Table 4.
Practices and perceived barriers or enablers to the provision of nutrition care for patients with cancer by Indonesian nutritionists and dietitians: survey questions addressing domains of the TDF mapped to the motivation aspect of the COM-B system.
| Theoretical domain framework | All (n = 268) |
Nutritionists/dietitians | Geographical Location | |||||
|---|---|---|---|---|---|---|---|---|
| Nutritionist (n = 181) | Dietitian (n = 86) | p-value | Metropolitan/large urban area (n = 140) | Regional or small city (n = 121) | Rural or remote (n = 6) |
p-value | ||
| Social/professional role and identity | ||||||||
| Responsibility, role, and awareness | ||||||||
| Nutritionists and dietitians play a crucial role in improving the daily lives of patients with cancer | 10 (8.5–10) | 10 (8–10) | 10 (9–10) | 0.827 | 10 (9–10) | 9 (8–10) | 9.5 (7.75–10) | 0.017 c* |
| I am aware that other health professionals may be providing nutrition recommendations | 9 (8–10) | 9 (7–9.5) | 9 (8–10) | 0.222 | 9 (8–10) | 8 (7–9) | 9 (7–9.25) | 0.014 o* |
| It is my responsibility to provide nutrition care to patients at risk of malnutrition | 10 (9–10) | 10 (9–10) | 10 (9–10) | 0.419 | 10 (9–10) | 10 (9–10) | 10 (8.75–10) | 0.251 |
| Beliefs about capabilities | ||||||||
| Beliefs of the scope of practice for nutritionists and dietitians, n (%) | ||||||||
| Decide the nutrition screening tool to be used | 260 (97) | 174 (96.1) | 85 (98.8) | 1.000 | 136 (97.1) | 118 (97.5) | 6 (100) | 0.903 |
| Conduct nutritional assessment through anthropometric measurements and interpretation of biochemical, clinical and dietary intake data for patients with cancer at risk of malnutrition | 263 (98.1) | 176 (97.2) | 86 (100) | 1.000 | 137 (97.9) | 119 (98.3) | 6 (100) | 0.524 |
| Identify nutrition problems, etiology, signs, and symptoms that formulate nutrition diagnosis for patients. | 258 (96.3) | 173 (95.6) | 84 (97.7) | 1.000 | 132 (94.3) | 119 (98.3) | 6 (100) | 0.266 |
| Determine nutritional intervention for patients with cancer | 255 (95.1) | 172 (95.0) | 82 (95.3) | 0.554 | 134 (95.7) | 115 (95.0) | 6 (100) | 0.948 |
| Monitor and evaluate the effect of nutritional intervention periodically | 258 (96.3) | 175 (96.7) | 82 (95.3) | 1.000 | 134 (95.7) | 117 (96.7) | 6 (100) | 0.950 |
| Provide nutritional recommendations for patients prior to discharge | 254 (94.8) | 175 (96.7) | 78 (90.7) | 0.524 | 133 (95.0) | 114 (94.2) | 6 (100) | 0.205 |
| Ensure that nutrition care is documented in the medical record | 257 (95.9) | 176 (97.2) | 80 (93.0) | 0.315 | 134 (95.7) | 116 (95.9) | 6 (100) | 0.454 |
| Provide nutrition care for outpatients with cancer | 224 (83.6) | 150 (82.9) | 73 (84.9) | 0.465 | 113 (80.7) | 104 (86.0) | 6 (100) | 0.574 |
| Determine the most appropriate tube feeding formula (if indicated) to meet a patient’s medical and nutrition needs. | 254 (94.8) | 172 (95.0) | 81 (94.2) | 1.000 | 132 (94.3) | 115 (95.0) | 6 (100) | 0.470 |
| Collaborate inter-professionally through oncology teams with nurses, medical professionals, and other health professionals to provide medical nutrition therapy | 245 (91.4) | 169 (93.4) | 75 (87.2) | 0.081 | 125 (89.3) | 114 (94.2) | 5 (83.3) | 0.690 |
| Confidence in ability | ||||||||
| Having medical and nursing support for my nutrition care practice would help me feel more confident. | 9 (8.5–10) | 9 (8–10) | 10 (9–10) | 0.267 | 10 (9–10) | 9 (8–10) | 9 (8.75–10) | 0.066 |
