Many patients are admitted to hospital and are already malnourished. Gaps in practice have identified that care processes for these patients can be improved. Hospital staff, including management, needs to work towards optimizing nutrition care in hospitals to improve the prevention, detection and treatment of malnutrition. The objective of this study was to understand how staff members perceived and described the necessary ingredients to support change efforts required to improve nutrition care in their hospital. A qualitative study was conducted using purposive sampling techniques to recruit participants for focus groups (FG) (n = 11) and key informant interviews (n = 40) with a variety of hospital staff and management. Discussions based on a semi-structured schedule were conducted at five diverse hospitals from four provinces in Canada as part of the More-2-Eat implementation project. One researcher conducted 2-day site visits over a two-month period to complete all interviews and FGs. Interviews were transcribed verbatim while key points and quotes were taken from FGs. Transcripts were coded line-by-line with initial thematic analysis completed by the primary author. Other authors (n = 3) confirmed the themes by reviewing a subset of transcripts and the draft themes. Themes were then refined and further detailed. Member checking of site summaries was completed with site champions. Participants (n = 133) included nurses, physicians, food service workers, dietitians, and hospital management, among others. Discussion regarding ways to improve nutrition care in each specific site facilitated the thought process during FG and interviews. Five main themes were identified: building a reason to change; involving relevant people in the change process; embedding change into current practice; accounting for climate; and building strong relationships within the hospital team. Hospital staff need a reason to change their nutrition care practices and a significant change driver is perceived and experienced benefit to the patient. Participants described key ingredients to support successful change and specifically engaging the interdisciplinary team to effect sustainable improvements in nutrition care. Retrospectively registered ClinicalTrials.gov Identifier: NCT02800304 , June 7, 2016.

Adaptive leadership has become an essential skill for leaders in health systems to respond to the COVID-19 pandemic as new knowledge emerges and case counts rise, fall, and rise again. This leadership approach has been described as an iterative process of taking a wide view of the situation, interpreting the meaning of incoming data from multiple directions, and taking real-time action. This process is also common in start-ups, which attempt to create new products or services of uncertain value for consumer markets that may not yet exist. Start-ups manage uncertainty through “pivots,” which can include changes in the target group, need, features, or intended benefit of a product or service. Pivots are large changes that account for the high likelihood of getting something wrong during development, and they are distinct from the “tweaks” or small tests of change that define quality improvement methodology. This case study describes three pivots in the launch of a remote monitoring program for COVID-19. Adaptive leadership helped inform strategic decisions, with pivots providing a framework for internal and external stakeholders to articulate options for changes to address shifting needs. There is considerable uncertainty in the appropriate design and implementation of health services, and although this case example focuses on the use of adaptive leadership and pivots during a pandemic, these strategies are relevant for health care leaders at any time.

The Integrated Nutrition Pathway for Acute Care (INPAC) is an evidence and consensus based pathway developed to guide health care professionals in the prevention, detection, and treatment of malnutrition in medical and surgical patients. From 2015 to 2017, the More-2-Eat implementation project (M2E) used a participatory action research approach to determine the feasibility, and evaluate the implementation of INPAC in 5 hospital units across Canada. Based on the findings of M2E and consensus with M2E stakeholders, updates have been made to INPAC to enhance feasibility in Canadian hospitals. The learnings from M2E have been converted into an online toolkit that outlines how to implement the key steps within INPAC. The aim of this short report is to highlight the updated version of INPAC, and introduce the implementation toolkit that was used to support practice improvements towards this standard.

The Nutrition Care in Canadian Hospitals (2010–2013) study identified the prevalence of malnutrition on admission to medical and surgical wards as 45%. Nutrition practices in the eighteen hospitals, including diagnosis, treatment and monitoring of malnourished patients, were ad hoc. This lack of a systematic approach has demonstrated the need for the development of improved processes and knowledge translation of practices aimed to advance the culture of nutrition care in hospitals. A narrative review was conducted to identify literature that focused on improved care processes and strategies to promote the nutrition care culture. The key finding was that a multi-level approach is needed to address this complex issue. The organization, staff, patients and their families need to be part of the solution to hospital malnutrition. A variety of strategies to promote the change in nutrition culture have been proposed in the literature, and these are summarized as examples for others to consider. Examples of strategies at the organizational level include developing policies to support change, use of a screening tool, protecting mealtimes, investing in food and additional personnel (healthcare aides, practical nurses and/or diet technicians) to assist patients at mealtimes. Training for hospital staff raises awareness of the issue, but also helps them to identify their role and how it can be modified to improve nutrition care. Patients and families need to be aware of the importance of food to their recovery and how they can advocate for their needs while in hospital, as well as post-hospitalization. It is anticipated that a multi-level approach that promotes being “food aware” for all involved will help hospitals to achieve patient-centred care with respect to nutrition.

Understanding the knowledge, attitudes, and practices (KAP) of hospital staff is needed to improve care activities that support the detection/prevention/treatment of malnutrition, yet quality measures are lacking. The purpose was to develop (study 1) and assess the administration and discriminative potential (study 2) of using such a KAP measure in acute care. In study 1, a 27-question KAP questionnaire was developed, face validated (n = 5), and tested for reliability (n = 35). Kappa and Intraclass Correlation (ICC) were determined. In study 2, the questionnaire was sent to staff at five diverse hospitals (n = 189). Administration challenges were noted and analyses completed to determine differences across sites, professions, and years of practice. Study 1 results demonstrate that the knowledge/attitude (KA) and the practice (P) subscales are reliable (KA: ICC = 0.69 95% CI 0.45–0.84, F = 5.54, p < 0.0001; P: ICC = 0.84 95% CI 0.68−0.92, F = 11.12, p < 0.0001). Completion rate of individual questions in study 2 was high and suggestions to improve administration were identified. The KAP mean score was 93.6/128 (range 51–124) with higher scores indicating more knowledge, better attitudes and positive practices. Profession and years of practice were associated with KAP scores. The KAP questionnaire is a valid and reliable measure that can be used in needs assessments to inform improvements to nutrition care in hospital.