Using intervention mapping to develop an outpatient nursing nutritional intervention to improve nutritional status in undernourished patients planned for surgery.

BACKGROUND: Undernutrition in surgical patients leads to a higher risk of postoperative complications like infections and delayed recovery of gastrointestinal functions, often resulting in a longer hospital stay and lower quality of life. Nurses at outpatient clinics can deliver nutritional care during outpatient preoperative evaluation of health status to ensure that patients are properly fed in preparation for hospital admission for surgery. However, nutritional nursing care was not determined in research yet. This paper describes the structural development of an Outpatient Nursing Nutritional Intervention (ONNI). METHODS: A project group followed the steps of the Intervention Mapping. The needs assessment included assessment of delivery of nutritional care and nutritional care needs at two anaesthesia outpatient clinics of an academic and a teaching hospital. Also, outpatient clinic nurses and patients at risk for undernutrition were interviewed. Determinants resulted from these methods were matched with theories on behaviour change and nutritional support. RESULTS: Both patients and nurses were unaware of the consequences of undernutrition, and nurses were also unaware of their roles with regard to nutritional support. The intervention goals were: 1) enabling surgical patients to improve or maintain their nutritional status before hospital admission for surgery, and 2) enabling nurses to deliver nutritional support. The ONNI was developed for outpatients at risk for or with undernutrition. A training was developed for nurses. The ONNI included the five following components: 1) identification of the causes of undernutrition; 2) provision of a nutritional care plan including general and individually tailored advice; 3) self-monitoring of nutrient intake; 4) counselling and encouragement; and 5) support during a telephone follow-up meeting. The intervention and training were tested. A multifaceted implementation strategy was used to deliver the intervention in daily practice. CONCLUSIONS: Despite the unique position of the nurses at outpatient clinics, nurses were unaware of their role with regard to nutritional care. The ONNI was developed and implemented along with a training program for nurses. The test confirmed that the training can improve nurses' knowledge, skills, and sense of responsibility for nutritional support. The intervention may empower patients to actively improve their nutritional status.

Malnutrition in community-dwelling older people: lessons learnt using a new procedure.

This article reports the implementation of a new procedure for screening and treatment of malnutrition in a community NHS trust in England. The barriers and facilitators to implementation were assessed with staff from Integrated Community and Older People's Mental Health teams. Data from interviews and surveys were collected at baseline, 2 months after initial training and 16 months after initial training as well as following deployment of a nutrition lead to embed new developments for nutritional care. The adoption of the procedure made screening and treatment of malnutrition simpler and more likely to be actioned. The benefit of a nutrition lead and local nutrition champions to support and empower staff (avoiding reliance on training alone) was shown to drive change for nutritional care across the community. Prioritisation and commitment of leadership at the organisational level are needed to embed and sustain malnutrition screening and treatment in routine practice.

Community nutrition nurse specialist role: a service improvement.

This article describes the introduction of a community nutrition specialist nurse role in Buckinghamshire. The need for this role arose from issues experienced by the large but busy district nursing team (caseload of >300 patients per day) in home enteral feeding management and troubleshooting. The post holder was appointed to support community, hospital, dietitians and industry home care nurses with nutritional screening in the community and home enteral feeding, with a greater focus on the former. The post holder was involved in the development of a community version of MUST along with a care pathway and the design of a training programme to improve district nurses' knowledge and confidence in managing malnutrition in the community. The post holder is also involved providing patients personalised advice for managing malnutrition and in referrals to the community dietetics team. Such innovations in staffing are vital if the negative impact of malnutrition on patients and the health service is to be curtailed.

Lack of focus on nutrition and documentation in nursing homes, home care- and home nursing: the self-perceived views of the primary care workforce.

