search terms can be combined together to generate the broadest range of literature but when there are too many publications to filter through or no acceptable articles are retrieved, adjustments can be made to make the search more specific and manageable (Price 2008; McGrath, Brown & Samra 2012).
In performing the actual search, the strategy involves the use of truncation, abbreviations, wildcards and Boolean operators. Truncation is the use of symbols (commonly *, $ or ?) to search for a word stem which can have several endings (Smith & Shurtz 2012). On the other hand, using a wildcard (symbolized by ?) retrieves words with varied spellings. Boolean operators include the words “and,” “or” and “not” where the use of “and” turns out publications including both of the key words used, the use of “or” turns out articles containing either of the key words, while the use of “not” excludes articles containing the key word that follows.
These methods ensure a more systematic search given that thousands of articles may be retrieved by a single search and reviewing all of them is an impractical endeavour (Younger & Boddy 2008; McGrath, Brown & Samra 2012). Further, an article is indexed by a database under different but synonymous words. Hence, using synonyms ensures that no relevant article is left out. A systematic search yields comprehensive reviews and the best evidence available on the chosen problem. A record of the search terms used and their corresponding hits should be kept to guide the process of refining the search terms and also subsequent searches in other databases.
It is practical to start a broad search at the onset before refining to see how extensive the available literature is (Smith & Shurtz 2012). Using keywords separately at first accomplishes this purpose. For the identified PICO question, “nutrition and/or hydration” represents the broadest search string encompassing the general intervention and patient population. When the search yields hundreds or thousands of hits, the search can be refined by including other search terms to serve as limits such as using the string “nutrition and/or hydration and adults.” Hits numbering less than 100 are considered to be acceptable (McGrath, Brown & Samra 2012).
When the search still yields a considerable number of publications, further adding search terms will continue to narrow down the hits such as when “individualized and nutrition and/or hydration and adults” is used. The truncated strings “personali?ed nutrition and/or hydration” or “individuali?ed nutrition and/or hydration” yield both British and American English spellings. The wildcard “nutrition*” retrieves those articles that could be using “nutritional” such as “nutritional intervention” and the wildcard “hospital” can yield articles using the term “hospitalised” such as in “hospitalised adult.”
Each particular database also has features that can be manipulated to limit hits to those that are the most relevant. CINAHL has options of finding any or all of the search terms or using a Boolean phrase (CINAHL 2012). Hits can also be limited to specific date of publication, type of publication such as full-text, peer-reviewed journals and language. The Cochrane database also has settings for limiting the date of publication and offers choices regarding the type of article such as systematic review or trial (About the Cochrane Library 2013). It also offers searches using not only keywords but also medical subject headings (MeSH). Using “nutrition” as MeSH term yields a selection of possible headings where articles can be indexed under such as “nutritional therapy.”
PICO and the Selected Research Problem
Utilizing the PICO format facilitates an outcome-based review process in that a clinical question is answered which promotes better clinical practice (Neville & Horbatt 2008). It ensures that improvements in practice are based on best practices or the strongest research evidence available which would benefit the patients. Regarding oral nutrition and hydration, asking a question in PICO format specifies what information needs to be obtained in order to make appropriate decisions regarding the problem. For this reason, literature review efforts are better focused and tend to be more productive. It systematises how nurses can actually address the poor nutritional outcomes and unmet needs of adult patients brought about by institutionalised nutrition and hydration practices. A review process using the PICO format is a problem solving tool and also a tool that nurses, as research consumers, can use to practice and promote evidence-based practice.
Developing inclusion and exclusion criteria helps the nurse filter through the high volume of related publications available in databases so that there is a guarantee that the studies reviewed are applicable to the chosen set of patients, the intervention being studied and the desired outcomes. The criteria ensure that the omission of notable studies and the addition of false positive hits are prevented (Smith & Shurtz 2012). This way, the nurse is certain that the literature retrieved comprehensively represents the range of knowledge pertaining to the clinical problem identified and that the evidence obtained will be applicable to the patient population.
Finally, planning a search strategy emphasises where the particular research problem stands in relation to the broader topic. Nutrition and hydration is certainly a broad topic encompassing artificial and oral means, various clinical settings, patient conditions and health professions as well as ethical problems, interventions and theories. Determining how to target the publications that are the most relevant to the evidence-base of individualised or personalised oral nutrition and hydration interventions will help the nurse accomplish the purpose set for the literature review in a very efficient manner.
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