Barriers and facilitators to screening and treating malnutrition in older adults living in the community: a mixed-methods synthesis.

BACKGROUND: Malnutrition (specifically undernutrition) in older, community-dwelling adults reduces well-being and predisposes to disease. Implementation of screen-and-treat policies could help to systematically detect and treat at-risk and malnourished patients. We aimed to identify barriers and facilitators to implementing malnutrition screen and treat policies in primary/community care, which barriers have been addressed and which facilitators have been successfully incorporated in existing interventions. METHOD: A data-base search was conducted using MEDLINE, Embase, PsycINFO, DARE, CINAHL, Cochrane Central and Cochrane Database of Systematic Reviews from 2012 to June 2016 to identify relevant qualitative and quantitative literature from primary/community care. Studies were included if participants were older, community-dwelling adults (65+) or healthcare professionals who would screen and treat such patients. Barriers and facilitators were extracted and mapped onto intervention features to determine whether these had addressed barriers. RESULTS: Of a total of 2182 studies identified, 21 were included (6 qualitative, 12 quantitative and 3 mixed; 14 studies targeting patients and 7 targeting healthcare professionals). Facilitators addressing a wide range of barriers were identified, yet few interventions addressed psychosocial barriers to screen-and-treat policies for patients, such as loneliness and reluctance to be screened, or healthcare professionals' reservations about prescribing oral nutritional supplements. CONCLUSION: The studies reviewed identified several barriers and facilitators and addressed some of these in intervention design, although a prominent gap appeared to be psychosocial barriers. No single included study addressed all barriers or made use of all facilitators, although this appears to be possible. Interventions aiming to implement screen-and-treat approaches to malnutrition in primary care should consider barriers that both patients and healthcare professionals may face. REVIEW REGISTRATIONS: PROSPERO: CRD42017071398 . The review protocol was registered retrospectively.

People with enteral tubes and their carers' views of living with a tube and managing associated problems: A qualitative interview study.

BACKGROUND: Nutrition by enteral tube is a complex therapy requiring significant management to ensure safe, timely delivery of nutrients and avoidance of complications. In the home setting, people with enteral tubes and their carers are required to self-manage the therapy, including the need to cope with problems that arise. Whilst previous studies have conveyed experiences of people with enteral tubes, few have described views on enteral tube problems. AIMS AND OBJECTIVES: Drawing on the findings of a previously reported study (Journal of Human Nutrition and Dietetics, 2019), this paper aims to describe in-depth the experiences of people with enteral tubes and their carers of living with the tube day to day and managing problems that arise. DESIGN: A qualitative descriptive design using semi-structured in-depth interviews was employed. METHODS: A purposive sample of 19 people with enteral tubes and 15 carers of people with tubes participated. Interviews were recorded and transcribed. Using a thematic analysis approach, codes were defined and applied; themes developed and refined. Five themes with associated subthemes were generated, of which one, "living with the tube," is reported in-depth. The COREQ checklist was used. RESULTS: Participants described the tube affecting both physical and psychosocial being and revealed it had resulted in significant changes to their daily living, necessitating adaptation to a new way of life. Participants reported spending much time and effort to manage tube problems, at times without support from healthcare practitioners knowledgeable in tube management. Discomfort associated with the tube was commonly described. CONCLUSIONS: Living with an enteral tube impacts significantly on daily life requiring adaptations to normal routine. People with tubes and their carers use a range of strategies to manage common complications. RELEVANCE TO CLINICAL PRACTICE: Knowledge and understanding of how people with enteral tubes live with their tube and manage issues as they arise will enable healthcare practitioners to provide better support.

Perceptions and experiences of nutritional care following the overwhelming experience of lower extremity amputation: A qualitative study.