BACKGROUND: Malnutrition is a comprehensive challenge for the nursing home, home care- and home nursing sector. Nutritional care and the subsequent documentation are a common and multifaceted healthcare practice that requires that the healthcare professionals possess complex combinations of competencies in order to deliver high-quality care and treatment. The purpose of this study was to investigate how a varied group of healthcare professionals' perceive their own competencies within nutrition and documentation and how organizational structures influence their daily work and the quality of care provided. METHODS: Two focus groups consisting of 14 healthcare professionals were conducted. The transcribed focus group interviews was analyzed using the qualitative content analysis approach. RESULTS: Six categories were identified: 1) Lack of uniform and systematic communication affect nutritional care practices 2) Experience-based knowledge among the primary workforce influences daily clinical decisions, 3) Different attitudes towards nutritional care lead to differences in the quality of care 4) Differences in organizational culture affect quality of care, 5) Lack of clear nutritional care responsibilities affect how daily care is performed and 6) Lack of clinical leadership and priorities makes nutritional care invisible. CONCLUSIONS: The six categories revealed two explanatory themes: 1) Absent inter- and intra-professional collaboration and communication obstructs optimal clinical decision-making and 2) quality deterioration due to poorly-established nutritional care structure. Overall, the two themes explain that from the healthcare professionals' point of view, a visible organization that allocates resources as well as prioritizing and articulating the need for daily nutritional care and documentation is a prerequisite for high-quality care and treatment. Furthermore, optimal clinical decision making among the healthcare professionals are compromised by imprecise and unclear language and terminology in the patients' healthcare records and also a lack of clinical guidelines and standards for collaboration between different healthcare professionals working in nursing homes, home care or home nursing. The findings of this study are beneficial to support organizations within these settings with strategies focusing on increasing nutritional care and documentation competencies among the healthcare professionals. Furthermore, the results advocate for the daily involvement and support of leaders and managers in articulating and structuring the importance of nutritional care and treatment and the subsequent documentation.

What more can community nurses do to manage adult malnutrition.

This article gives an outline of the key groups at risk of malnutrition in the community and the effects and clinical consequences of not identifying and managing these groups. It outlines the potential health and social costs of not identifying and treating malnutrition in the community and advises how malnutrition arises in these 'at-risk' groups. As 93% of those affected by malnutrition are living in our communities, advice is given on how community nurses can play a pivotal role in identifying malnutrition by initiating conversations about dietary intake with patients and integrating screening and nutritional care into pathways of care.

Dietary management of older people with diabetes.

Diabetes UK's revised nutrition guidelines for the prevention and management of diabetes, published recently, encourage education in self-management and include additional guidance for older people with diabetes. The incidence of diabetes in older people is increasing. Many older people with diabetes are healthy and mobile, and live in the community, but a number are frail and living in care homes. Those who are frail are at increased risk of malnutrition from a range of causes. Older people with diabetes should be assessed for malnutrition risk and referred to a dietitian if required. Management of these patients focuses on foods that are high in protein and energy foods. A case study gives an example of how a community nurse may be involved.

Prevalence of malnutrition among older people in medical and surgical wards in hospital and quality of nutritional care: A multicenter, cross-sectional study.

AIMS AND OBJECTIVES: To determine and compare the prevalence of malnutrition in medical and surgical hospital units; to assess quality of nutritional care and patients' perception about quality of food and nutritional care. BACKGROUND: Hospital malnutrition in older people leads to increased mortality, length of stay, risk of infections and pressure ulcers. Several studies show that malnutrition is often caused by hospitalisation and related to poor nutritional care. Few studies report data on surgical older patients. DESIGN: A cross-sectional, multicenter study was conducted in 12 hospitals in northern Italy. METHODS: Malnutrition prevalence was determined according to the Mini Nutritional Assessment full-version. Head nurses were interviewed in 80 units, through a validated questionnaire regarding quality of nutritional care. Semi-structured interviews were administered to a sample of patients, to investigate their perception about quality of food and nutritional care. RESULTS: Two hundred twenty-eight patients of 1,066 were malnourished (21.4%). Medical patients were at higher risk, so were women, patients aged 85 or more, with impaired autonomy, pressure ulcers or taking more than three drugs. The lack of personnel impacts on quality of care: in 55% of the units, no nutritional screening is performed; nutritional history is investigated in 48% only. No protocols for nutritional problems exist in 70% of the wards; hardly ever the intake is measured. Patients are mostly satisfied, even though they report that food has no taste and is not well presented. They remark the need for more personnel. CONCLUSION: Prevalence was high, as found in other studies. Medical patients were at higher risk. Nutritional care was inadequate, and often no measures were adopted to prevent malnutrition. Staffing should be increased during meals. RELEVANCE TO CLINICAL PRACTICE: These findings will provide indications on the strategies needed to overcome such barriers.