| Having more training in nutrition care practices in patients with cancer would help me feel more confident in this area | 10 (9–10) | 10 (9–10) | 10 (9–10) | 0.742 | 10 (9–10) | 10 (9–10) | 10 (8.75–10) | 0.642 |
| Hospital-based nutritionists and dietitians are best equipped to manage the nutrition care of patients with cancer | 9 (8–10) | 9 (8–10) | 9 (8–10) | 0.333 | 9 (8–10) | 9 (8–10) | 8.5 (8–9.25) | 0.164 |
| Nutritionists and dietitians are capable of providing nutrition care for patients with cancer | 10 (9–10) | 10 (9–10) | 10 (9–10) | 0.665 | 10 (9–10) | 9 (9–10) | 9.5 (8.5–10) | 0.196 |
| I know where to find best practice guidelines for the nutritional management of patients with cancer | 8 (7–9) | 8 (7–9) | 8 (7–9) | 0.103 | 8 (7–9) | 8 (6–9) | 8.5 (7.75–10) | 0.017 p* |
| I have a clear plan under what circumstances I will recommend formula drinks to patients with cancer to increase overall intake. | 9 (8–10) | 8 (7.75–10) | 9 (8–10) | 0.314 | 9 (8–10) | 8 (7–9) | 8.5 (7.75–10) | 0.015 o* |
| Beliefs about consequences | ||||||||
| Potential repercussions of not providing nutrition care to patients with cancer who have complications and/or at risk of malnutrition, n (%) | ||||||||
| Longer length of stay in the hospital | 239 (89.2) | 158 (87.3) | 80 (93.0) | 0.160 | 128 (91.4) | 109 (90.1) | 2 (33.3) | <0.001 q**, r*** |
| More patients develop malnutrition | 235 (87.7) | 157 (86.7) | 77 (89.5) | 0.517 | 123 (87.9) | 108 (89.3) | 4 (66.7) | 0.250 |
| More patients have complex complications | 217 (81.0) | 148 (81.8) | 68 (79.1) | 0.600 | 111 (79.3) | 100 (82.6) | 5 (83.3) | 0.779 |
| Increased healthcare cost | 195 (72.8) | 130 (71.8) | 64 (74.4) | 0.657 | 105 (75.0) | 88 (72.7) | 2 (33.3) | 0.111 |
| Other | 18 (6.7) | 12 (6.6) | 6 (7.0) | 0.916 | 11 (7.9) | 7 (5.8) | 0 (0) | 0.642 |
| The importance of nutrition care | ||||||||
| Patients with cancer who do not receive adequate nutrition support are at risk of adverse consequences | 10 (9–10) | 10 (9–10) | 10 (9–10) | 0.064 | 10 (9–10) | 10(9–10) | 10 (7.75–10) | 0.654 |
| I see the value in providing nutrition care to patients with cancer | 10 (9–10) | 10 (9–10) | 10 (9–10) | 0.132 | 10 (9–10) | 10(9–10) | 9.5 (7–10) | 0.043 |
| Nutrition assessment and diagnosis are essential in providing person-centred nutrition intervention | 10 (9–10) | 10 (9–10) | 10 (9–10) | 0.662 | 10 (9–10) | 10(9–10) | 9 (8–10) | 0.087 |
| Intentions | ||||||||
| Intention to learn and manage more patients | ||||||||
| I would like to manage more patients with cancer in a clinical setting | 9 (8–10) | 9 (8–10) | 9 (8–10) | 0.016 | 9 (8–10) | 9(8–10) | 8 (7.75–9.25) | 0.163 |
| I would like to learn more about nutrition care for patients with cancer, including patients with complex comorbidities and malnutrition | 10 (9–10) | 10 (9–10) | 10 (9–10) | 0.582 | 10 (9–10) | 10(9–10) | 9 (8–10) | 0.280 |
| Goals | ||||||||
| Learning/development opportunities planned to be completed within the next 12 months, n (%) | ||||||||
| Online workshop on advanced nutrition care for patients with cancer | 147 (54.9) | 96 (53.0) | 51 (59.3) | 0.336 | 85 (60.7) | 59 (48.8) | 3 (50.0) | 0.148 |
| Webinar featuring case studies and real-world scenarios in managing patients with cancer | 205 (76.5) | 137 (75.7) | 68 (79.1) | 0.541 | 100 (71.4) | 101 (83.5) | 4 (66.7) | 0.057 |