INTRODUCTION: Good nutritional care of people following major lower extremity amputation is essential as poor nutritional status can lead to delayed wound healing. Working with patients to identify their perspectives on food, views on nutritional care and the need for dietary counselling enables the development of optimised nutritional care. AIMS AND OBJECTIVES: To explore hospital patients' perspectives on food, dietary counselling and their experiences of nutritional care following lower extremity amputation. DESIGN: A qualitative, explorative study design was employed. METHOD: An inductive content analysis of semi-structured interviews with a purposive sample of 17 people over 50 years of age, who had recently undergone major lower extremity amputation, was undertaken. The study was reported according to the consolidated criteria for reporting qualitative research guideline. FINDINGS: Three themes emerged: responsible for own dietary intake, diet based on preferences and experiences with dietary counselling and feeling overwhelmed. The participants expressed motivation to ensure their nutritional needs were met but described feeling emotionally overwhelmed by the experience of amputation. They appeared not to expect nursing staff to focus on nutritional issues as they expressed belief that they themselves were solely responsible for their dietary intake. They described being motivated to receive nutritional counselling but indicated advice should be compatible with their lifestyle and eating habits. CONCLUSION: Lower extremity amputation can be an overwhelming experience which affects nutritional intake. People appear to consider themselves responsible for their nutritional care and describe not experiencing or expecting nursing staff to engage in this aspect of care. Dietary counselling by nurses who respect and incorporate patient preferences and experiences following amputation has the potential to enhance nutritional care. RELEVANCE TO CLINICAL PRACTICE: This study illustrates that nurses caring for people who undergo lower extremity amputation need to recognise that nutritional care is an essential component of nursing and should focus on working in partnership with the patient.

The effect of caffeinated versus decaffeinated drinks on overactive bladder: a double-blind, randomized, crossover study.

PURPOSE: The primary aims of this study were to test the methodology for use in a future randomized control trial and to investigate the effect of drinking caffeinated versus decaffeinated fluids on symptoms of overactive bladder (OAB) in women. DESIGN: A double-blind, randomized, crossover study was conducted. METHODS: Fourteen community-dwelling women newly diagnosed with OAB and a history of caffeine consumption were randomly allocated to group A (14-day caffeinated drink period followed by 14-day decaffeinated drink period) or group B (14-day decaffeinated drink period followed by 14-day caffeinated drink period). The periods were preceded by a 14-day run-in period and interspersed with a 14-day washout period. Primary outcomes were episodes of urgency, frequency, volume per void, and incontinence obtained each period on 3-day bladder diaries. Secondary outcome measures were OAB symptom severity and health-related quality of life (QOL) recorded each period using International Consultation on Incontinence-Overactive Bladder Module (ICIQ-OAB) and ICIQ-OAB-Quality of Life (ICIQ-OABqol) tools. Effects of caffeine reduction were measured each day using visual analogue scales. RESULTS: Eleven participants completed the study. A significant reduction in urgency (P < .01) and frequency (P < .05) of urinary voids on day 3 of the diary, total ICIQ-OAB score (P < .01), and a non-significant directional change for the total ICIQ-OABqol score (P = .065) was found using sign tests for the period of decaffeinated compared to caffeinated drink intake. No significant differences were found for any caffeine withdrawal measures. CONCLUSIONS: Despite the small sample size, this pilot study demonstrated that reducing caffeine intake may alleviate the severity of some symptoms and health-related QOL factors associated with OAB. Furthermore, caffeine substitutes were well tolerated.

A systematic review of the use of volunteers to improve mealtime care of adult patients or residents in institutional settings.

AIMS AND OBJECTIVES: The objective of this review was to locate and assess the evidence obtained from articles reporting empirical research that volunteers improve mealtime care of adults in institutional settings. BACKGROUND: Malnutrition in adult patients or residents in institutional care settings is common. Poor standards of mealtime care have been suggested to contribute to the development of malnutrition. DESIGN: A systematic review of the literature was undertaken. METHOD: Key words were identified and used separately and in combination to search the electronic databases MEDLINE, CINHAL, BNI and EMBASE and the internet for relevant articles. Searches were undertaken in August 2008, April 2009 and July 1010. RESULTS: Ten studies fulfilled the criteria for inclusion. The methodologies of five of the 10 studies were unclear due to the brevity of the reports. The validity of the design of the other five studies varied. Generally the results suggested the use of volunteers in mealtime care increased satisfaction of patients, relatives, volunteers and staff concerning meal-time assistance (assessed using methods such as questionnaires and focus groups) and three studies found increased nutritional intake in groups assisted by volunteers. However, few well designed and reported studies were identified. CONCLUSIONS: There is some evidence that volunteers can improve mealtime care of adult patients or residents in institutional settings, however few well designed studies are reported. Relevance to clinical practice. This review demonstrates that there is limited evidence that the use of volunteers improves mealtime care of adult patients or relatives in institutional settings.