Part 3: Impact of systemic conditions and medications on oral health.

The people who are treated in the community setting will often have multiple comorbidities. Systemic medical conditions can have a negative impact on oral health. In addition, the medications used to treat systemic conditions may also themselves cause oral symptoms. As a large proportion of patients treated by the community nursing team will be elderly, this paper will focus on common geriatric conditions that can display oral or dental symptoms. The effects of medications will be discussed and linked to oral complaints patients may express. The primary aims are to give a broad overview of the oral effects of ageing, of illness and of polypharmacy and advise on how these can be best managed by the nursing team.

Food for thought: delivering effective nutritional care.

Janet Scammell, Associate Professor (Nursing), Bournemouth University, asks whether nurse education places enough emphasis on the importance of ensuring good nutrition and hydration for patients.

Causes, assessment and treatment of malnutrition in older people.

Malnutrition is a growing problem in the UK with as many as 14% of people aged over 65 at risk. It is of particular concern in care homes where more than one third of residents are undernourished. Weight loss is not the only symptom of malnourishment and nurses should examine any changes to a person's health and well-being to identify causes. Regular monitoring of patients' risk of malnutrition through use of screening assessments, such as the Malnutrition Universal Screening Tool, ensures undernourishment is identified early. As the population ages, it is more important than ever that the implications of malnutrition are recognised and addressed.

Concordance between nurse-reported quality of care and quality of care as publicly reported by nurse-sensitive indicators.

BACKGROUND: Nurse-sensitive indicators and nurses' satisfaction with the quality of care are two commonly used ways to measure quality of nursing care. However, little is known about the relationship between these kinds of measures. This study aimed to examine concordance between nurse-sensitive screening indicators and nurse-perceived quality of care. METHODS: To calculate a composite performance score for each of six Dutch non-university teaching hospitals, the percentage scores of the publicly reported nurse-sensitive indicators: screening of delirium, screening of malnutrition, and pain assessments, were averaged (2011). Nurse-perceived quality ratings were obtained from staff nurses working in the same hospitals by the Dutch Essentials of Magnetism II survey (2010). Concordance between the quality measures was analyzed using Spearman's rank correlation. RESULTS: The mean screening performances ranged from 63% to 93% across the six hospitals. Nurse-perceived quality of care differed significantly between the hospitals, also after adjusting for nursing experience, educational level, and regularity of shifts. The hospitals with high-levels of nurse-perceived quality were also high-performing hospitals according to nurse-sensitive indicators. The relationship was true for high-performing as well as lower-performing hospitals, with strong correlations between the two quality measures (rS = 0.943, p = 0.005). CONCLUSIONS: Our findings showed that there is a significant positive association between objectively measured nurse-sensitive screening indicators and subjectively measured perception of quality. Moreover, the two indicators of quality of nursing care provide corresponding quality rankings. This implies that improving factors that are associated with nurses' perception of what they believe to be quality of care may also lead to better screening processes. Although convergent validity seems to be established, we emphasize that different kinds of quality measures could be used to complement each other, because various stakeholders may assign different values to the quality of nursing care.

A prospective audit of preprocedural fasting practices on a transplant ward: when fasting becomes starving.

