Exploring the influence of organisational culture: An action research study to improve ward practices in the provision of food and nutritional care to hospitalised adult inpatients.

Context: Providing optimum nutritional care is fundamental to patient recovery and reduces complications associated with the adverse effects of malnutrition (undernutrition). Problems with malnutrition are well recognised in UK hospitals. On admission, about 34% of people aged 65 years or over already have or are at risk of malnutrition. Despite considerable research efforts and policy initiatives, malnutrition remains a health concern besides the costly economic implications. Of significance is the organisational culture within healthcare institutions, as it influences staff actions, behaviours and the quality of care delivered to patients. Yet, there is limited evidence on how this may impact optimal food and nutritional care. The scoping review findings undertaken as part of this study by Yinusa et al. (2021) indicated that a multidisciplinary approach was required if nutritional outcomes are to be optimised. The review also highlighted the value of involving service users (patients, relatives), volunteers, and staff from different disciplines in participatory research to enhance ward practices. Consequently, an action research (AR) approach was adopted to address the aim of the study: To explore the influence of organisational culture in the provision of food and nutritional care for older adult inpatients in collaboration with a multidisciplinary team to influence change and improve practice. Methodology: Action research was selected because this promotes a collaborative and democratic approach to research-based organisational and social-cultural change and improvements. This study was based in an acute NHS hospital in the South West of England. The research was conducted in two wards, one providing longer stay and the other shorter stay acute care for older inpatients (>65 years) with or at risk of malnutrition. The study was undertaken through the collaborative efforts of an 18- member multidisciplinary AR team responsible for providing food and nutritional care to inpatients (clinical and non-clinical members as co-researchers). Three action groups (AGs) were formed from the AR team who enacted change actions on these wards. Multiple methods were utilised to develop an understanding of the current practice. Qualitative data was gathered during the research process through six AR team meetings held over 11 months, service user narratives (through semi-structured interviews that fed into the AR team) and the project researcher's journal. The study also drew on quantitative data from the hospital's existing audit. Data analysis occurred concurrently with co-researchers and retrospectively by the project researcher using thematic analysis. Findings: Findings revealed five key facilitators to nutritional care, which are: good teamwork, communication, specific staff, and volunteer job roles (ward host and mealtime companion), organisational resources, and monitoring and inspection in practice. The key barrier in these two wards was that mealtime companions were an untapped resource. This led to prioritising changes in ward practices during mealtimes. The change actions included embedding mealtime companions as part of the ward team and enacting a colour-coded system to recognise and support patients requiring feeding assistance. There were apparent differences across the two participating wards, with a more successful implementation of changes in the longer stay than the shorter stay ward. The thematic analysis revealed five main themes were the most significant influences of organisational culture on nutritional care. These were: communication between staff groups, appropriate staff knowledge and training, multidisciplinary collaboration, accountability for effective nutritional care and organisational support for nutritional care, including the influence of nursing leadership and constraints posed by hospital organisational systems in the successful translation of Trust policies to practice. Conclusions: This study contributes valuable insights into the role of organisational culture in food and nutritional care. It revealed the role of organisational culture in promoting or constraining care provision. The AR approach was invaluable in establishing a communicative space to facilitate collaborative working, allowing for shared learning from different perspectives to better understand each other's roles. Improvements in practice will benefit from the evidence gathered through involving and engaging service users (patients, relatives), volunteers, and different staff groups who are the people within the care area. It is recommended that future research into the dynamics at play within the hospital organisations would extend and strengthen the evidence base on the influence of organisational culture in food and nutritional care. Recommendations are made for healthcare professional education, practice, and policy to advocate that organisational culture must be considered a vital factor in any nutritional care processes or change initiatives