VOL: 98, ISSUE: 34, PAGE NO: 59
Sue Green, RN, BSc, MMedSci, PhD, and Pam Jackson, MPhil, BSc, RGN, RHV, RNT, are lecturers, School of Nursing and Midwifery, University of Southampton
It has long been recognised that nursing care which promotes nutritional intake when and as appropriate can aid recovery from illness and enhance the quality of life of patients. Recently there has been growing concern that nurses do not pay sufficient attention to the nutritional needs of patients or clients (Association of Community Health Councils for England and Wales, 1997; O’Dowd, 2000). Indeed, food and nutrition is one of the eight aspects of care highlighted in The Essence of Care (Department of Health, 2001a).
The role of the nurse in nutritional support
The role of the nurse in the nutritional care of patients and clients is extremely diverse and can range from promoting a healthy diet in a client with learning disabilities to the provision of parenteral nutrition to a critically ill patient.
The focus of nursing activities in the delivery of nutritional care has altered over the past few decades. Increasingly the registered nurse is becoming more involved in aspects of nutritional care relating to health education, particularly related to the rise in the incidence of obesity (Obesity Resource Information Centre, 2000) and non-insulin dependent diabetes mellitus (Department of Health, 2001b). Other areas where the role of the nurse has developed are enteral nutrition via a gastrostomy tube and parenteral nutrition, as these interventions are now more commonly used in hospitals and the community.
Nurses’ role in preparing and serving food
Nurses now have a reduced role in the preparation and serving of food in many settings. Changes in the application of food and hygiene regulations in institutions have, to a degree, limited the foods available in the ward or unit kitchen for use by nurses for individuals in their care. While food hygiene within the kitchen attached to the ward or unit has undoubtedly improved, it is now more difficult for a nurse to provide food on demand.
Changes in food delivery and serving methods have acted to reduce the nursing input required at mealtimes. While this frees nurses for other clinical duties, it is now more difficult to serve the food the patient or client wants at the time of the meal, in the right portion size, and to monitor how much has been consumed.
The chronic shortage of qualified nurses in some areas has led to a necessary delegation of responsibility concerning mealtime care to qualified health care assistants or unqualified staff. While health care assistants with national vocational qualifications are trained in food provision and assisting patients or clients to eat appropriately, unqualified health care assistants may well not have received any training.
Nurse education and nutrition
Education is the key factor in enabling nurses to instigate nutritional care appropriately. Nursing students need be educated in the screening and assessment, planning, implementation and evaluation of nutritional care. A firm grounding in the principles of nutritional science is essential to understand the rationale behind the components of nutritional care.
Nutrition education guidelines
One of the key documents, which can be used to provide a framework for the planning, and delivery of nutritional care within the pre-qualification nursing curricula is Nutrition, Core Curriculum for Nutrition in the Education of Health Professionals (Department of Health, 1994). This document was produced by the government’s Nutrition Task Force, which included representatives from all the relevant professional groups. It discusses the education and training in nutrition required by nurses, midwives, health visitors, doctors, pharmacists, dentists, professions allied to medicine and health promotion specialists.
Within the document, three broad categories are outlined - principles of nutritional sciences, public health nutrition and clinical nutrition and nutritional support.
Each category is divided into six different subsections. The emphasis given to each section and the depth of knowledge to be achieved varies between health professionals. The document suggests that three one-hour presentations would give a broad overview of the categories but a total of 18 hours, supported by practical experience, would give more comprehensive coverage. It is also suggested that inclusion of nutritional issues in professional examinations and assessment procedures would indicate acceptance of nutrition (by teachers and students) as an important and valued subject area. The categories and subsections are also useful to inform post-qualifying educational programmes.
The importance of joint education for health professionals from all disciplines is highlighted in this document as desirable, as this helps to ensure consistency in curriculum content and acts to promote interdisciplinary working.
The presence of a coordinator within a school of nursing and midwifery with responsibility for coordinating activities concerning nutritional education can help to ensure that the issues raised in the document are addressed and that nutrition is integrated into the curriculum.
Nutritional education for all nurses
All branches of nursing and also midwifery should receive the same basic nutrition education. There is perhaps a tendency to ensure that aspects of nutritional care, and the skills associated with this, feature in the adult and child branch but not in others. However, nurses studying in all branches will encounter people requiring nutritional screening, assessment, planning and implementation. For example, a number of people with learning disabilities require enteral feeding via a gastrostomy tube, and obesity management may be a significant part of the role of the learning disability nurse. In the mental health setting, poor appetite and dietary intake are associated with many mental health problems, and therefore screening and assessment of nutritional status should be an essential part of the assessment process.
Nutrition is a vital component of care and thus a programme of nutritional education should be evident in all pre-qualifying educational programmes. Relevant aspects of nutrition should also be included within post-qualifying programmes. Nutritional care is a multidisciplinary undertaking and the roles of other health care professionals need to be emphasised. Indeed, a post-qualifying programme of nutritional care, open to all health professionals, would serve to underline its importance to the improvement and maintenance of health and patient care.