Perioperative nursing: maintaining momentum and staying safe.

Background: Perioperative practice underpins one of the key activities of many healthcare services, but the work of perioperative nurses is little known. A better understanding of their work is important to enable articulation of their contribution to clinical practice. Aim: This study observed the practice of perioperative nurses and explored how they described their role. Methods: Using ethnographic observation and interview, 85 hours' observation of 11 nurses were undertaken, and 8 nurses were interviewed. Results: Thematic analysis was undertaken enabling themes to emerge with two being identified. The first, 'maintaining momentum', described the need to keep people and equipment moving. The second, 'accounting for safety', referred to the need to keep the patient safe during this dangerous period. Tension between these two phenomena was apparent. Conclusions: Perioperative nurses describe one of their key roles as maintaining the momentum of the patient's journey through the operating theatre, but having to balance this with the need to ensure the patient's safety. A core component of the perioperative nurse's work is thus management of the tension between these two elements. This study illuminated how these nurses understand their practice.

The development and evaluation of the use of a virtual learning environment (Blackboard 5) to support the learning of pre-qualifying nursing students undertaking a human anatomy and physiology module.

Students commence nurse education with varying levels of understanding of human anatomy and physiology due to a wide range of previous exposure to the topic. All students, however, are required to attain a broad knowledge of this topic prior to qualification. This paper describes the use of a Virtual Learning Environment (VLE), Blackboard 5, and the associated development of appropriate resources aimed at supporting nursing students undertaking a human anatomy and physiology module at Higher Education Level 1. The VLE was used as part of a blended learning approach. The results suggested that the majority of students utilised the VLE throughout the academic year. Opportunities for independent and self-directed learning were available in that students chose when and where to learn. Students generally commented favourably on ease of use and type of resources available. Frequency of use of the VLE, however, did not correlate strongly with the final examination mark achieved. Overall the VLE and the associated available resources appeared useful in supporting student learning and has been adopted for use in subsequent years.

Development and evaluation of a home enteral nutrition team.

The organisation of services to support the increasing number of people receiving enteral tube feeding (ETF) at home varies across regions. There is evidence that multi-disciplinary primary care teams focussed on home enteral nutrition (HEN) can provide cost-effective care. This paper describes the development and evaluation of a HEN Team in one UK city. A HEN Team comprising dietetians, nurses and a speech and language therapist was developed with the aim of delivering a quality service for people with gastrostomy tubes living at home. Team objectives were set and an underpinning framework of organisation developed including a care pathway and a schedule of training. Impact on patient outcomes was assessed in a pre-post test evaluation design. Patients and carers reported improved support in managing their ETF. Cost savings were realised through: (1) prevention of hospital admission and related transport for ETF related issues; (2) effective management and reduction of waste of feed and thickener; (3) balloon gastrostomy tube replacement by the HEN Team in the patient's home, and optimisation of nutritional status. This service evaluation demonstrated that the establishment of a dedicated multi-professional HEN Team focussed on achievement of key objectives improved patient experience and, although calculation of cost savings were estimates, provided evidence of cost-effectiveness.

Evaluating the use of streaming video to support student learning in a first-year life sciences course for student nurses.

Streaming video was used to support the learning of first year student nurses on a Life Sciences module, as one of many innovations designed to increase the range of resources and support available to students. This paper describes the background to this innovation, the procedures adopted and the results of extensive evaluation. The use of streaming video was evaluated in three applications in the module. A total of 656 students used online directed-learning sessions that incorporated streamed video. Just over half of these students actually viewed the video streams. Their feedback showed that 32% found access easy, 59% enjoyed using the resources, and 25% were very confident that they learned from them. Different types of video were used, and embedded in diverse ways, but the results were consistent across the three applications. They suggest that streamed video can contribute to useful resources to support learning by student nurses but, for a variety of reasons, it may not appeal or be adequately accessible to all students at present.

Nutritional screening and assessment tools for older adults: literature review.

