This article outlines an audit project to assess practice in nutritional care for older people
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Rebecca Maud, DipHE Adult Nursing, RN, is acting ward sister; Jonathan Webster, PhD, MSc, BA, DPS(N), RGN, is consultant nurse, older people; both at University College London Hospitals NHS Foundation Trust.
Maud, R., Webster, J. (2009) Improving nutrition for older people in hospital by assessing current practice. Nursing Times; 105: 5, 18-19.
Malnutrition is a major challenge in acute care. This article outlines the development of an audit tool to improve nutritional care for older people on an acute admissions unit. The aim was to examine current practice, identify aspects of good practice and areas for improvement. The audit’s outcomes are also reported.
Implications for practice
Poor nutritional care and the incidence of malnutrition in hospital patients have long been recognised as challenges. Older people are particularly vulnerable and at risk of becoming malnourished while in hospital.
Nutritional needs change during ageing and many factors affect nutritional status in older patients, including illnesses that affect digestion, absorption and metabolism. NICE (2006) guidance identifies that psychosocial issues also have a significant effect on dietary intake for some older people.
The RCN carried out a survey of nursing staff to explore attitudes towards nutritional care. While 81% of nurses thought nutrition was ‘extremely important’, 42% felt there was not enough time to devote to patients’ nutrition. They listed barriers as: not enough staff to help patients eat or to monitor intake; conflicting priorities; and poor choice and quality of food (RCN, 2007).
The RCN stresses it is nurses’ responsibility, as part of the multidisciplinary team, to ensure that patients’ nutritional needs are met. The British Association for Parenteral and Enteral Nutrition’s (2009) report says that all patients should be screened for malnutrition on admission to hospital and given follow-up monitoring.
Dickinson et al (2007) suggested that nutritional care can reflect the wider workplace culture. We believe that understanding workplace culture is key to the success of any programme that aims to transform patients’ experience of care.
Across our organisation, Essence of Care clinical benchmarking is well established and coordinated. However, we recognised there was a need to review practice in relation to preventing malnutrition in hospital, as outlined by Age Concern (2006).
We developed an audit tool, in collaboration with a junior sister and medical consultant, that used a multi-method approach to help us understand practice. Using this approach (observations of care and a traditional audit) gave us a rounded view. The acute admissions unit offered to pilot the tool as this is where all non-elective patients are first admitted. It is also a highly pressured and busy area.
Method 1: observations of care
Observing care is a well-recognised approach to seeing practice in the ‘real world’ and a means of collecting evidence for evaluation in practice development.
In most cases, observations are carried out by someone from outside the area being observed, to reduce the likelihood of bias. However, ownership by the team, where the outcome of observing practice is fed back and belongs to the clinical setting to which it relates, is key to success. For this reason we decided to use three observers, one of whom was not based on the unit and two who were. This provided a balance and reduced the likelihood of bias.
A pilot framework was developed that aimed to audit care against the seven steps recommended by Age Concern (2006). This included key headings to help structure observation (Polit and Tatano Beck, 2004):
Activities and behaviour;
Skill attainment and performance;
Underpinning each heading were key indicators/descriptors to enable clarity, such as:
Activities and behaviour: Are older people who need help to eat and drink readily identified? Are patients who need help offered fluid and can patients reach their food and fluid? How do staff behave when helping older people to eat and drink? Do staff enable them to make informed choices about dietary requirements? Is unnecessary activity on the ward reduced during protected mealtimes to free up staff?
Over a two-month period, mealtimes were observed on eight different occasions at different times of the day. Notes taken during the observations were later compiled, and recurrent themes across the eight observation periods were identified.
Method 2: the audit
In total, 35 sets of medical records and nursing assessments were audited on five separate occasions.
To meet the selection criteria, the patient should have been on the unit for at least 24 hours, be over 65 and have complex multiple needs associated with ageing. The audit looked at documentation of nutritional care. Specific areas addressed are outlined below.
Listening to older people, their relatives and carers:
Are factors related to nutrition documented within 24 hours of admission?
Are patients’ wishes regarding nutrition recorded?
Are relatives’/carers’ wishes regarding nutrition recorded?
Where a nutritional need is identified, is there a documented care plan?
Are identified needs recorded in patients’ notes?
Food awareness: Where there are concerns about a person’s nutritional state, the following should have been done
MUST (malnutrition universal screening tool) screening;
Red-card system used;
Food chart used;
Where a need for help to eat is identified, appropriate steps taken to address this;
Where relevant, that the patient is appropriately positioned during mealtimes.
In reviewing and combining data from both methods, some themes emerged that enabled us to identify what was working well and areas that needed addressing.
These are outlined below:
Documentation did not reflect the care provided - often, where it was evident through observation that care had been given, it had not always been documented;
There was a general lack of consistency in practice - an ‘all-or-nothing’ approach. We observed some excellent practice in which nurses paid close attention to identifying and assisting people who needed help to eat. However, at other times practice was suboptimal;
Documented evaluation of nutritional care was inconsistent;
There was a general lack of awareness around meeting patients’ nutritional needs and the impact of behaviour and environment on care;
A lack of focus on multidisciplinary working was evident, and patients and relatives were not involved during nutritional assessment.
These themes provided a foundation to produce an action plan, based on a ‘real’ picture of practice.
The audit helped us to understand what was happening in practice. As a result, we set up a nutrition group on the unit to continue promoting ownership and developing a much greater person-centred approach to nutritional care. This consists of nurses of all levels and a dietitian with a specific interest in nutritional care for older people. The group’s aim is to look at issues raised by the audit and develop action plans to change practice.
The five key goals being addressed are:
Every patient should have their nutritional needs assessed and documented within 24 hours of admission and regularly evaluated;
All staff involved in patient care should have training on the importance of nutrition;
All staff must be aware of the importance of good nutritional care and act as champions to ensure this occurs consistently; Patients and/or relatives/carers must be involved wherever possible in planning, implementing and assessing care;
A shared practice or set standard on nutrition for the unit should be developed.
In developing this tool, our intention was never to replace other methods of benchmarking. Rather, we aimed to support and complement them, thus raising the profile of nutrition.
Having tested this tool, it has now been refined further and will be tested in other acute clinical areas within the trust.
Incorporating patient stories into the audit process is also being considered to better inform and, consequently, help change practice.
Age Concern (2006) Hungry to be Heard: The Scandal of Malnourished Older People in Hospital. London: Age Concern England.
British Association for Parenteral and Enteral Nutrition (2009) Improving Nutritional Care and Treatment. Perspectives and Recommendations From Population Groups, Patients and Carers. Redditch: BAPEN.
Dickinson, A. et al (2007) No longer hungry in hospital: improving the hospital mealtime experience for older people through action research. Journal of Clinical Nursing; 17: 11, 1492-1502.
NICE (2006) Nutrition Support in Adults: Oral Nutrition Support, Enteral Tube Feeding and Parenteral Nutrition. London: NICE.
Polit, D., Tatano Beck, C. (2004) Nursing Research: Principles and Methods. Philadelphia, PA: Lippincott Williams and Wilkins.
RCN (2007) Nutrition Now. London: RCN.