| Certification program for specialized skills in managing patients with cancer | 136 (50.7) | 86 (47.5) | 50 (58.1) | 0.105 | 84 (60.0) | 51 (42.1) | 1 (16.7) | 0.003 m* |
| Interactive virtual simulations for hands-on experience in malnourished patients with cancer, i.e., patients with tube feeding | 88 (32.8) | 58 (32.0) | 30 (34.9) | 0.645 | 49 (35.0) | 39 (32.2) | 0 (0) | 0.079 |
| Access to a comprehensive online resource library with the latest research and nutritional guidelines for managing patients with cancer | 98 (36.6) | 63 (34.8) | 35 (40.7) | 0.351 | 55 (39.3) | 43 (35.5) | 0 (0) | 0.051 |
| Regional meetings to network and share experiences with other professionals in the related field | 88 (32.8) | 57 (31.5) | 31 (36.0) | 0.459 | 48 (34.3) | 38 (31.4) | 2 (33.3) | 0.885 |
| Mentorship program connecting nutritionists and dietitians for ongoing guidance in managing patients with cancer | 128 (47.8) | 87 (48.1) | 41 (47.7) | 0.952 | 64 (45.7) | 60 (49.6) | 3 (50.0) | 0.817 |
| Collaborative research opportunities with supporting funding in the field of nutrition care for patients with cancer | 91 (34.0) | 56 (30.9) | 35 (40.7) | 0.116 | 59 (42.1) | 32 (26.4) | 0 (0) | 0.002 a* |
| Other | 5 (1.9) | 4 (2.2) | 1 (1.2) | 1.000 | 2 (1.4) | 3 (2.5) | 0 (0) | 0.737 |
| Plan to access training | ||||||||
| I have a clear plan to access training so that I can be more effective in delivering nutrition care | 8 (7–10) | 8(7–10) | 8(8–9) | 0.614 | 9(8–10) | 8 (7–9) | 8 (7–9.25) | 0.012 s* |
| Reinforcement | ||||||||
| Satisfaction and recognition | ||||||||
| I feel a sense of personal satisfaction whenever patients indicate that they are pleased with the nutrition care that I provide | 10 (9–10) | 10 (9–10) | 10 (9–10) | 0.717 | 10 (9–10) | 10 (9–10) | 9.5 (7–10) | 0.049 |
| I receive recognition from my colleagues whenever patients indicate that they are pleased with the nutrition care that I provide | 9 (8–10) | 9 (8–10) | 9 (8–10) | 0.549 | 9 (8–10) | 9 (8–10) | 8.5 (8–9.25) | 0.338 |
| Emotion | ||||||||
| Feeling overwhelmed, enjoyment and respected | ||||||||
| As a nutritionist/dietitian working with patients with cancer, have you felt overwhelmed while doing your day-to-day work during the past two weeks? | 5 (2–8) | 5 (2–8) | 5 (2–8) | 0.625 | 5 (2–8) | 5 (2–7) | 5 (0–7.5) | 0.538 |
| As a nutritionist/dietitian working with patients with cancer, have you been able to enjoy your normal day-to-day activities during the past two weeks? | 8 (7–10) | 8 (7–10) | 8 (7–10) | 0.446 | 8 (7–10) | 8 (7–10) | 8 (6.25–10) | 0.687 |
| I am a respected member of the oncology team. | 7 (5–8) | 7(5–8) | 8 (5–8) | 0.016 | 7 (5–8) | 7 (5–8) | 7 (6.5–8.5) | 0.618 |
Bold indicates p < 0.05. *significant difference is between participants working in metropolitan/large urban areas and regional/small cities; ** significant difference is between participants working in metropolitan/large urban areas and rural/remote; *** significant difference is between participants working in regional/small cities and rural/remote; a p = 0.008; c p = 0.014; m p = 0.004; o p = 0.011; p p = 0.030; q p = 0.001; r p = 0.002; s p = 0.010; Participants indicated level of agreement for each statement, 0 = ‘strongly disagree’, 10 = ‘strongly agree’; Numbers were described as median (interquartile range/IQR) from 10-point Likert scale of agreement.