AIM: This paper reports a literature review to examine the range of published tools available for use by nurses to screen or assess nutritional status of older adults, and the extent to which validity, reliability, sensitivity, specificity and acceptability of the tools has been addressed. BACKGROUND: The incidence of malnutrition in older adults is high. One method by which malnutrition or risk of malnutrition can be detected is by the use of nutritional screening or assessment tools. METHODS: A comprehensive literature review methodology was employed. A variety of electronic databases were searched for the period 1982-2002. Search terms incorporating nutrition, screening, validity, reliability and sensitivity and specificity were combined to retrieve relevant literature. In addition, manual searches were conducted and articles retrieved from those listed in key papers. In this paper, nutritional screening or assessment tools are described as tools which use a questionnaire-type format containing more than one risk factor for malnutrition, and give a quantitative or categorical assessment of risk. RESULTS: Seventy-one nutritional tools were located, 21 of which were identified as designated for use with an older population. A wide variety of risk factors for malnutrition are used with the tools, ranging from objective measurements to subjective assessment. Some tools identify an action plan based on the score obtained. Many tools appear not to have been subjected to validity and/or reliability testing but are used clinically. CONCLUSIONS: As malnutrition is present in the older adult population, nutritional assessment and screening tools can be useful to highlight those in need of a nutritional care plan. However, many have not been subjected to evaluation and consequently may not demonstrate sensitivity and/or specificity in clinical use. The decision to use a particular tool should therefore be considered carefully.

Feeding and dementia: a systematic literature review.

AIM: This paper reports a systematic review of the literature on interventions to promote oral nutritional intake of older people with dementia and feeding difficulty between 1993 and 2003. BACKGROUND: Older people with dementia commonly experience difficulty with feeding, especially in the later stages of the condition. This topic and related nursing care was reviewed in 1993 and the conclusion was that there was little research into interventions that nurses could use to alleviate feeding difficulty. METHOD: A systematic review of the literature was carried out using the CINAHL, Medline, EMBASE and Cochrane databases and the search terms 'feeding', 'eating' and 'dementia' combined as follows: '(feeding or eating) and (dementia)'. A second search was carried out combining the search terms 'mealtimes' and 'dementia' as follows: 'mealtimes and dementia'. The literature search was carried out on 1 December 2003 and papers were included in the review if retrieved by 31 December 2003. English language papers only were retrieved. RESULTS: Sixty-seven papers were retrieved, of which 13 addressed interventions aimed at helping older people with dementia to feed. All studies reported positive outcomes but only one randomized controlled trial was reported. Music was the most common intervention but there were no standardized interventions or outcomes across the studies and none reported the use of power analysis to decide on sample size. There were problems in some studies with confounding variables. CONCLUSIONS: Further research is needed into interventions aimed at how nurses can help older people with dementia to feed. There are some promising lines of enquiry, with music being one of these, but future studies need to use adequate samples and to use power calculations and account adequately for confounding variables. There is also a need to standardize interventions and outcomes across such studies to facilitate meta-analysis.

Nutritional screening and assessment tools for use by nurses: literature review.

AIM: This paper reports a literature review describing the range of published tools available for use by nurses to screen or assess nutritional status of patients/clients, and to examine whether the validity, reliability, sensitivity, specificity and acceptability of the tool have been investigated. Tools developed specifically for use with older adults are not considered in this review. A screening/assessment tool is described as a tool that uses a questionnaire-type format, contains more than one risk factor for malnutrition and gives an assessment of risk. BACKGROUND: The incidence of malnutrition in people cared for by nurses is high and screening or assessment tools are often used to identify those with, or at risk of, malnutrition. METHODS: A comprehensive literature review methodology was employed. A range of electronic databases was searched from 1982 to 2002. Search terms incorporating "nutrition", "screening", assessment, feeding, instrument, tool, validity, reliability, sensitivity and specificity were combined. Manual searches were also conducted. RESULTS: Seventy-one nutritional screening/assessment tools were identified of which 35 were reviewed. Tools not reviewed included those which incorporated significant use of biochemical measures (8), included complex anthropometric measures (3), were concerned specifically with ingestion (4) or were designated for use with an older population (21). The tools reviewed use a wide variety of risk factors for malnutrition, varying from anthropometric measurements to socio-cultural aspects of eating behaviour. Some identify an action plan based on the score obtained. Many have not been subjected to validity and/or reliability testing and yet appear to be in use in clinical practice. The sensitivity, specificity and acceptability of the tools are often not investigated. CONCLUSION: There are many published nutritional screening/assessment tools available for use by nurses to screen or assess the nutritional status of patients/clients. Many have not been subject to rigorous testing. Future work should consider a more standardized approach to the use of these tools.