VOL: 96, ISSUE: 50, PAGE NO: 33
Donna Horan, BSc, RN, is a former BSc nursing student, European Institute of Health and Medical Sciences, University of Surrey
Jane Coad, PhD, BSc, is a senior lecturer, European Institute of Health and Medical Sciences, University of SurreyMalnutrition in hospitals has been a well-documented phenomenon for over a quarter of a century. Recent studies have found that some patients were not eating and drinking adequately while in hospital and that patient malnutrition is more widespread than previously thought (Association of Community Health Councils, 1997). In acute hospitals within the UK, up to 40% of patients are malnourished at admission (McWhirter and Pennington, 1994) and their nutritional status often continues to deteriorate during the course of their hospital stay (McWhirter and Pennington, 1994; Corish, 1999). Inadequate dietary intake increases patients' metabolic demands and with coexisting nutrient loss can accelerate the development of under-nutrition (Corish and Kennedy, 2000).
Malnutrition in hospitals has been a well-documented phenomenon for over a quarter of a century. Recent studies have found that some patients were not eating and drinking adequately while in hospital and that patient malnutrition is more widespread than previously thought (Association of Community Health Councils, 1997). In acute hospitals within the UK, up to 40% of patients are malnourished at admission (McWhirter and Pennington, 1994) and their nutritional status often continues to deteriorate during the course of their hospital stay (McWhirter and Pennington, 1994; Corish, 1999). Inadequate dietary intake increases patients' metabolic demands and with coexisting nutrient loss can accelerate the development of under-nutrition (Corish and Kennedy, 2000).
The effects of under-nutrition on health and healing are clearly understood. Lack of optimal nutrition can increase patients' physical and psychological stress and can affect almost every body system. Healing rates may be slowed (Haydock and Hill, 1986; Holmes et al, 1987), the immune system may be compromised (Chandra, 1999) and thermoregulation impaired (Fellows et al, 1985). Muscle weakness occurs (Pichard and Jeejeebhoy, 1988), affecting respiratory function (Arora and Rochester, 1982) and mobility, which subsequently affects cardiovascular function and skin integrity. Undernutrition also results in altered structure and function of the gastrointestinal tract (Reynolds et al, 1996) and promotes a cycle of accelerated deterioration of nutritional status. Malnourished patients have a higher risk of major complications (Windsor and Hill, 1988), an extended hospital stay (Shaw-Stiffel et al, 1993) and increased rates of unplanned readmission. The financial implications of these factors are serious for an already stretched health service (Tucker and Miguel, 1996).
The study took place at an acute hospital on two wards, one general medical and one orthopaedic. This provided manageable patient numbers but covered a range of procedures and conditions, which could potentially affect food consumption. The maximum number of patients present for any meal was 58 (30 medical and 28 orthopaedic) but, in practice, some beds were empty. We observed seven of each of the three daily meals (breakfast, lunch and supper) on a random basis. We used a participant-observer method in which meal trays were collected from the patients at the end of the meal period by the researcher in exactly the same way as would normally be done by a member of the ward domestic staff. The number of meals that had not been eaten was recorded and reasons for lack of consumption were identified. A meal was regarded as missed if the meal was untouched or only one mouthful was consumed. We did not include patients not eating meals for preoperative or postoperative reasons and those not consuming food orally.
If a meal had been missed because the patient needed help with eating, it was not considered ethical to remove it without offering assistance or informing the ward staff. Although domestic staff might normally inform nursing staff that a patient had not eaten, there was no standard procedure for reporting this.
Identifying which daily meal is most frequently missed is important when considering how nutrients should be distributed throughout the day. In our study lunch was missed least often and supper most often (Table 1). This suggests the importance of keeping lunch as the main meal of the day. However, lunch may have been missed less frequently precisely because it was the main meal. The fact that supper was most frequently missed means that many patients went without food for an excessively long period of time - between lunch and breakfast the following day.