AIMS AND OBJECTIVES: To investigate the prevalence and duration of preprocedural medically ordered fasting during a period of hospitalisation in an Australian population of patients with hepatic cirrhosis or following liver transplantation and to identify potential solutions to reduce fasting times. BACKGROUND: Protein-energy malnutrition is a common finding in patients with hepatic cirrhosis and can impact significantly on survival and quality of life. Protein and energy requirements in patients with cirrhosis are higher than those of healthy individuals. A significant feature of cirrhosis is the induction of starvation metabolism following seven to eight hours of food deprivation. Many investigative and interventional procedures for patients with cirrhosis necessitate a period of fasting to comply with anaesthesia guidelines. DESIGN: An observational study of the fasting episodes for 34 hospitalised patients with hepatic cirrhosis or following liver transplantation. METHODS: Nutritional status was estimated using subjective global assessment and handgrip strength. The prevalence and duration of fasting practices for diagnostic or investigational procedures were estimated using electronic records and patient notes. RESULTS: Thirty-three patients (97%) were malnourished. Twenty-two patients (65%) were fasted during the observation period. There were 43 occasions of fasting with a median fasting time of 13·5 hours. On 40 occasions fasting times exceeded the maximum six-hour guideline recommended prior to the administration of anaesthesia by the majority of Anaesthesiology Societies. The majority of procedures (77%) requiring fasting occurred after midday. Eating breakfast on the day of the procedure reduced fasting time by 45%. CONCLUSIONS: Medically ordered preprocedural fasting times almost always exceed existing guidelines in this nutritionally compromised group. RELEVANCE TO CLINICAL PRACTICE: Adherence to fasting guidelines and eating breakfast before the procedure can reduce fasting times significantly and avoid the potential induction of starvation metabolism in this nutritionally at risk group.

Nutritional screening of patients at a memory clinic--association between patients' and their relatives' self-reports.

AIMS AND OBJECTIVES: To compare individual reports by patients and relatives (proxy) of the Nutritional Form For the Elderly and relate the Nutritional Form For the Elderly scores to Mini Mental Status Examination scores, weight loss, Body Mass Index, five-point Clock Drawing Test and background variables. BACKGROUND: Undernutrition or risk of undernutrition is a significant problem among people with dementia. A poor nutritional state increases the risk of infections, delayed convalescence after acute illness and reduced quality of life. DESIGN: A cross-sectional study. METHOD: Application of the Nutritional Form For the Elderly in addition to clinical nutrition parameters and cognitive tests in a memory clinic among 213 persons referred for assessment due to possible cognitive impairment or dementia. RESULTS: Patients' and proxy Nutritional Form For the Elderly scores yielded comparative results. Nutritional Form For the Elderly scores ≥6 (medium to high risk of undernutrition) were found in 32% of the patients vs. 43% of proxy. Mean Mini Mental Status Examination score was 23·2 (SD 4·5) and 50% failed the Clock Drawing Test. Involuntary weight loss was reported by 42% of the patients, and in 26% of the patients, Body Mass Index values were below 22 kg/m(2) , indicating undernutrition. By regression analysis, Clock Drawing Test (p = 0·019) and Mini Mental Status Examination (p = 0·04) might predict the risk of reduced nutritional status. CONCLUSION: The study demonstrates that a significant proportion of patients at our memory clinic were at nutritional risk. Corresponding results exist between patients' and proxy Nutritional Form For the Elderly scores; however, the patients assessed themselves more well-nourished as compared to proxy assessment. The discrepancies seem to increase with more severe cognitive impairment. Females and single-dwelling individuals were at higher risk of undernutrition compared to males and cohabitants. RELEVANCE TO CLINICAL PRACTICE: Self-reporting and proxy-rating seem both applicable for nutritional screening among moderate cognitive impaired. Cognitive decline seems to affect the accuracy when patients rate themselves. A reduced Mini Mental Status Examination and/or failed Clock Drawing Test might predict the risk of undernutrition.

A longitudinal qualitative study of health care personnel's perceptions of simultaneous implementation of three risk assessment scales on falls, malnutrition and pressure ulcers.

