Evidence‐based practice in nutrition and dietetics

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EDITORIAL

Evidence-based practice in nutrition and dietetics:

Translating evidence into practice

Although the body of health-care research is increasing exponentially, only a fraction is implemented into routine practice.^1,2Translating evidence into practice is a complex issue involving the consideration of health-care systems, context, policies and health-care practitioner and client knowledge and behaviours.³ One of the challenges of research in this ﬁeld is the lack of international agreement on terminology, with knowledge translation science, implementation and dissemination science being commonly used terms.⁴It leads to new knowledge and a better understanding about the complexity of how evidence is integrated into practice settings, such as changing practitioners and client behaviour, the importance of practice contexts, limitations of passive dissemination strategies, the challenge of exten- ding innovations to new sites and sustainability.^5–7 Several studies have reported individual and institutional barriers to dietitians using evidence in practice, such as a lack of time and funding and the absence of cultural and manage- rial support.^8–10Adoption and sustainable implementation will be unlikely to succeed in an environment that is not supportive of evidence-based practice.¹¹

Implementation science is an evolving field with rapid expansion of theories and frameworks and advancement in research designs, methods and analysis, as well as increased funding and capacity to undertake this research. Over 80 theories, models and theoretical frameworks have been used in translational research to help guide effective plan- ning, implementation, evaluation and/or de-implementation. These include the Knowledge-to-Action Framework,¹² Theoretical Domains Framework,¹³ the Consolidated Framework for Implementation Research,¹⁴Proctor’s Imple- mentation Outcomes Framework¹⁵ and the i-PARIHS Framework.¹⁶ Proctor’s Framework outlines implementation, service and client outcomes, with an emphasis that implementation outcomes (acceptability, adoption, appro- priateness, costs, feasibility, fidelity, penetration, sustainability) precede client and service outcomes as new interventions, practices and services are unlikely to be effective if not implemented well.¹⁵ These robust theoretical frameworks provide a structured approach to guide translation research and ensure that important aspects of implementation and sustainability are considered, which may ultimately lead to more successful outcomes. Implementa- tion research usually includes a multidisciplinary research team rather than discipline-specific focus, frequently uses a mixed methods approach where qualitative and quantitative methods are integrated to explain findings and engages multiple stakeholders to increase the understanding of change and context. One of the challenges for health-care

professionals wanting to use an implementation science approach is a lack of knowledge of the complexity of qualitative methodology and experience in using it. Qualitative research contributes to eliciting stakeholder perspectives, informs design and implementation, assists understanding contexts across diverse settings, encourages reﬂection on implementation processes, helps gain insight into implementation effectiveness, helps understand mechanisms of change and contributes to theoretical development.¹⁷

This issue ofNutrition & Dietetics explores the theme of translating evidence into practice and provides the opportunity to showcase the innovative contribution of dietitians in thisﬁeld. Williamset al.¹⁸used the i-PARIHS Framework¹⁶ to improve nutritional management for adult inpatients with inborn errors of metabolism. Following a review of the evidence and identiﬁcation of nutrition service gaps, con- sensus recommendations and service innovations were implemented. Nutrition assessment and appropriate nutrition intervention within 24 hours of admission improved with the new model of care.

Three manuscripts in this issue examine different aspects of the nutritional management of patients with chronic kidney disease on haemodialysis. This includes the development and implementation of an evidence-based model of care¹⁹ and service improvement from different stakeholder perspectives.^20,21 The Knowledge-to-Action Framework,¹² Theoretical Domains Framework¹³ and Behaviour Change Wheel²² were used to guide the implementation research by Mackay et al.¹⁹ to identify barriers and enablers, to improve nurses’knowledge by undertaking training, implement new procedures and create a database to monitor outcomes. The new model of care aligned practice with evidence-based guidelines and improved the prevalence of malnutrition. Morgan et al.²⁰ also used the Theoretical Domains Framework¹³to guide the development of a ques- tionnaire exploring patient satisfaction with dietetic services, identiﬁcation of engagement barriers and enablers and the patient-preferred methods of nutrition education delivery in three haemodialysis units. Although satisﬁed with dietetic care, low patient motivation was a major bar- rier, and the authors conclude that patient-centred models of nutrition care need to be further explored. This is consistent with recommendations from Lambert et al.,²¹ who describe the emotionally and professionally challenging experiences of renal dietitians providing dietary advice to this patient group with low adherence to nutrition recommendations. These are common responses from health-care professionals when client behaviour is not consistent with clinical practice guidelines or practitioner