During one observed supper on the medical ward, 21% of patients missed their meal. On the surgical ward, 24% patients missed their meal at one observed breakfast. We also considered the frequency of missing a meal in relation to the type of ward (Table 2). On average, breakfast and lunch were missed more often on the surgical ward while supper was missed more often on the medical ward.
We identified the reasons for missing meals. During the study 103 (9.2%) of 1,127 meals were missed. The most frequently observed reasons for missing a meal were lack of appetite (22.3%); nil-by-mouth for reasons other than pre- or post-operative fasting (19.4%); sleeping (16.5%); nausea or vomiting (9.7%); not fed by a member of staff (5.8%); breathlessness (4.9%). We did not access patients' notes for the purpose of the study, so patient sedation during a meal might have been associated with medication including pain relief. Other less frequent reasons for missing meals included not liking the taste, smell or appearance of the food; being unable to reach the meal tray; being absent from the ward during a mealtime; the meal received was not the one that the patient ordered; feeling unwell (either non-specifically or experiencing pain, convulsions or diarrhoea); and awaiting assessment by a speech therapist. Apart from breathlessness, which only occurred on the medical ward, there were no marked differences in the reasons for missing meals between the wards.
The critical issues of providing adequate nutrition in hospital relate to delivering the food in a manner appropriate to the individual patient and optimising the amount of food that is actually consumed. Some of the problems lie with the mechanism for meal preparation and delivery, which is unable to respond to an individual patient's needs. Presentation and appearance of a meal is important in stimulating appetite but difficult to achieve in mass catering. Portion size, meal temperature, positioning the meal within easy reach and using containers or wrappers that are easy to open are also important considerations.
There have been a number of calls for nutrition in hospitals to be given a higher priority. Writing in the foreword of Eating Matters (Bond, 1998), Yvonne Moores, who was then chief nursing officer for England, stressed that although a wide range of staff may be involved in patient nutrition, the ultimate responsibility for ensuring patients' nutritional needs are met lies with registered nurses. Her successor, Sarah Mullally, reiterated that nutrition and hydration are as important to good nursing care as the administration of medication (Mullally, 2000). It is a serious matter for nurses to neglect nutrition (Oulton, 1999) but they may not be aware of patients' food intake or problems encountered when choosing or eating the meal. Nurses prioritising mealtimes may reduce disturbances and movements around the ward, which have been shown to have a detrimental effect on food consumption (Deutekom et al, 1991).
However, the focus of nutritional care in nursing seems to be on assessment (Perry, 1997) rather than on providing practical solutions to improving food consumption. Relegating meal distribution and tray collection to domestic staff means nurses are unable to monitor patient intake. Providing help during meals is demanding and time-consuming and compromised by staff shortages. Unqualified staff may not have the skills or knowledge necessary to assist patients with chewing and swallowing difficulties, or to help with the selection of the most appropriate meal from the menu. However, the contribution of these staff to feeding patients is invaluable and easily relied upon by qualified staff.
Problems are not solely related to the meal delivery and distribution systems. Communication between nursing, catering and domestic staff also needs to be considered. Adoption of healthy eating guidelines and the widespread provision of a low-fat, low-energy diet may not be appropriate for all patients within a hospital (Corish and Kennedy, 2000). Lack of provision of food between early evening and breakfast has been identified as an area of patient dissatisfaction (Rushe and Moloney, 1998) but facilities for preparation and storage of snacks on wards are often inadequate.
A greater focus on mealtimes could have beneficial social consequences for the patients and positively affect their well-being. One recent initiative to improve patients' food intake was the ward hostess scheme in Basildon and Thurrock NHS Trust (Cartwright, 2000), which provided assistance with feeding and drinking and accurate records of patient intake.
The cost of plate wastage in hospitals is high, not merely in the food rejected but in the cost to the patients' health and the possible prolonged stays in hospital resulting from this. Our study identified ways of increasing patient intake (Table 3). Feeding patients in hospitals may be improved by altering nursing practice and by placing a higher priority on nutrition. Feeding patients, as well as nutritional assessment, should be a nursing responsibility and a crucial element of nursing care.