AIMS AND OBJECTIVES: In this study, the aim was to understand health care personnel's expectations and experiences of participating in an intervention aimed at the implementation of three assessment scales for fall injuries, malnutrition and pressure ulcers, and the performance of preventive measures in these areas over the period of 18 months. BACKGROUND: Fall injuries, malnutrition and pressure ulcers among older people are challenging issues for caregivers at different levels in the health care system. DESIGN: A descriptive design with a qualitative approach was used to follow health care personnel before, during and after implementation of a care prevention intervention. METHODS: Twelve health care personnel with different professions at the hospital, primary care and municipal care levels participated in a preventive care introduction. Seminars were held at four occasions, with assignments to be completed between seminars. Lectures and group discussions were performed, and three risk assessment scales were introduced. The participants were interviewed before, during and after the introduction. Manifest and latent content analysis were used. RESULTS: The main results are presented in the theme 'Patient needs are visualised through a gradually developed shared understanding' and in five categories. The work approach of performing three risk assessments simultaneously was perceived as positive and central to ensuring quality of care; it was not, however, perceived as unproblematic. CONCLUSION: The participants as well as health care team members showed a positive attitude towards and described the advantages of being given opportunities for shared understanding to improve patient safety and to provide structure for the provision of good care. RELEVANCE TO CLINICAL PRACTICE: The managerial approach of listening to and acting on issues stressed by health care personnel is important to ensure ongoing and future improvement initiatives.

Treating malnutrition in the community.

Malnutrition is a clinical and public health problem. It has adverse effects on the physical and psycho-social wellbeing of individuals by predisposing to disease, negatively affecting its outcome and reducing the likelihood of independence. An estimated 3 million people in the UK are affected by malnutrition, most of whom live in the community ( BAPEN, 2011 ). Despite the scale of this problem, it remains under-detected, under-treated, underresourced and often overlooked by those involved in the care of at risks individuals such as the elderly. In most cases malnutrition is a treatable condition that can be managed by optimising food intake and using oral nutritional supplements (ONS) where necessary. The main focus of this article is on the dangers of malnutrition for older people in the community and the use of ONS in the treatment and management of malnutrition.

Integrating nutrition into pathways for patients with COPD.

This article looks at the role of the community nurse in assessing the nutritional status of patients with COPD and in integrating nutrition into the COPD care pathway.

Nutritional screening: a user-friendly tool adapted from Sweden.

Screening for undernutrition is highly important and may reduce morbidity and mortality. The Minimal Eating Observation and Nutrition Form Version II (MEONF-II) is a nutritional screening tool specifically developed for use by nurses. The authors describe the translation, performance and appropriateness of MEONF-II for the UK. Following translation from Swedish to British English, the user-friendliness and appropriateness of the British MEONF-II was tested by 29 registered nurses and final-year student nurses on 266 hospital inpatients. The new British MEONF-II was perceived as highly user-friendly and appropriate. Assessors found MEONF-II to compare favourably with other similar tools in terms of preference, usefulness and helpfulness in providing good nutritional care. Dependency in activities and poorer subjective health were associated with a higher risk of undernutrition. These findings support the appropriateness of the British MEONF-II version and suggest it may act as a user-friendly facilitator for good nutritional nursing care.

Addressing the nutritional needs of older patients.

Malnutrition affects three million people in the UK each year, 10% of whom are aged 65 and older. Chronic malnutrition is associated with well-documented clinical criteria for frailty: unintentional weight loss, weakness, immobility and sarcopenia. Frail, older people who are malnourished visit their GP twice as often as well-nourished equivalents and are three times more likely to be admitted to hospital where, on average, their stay is three days longer. Despite publication of various guidelines and standards, and numerous initiatives aimed at improving nutritional care, there is still much to do if older people who are malnourished or at risk of malnutrition are to receive the help and support they need. This article outlines a free online tool launched by the British Association for Parenteral and Enteral Nutrition that helps staff in NHS and social care settings measure the quality of the nutritional care they provide. It explains how use of the tool by nurses caring for older people can benefit patients. Nurses should take the lead in multidisciplinary teams to measure nutritional care provided to older patients. This will enable identification of good practice and areas for improvement.

[All the bodies of anorexia]. / Tous les corps de l'anorexie.

Anorexia is an active struggle against hunger. In this fight, the body is a real battlefield where the therapies used aim to re-establish peace. Hence the importance of an integrative 'body to body' approach between patient and caregiver.