(416) The Influence of Organizational History on Nutrition Protocol Implementation in Critical Care

Introduction: Using feeding protocols on the intensive care unit (ICU) may improve patient and hospital outcomes. Contextually tailored implementation strategies have achieved variable compliance in multicentre ICU studies.

Little is known about how context influences behaviour in complex care systems. In organizational research, path dependence (PD) and path creation (PC) describe mechanisms that connect past events to influence current ways of working.

This research aims to describe how historical organisational context influences current nutrition implementation behaviours in the ICU and explain differences in compliance described to date.

Methods: A focussed ethnographic research design was situated within a case study approach. Methods included literature synthesis, documentary analysis, and 42 timeline interviews with 59 ICU multidisciplinary (MDT) staff in three Welsh ICUs. Path Constitution Analysis harnessed PD and PC, allowing the impact of macro and micro level actors to be captured from a processual perspective.

Results: Analysis revealed three influential levels. The focus level is where shared acceptance of nutrition practice structures, including norms, beliefs and power develops. The macro level includes research and the political domain. At the micro level is the ICU team culture.

In all cases, the levels interrelated to reinforce nutrition practice structures over time. Interviewees related co-evolving forces originating from the macro level, such as resources, professional roles, or governance processes, to exerting a powerful influence on team culture, and its elasticity to change nutrition practice structures. Interwoven through each case were individuals acting purposefully to create or capitalise on change at each level.

Whether or not the path evolved toward successful nutrition protocol implementation prospectively, depended on the antecedent characteristics of interrelated levels. Notable were the legacy actions of individuals to drive: a positive MDT culture, shared ownership of nutritional care, and quality improvement.

Conclusions: Findings support the contextual influence of organisational history in the implementation of ICU nutrition practice protocols. Integral to success are a historically informed MDT culture empowered to own, prioritise, and change nutrition practice.