AA AADDDietitians Associationofof Australia

Nutrition & Dietetics2019;76: 123–125 DOI: 10.1111/1747-0080.12533

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recommendations.²³Understanding different perspectives is essential to ensuring that interventions address problems and use approaches that are feasible and acceptable within practice contexts.^24,25 Establishing meaningful engagement with clients can be challenging when client motivation is low but is essential for the shared decision-making process and to transform future practice.

In the exploration of the nutrition care practices of a cohort of Australian and New Zealand surgeons performing total gastrectomy and oesophagectomy procedures, Lahoud et al.²⁶ demonstrate considerable variation in referral pat- terns to dietitians and nutrition care practices. Consistent with the Knowledge-to-Action Framework,¹² establishing the evidence-to-practice gap will contribute to future collab- oration to develop evidence-based practice guidelines for the nutritional management of total gastrectomy and oesophagectomy. Duxet al.²⁷evaluated the implementation of a new nurse-led transition feeding protocol on improving nutrition care for neurosurgery patients. The protocol improved the consistency and commencement of tube feeding and nurses’conﬁdence and knowledge. Contributing to the dialogue of assessment of competence in nutrition and dietetics, Porteret al.²⁸describe the review and moderation of an assessment artefact of foodservice work-integrated learning. Their ﬁndings of assessment inconsistencies underlie the importance of multiple assessors and assessment artefacts across a program.

The synthesis of research evidence into systematic reviews can promote translation of research into practice, and this issue has two systematic reviews with meta-analysis.² Rosset al.²⁹examine the effectiveness of dietetic con- sultation for lowering serum lipid levels in high-risk individuals in primary health-care settings. From 10 randomised controlled trials of 1530 participants, dietetic counselling was effective for lowering tryglycerides and at least as effective as usual or minimal care for improving cholesterol. Dietary intervention strategies for ethnic Chi- nese women with gestational diabetes mellitus is explored in a systematic review and meta-analysis of 29 studies (n = 3944).³⁰ Low glycaemic index, low glycaemic load and ﬁbre-enriched diets were associated with improved glycaemic control and pregnancy outcomes. Further research directly comparing these intervention strategies is required.

Another strategy that supports the introduction and use of evidence in practice is access to computerised clinical decision support systems. The Practice-based Evidence in Nutrition system is a dynamic and innovative online evidence-based knowledge translation platform designed to accelerate the global application of nutrition and dietetics research into practice. It incorporates key aspects of the Knowledge-to-Action Framework,¹² such as knowledge synthesis (>1100 tailored systematic reviews of practice- based nutrition questions), knowledge products and tools (>1700 evidence-based, peer-reviewed professional tools and 1500 client resources) and online training models and webinars related to evidence-based practice. This strategic international collaborative partnership between the

nutrition and dietetics professional associations of Canada, Australia and the United Kingdom provides over 20 000 members the opportunity to ensure that their decision- making is based on evidence.

AsNutrition & Dieteticsis now in its 76th year of publi- cation, it is time to reﬂect on the role it plays in knowledge translation. As one of four practice-based journals in the ﬁeld, the Journal remains pivotal for the successful dissemination of nutrition and dietetics research from discovery to translation. Our profession is dependent on a vibrant and progressive research culture guiding clinical practice inno- vation and generating evidence that demonstrates the impact of dietitians on outcomes in all settings. To achieve this goal, translation research is increasingly important to the future of all dietitians.

Funding source

The author received no funding to write this editorial.

Conﬂict of interest

The author has no conﬂicts of interest to declare.

Authorship

JB was the sole author of this manuscript.

Judy Bauer, BSc, GradDipNutrDiet, MHlthSc, PhD, FDAA, School of Human Movement & Nutrition Sciences, University of Queensland and PEN Translational Research Leader, Dietitians Association of Australia, Australia

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