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Using Normalization Process Theory to Implement and Embed Improved Nutritional Practices into the Routine Care of Preterm Infants in Neonatal Intensive Care

Presented at the Neonatal Society 2015 Summer Meeting (programme).

Johnson MJ1,2, Pond JP1,2, Pearson F2, May CR3, Leaf AA1,2

1 NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, UK
2 Department of Neonatal Medicine, University Hospital Southampton NHS Foundation Trust, Southampton, UK
3 Faculty of Health Sciences, University of Southampton, Southampton, UK

Background: The nutritional care of preterm infants is often variable and nutrient intakes suboptimal, despite increasing literature regarding best practice in this area, suggesting a failure to translate this into routine care. Using current available evidence for practice, we developed a complex (multifaceted) intervention aimed at optimising nutrient intakes and growth. In order to embed (‘normalise’) the new practices into routine care, we used Normalization Process Theory (NPT), a novel sociological framework, to develop and guide implementation.

Methods: We developed a complex intervention to improve the nutritional care of preterm infants (born <30 weeks or 1500g) and introduced this in a phased manner: Phase 1 (Control period, Jan-Aug 2011); Phase 2 (Partial Implementation, with improved parenteral and enteral nutrition solutions, nutrition team, staff education, Aug– Dec 2011); Phase 3 (Full implementation, with guidelines, screening tool, ‘nutrition nurse champions’, Jan-Dec 2012); Phase 4 (Post implementation, to assess sustainability of the intervention, Jan-Jun 2013). Bimonthly audits and a staff questionnaire based on NPT were carried out to measure guideline compliance and ‘normalisation’ of the new practices into routine care respectively. Focus groups and NPT scores were used to guide implementation in real time. Data on nutrient intakes and growth were collected in each phase.

Results: Infant characteristics, mean nutrient intakes and growth in each phase of the study are given in the table below. There were significant improvements in protein intake in phases 2 and 3 compared to phase 1 (both p<0.001), and this was sustained beyond the intervention into phase 4 (p<0.01 vs phases 1 and 2). There was a significant improvement in the change in standard deviation score from birth (cSDS) for weight in periods 2 and 3 compared to period 1 (both p<0.01), which again were sustained post implementation in phase 4 (p<0.001 vs phases 1 and 2). There was a non-significant improvement in the cSDS for head circumference (HC) across the study. Mean audit guideline compliance and NPT scores both increased in a linear fashion over time, (r=0.86 and 0.15, p<0.03 for both), with a significant linear association between the two (r=0.22, p<0.01).

Conclusion: Both the partial and full implementation of the intervention was associated with improvements in protein intake and weight gain which seemed to be sustained beyond the main implementation period. Measures of ‘normalisation’ using NPT can be related to real measures of clinical practice, suggesting that NPT offers an effective way of implementing new practices that it may lead to sustained changes in practice. This study also suggests that complex interventions based on current evidence have potential to improve practice and outcomes.

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