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A nurse-led, multiprofessional approach to nutrition

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A team of nurses organised a multidisciplinary group to implement trust-wide initiatives, supported by patient involvement, to improve nutritional care

  • This article has been double-blind peer reviewed
  • Figures and tables can be seen in the attached print-friendly PDF file of the complete article found under “related files”


Janet Thomas, Dip Professional Practice, MBA, RGN, is directorate nurse; Sarah Davies, BSc, RGN, is senior nurse; both at Medical Directorate, Carmarthenshire NHS Trust.

Nutrition is essential to patient care. It plays a vital part in encouraging a healthy lifestyle as well as supporting treatment and rehabilitation of patients. Good quality food is a contributing factor to rapid recovery and reducing time spent in hospital. To support this, Carmarthenshire NHS Trust, through a nurse-led Nutritional Strategy Group (NSG), adopted a multiprofessional approach to nutritional management, incorporating quality standards, statutory guidance and legislative requirements. As part of this process, patient participation was actively sought and implicit within the clinical governance framework.

The project
Many patients are at risk from malnutrition in hospital and about 40% are malnourished on admission. The NSG, led by the deputy director of nursing, was established in 2004 and comprises dietitians, speech and language therapists, hotel services and senior nurses.

The group ensures a coordinated and consistent approach to all aspects of nutritional care trust-wide and implements procedures that reflect national guidance and good practice.


The NSG has developed an inpatient nutrition screening tool, care plans, oral hygiene guidelines, protected mealtimes, a red-tray system and nutritional symbols. In addition, a new menu cycle was developed incorporating nursing diagnosis and patient outcomes to meet the patients’ needs.

  • Patient assessment One of the key priorities for the NSG was to develop an inpatient nutritional screening tool to determine patients’ risk status. Assessment is fundamental to ensuring the nutritional needs of patients are met. The screening tool was developed and rolled out to all inpatient areas. An audit of nutrition risk assessments demonstrated an improvement in the number of patients having risk assessments – this rose from 75% in 2006 to 84% in 2007.

  • Oral hygiene This is an essential and complex part of patient care and can be influenced by a range of factors. In line with the trust’s nutrition policy, oral hygiene guidelines were developed and are now used in clinical practice. The Fundamentals of Care audit results in 2006 demonstrated that 90% of patients received oral hygiene at the trust.

  • Red tray Food served on a red tray provides an effective signal to staff, without compromising patient dignity, that patients are at risk of malnutrition and that they need help and support. A group was established to implement the red-tray system within
    the clinical areas. Flow charts, guidelines, and staff and patient information boards were developed.

  • Protected mealtimes The aim of protected mealtimes is to ensure that ward activity is reduced to a minimum so that patients can take their meals in a calm and peaceful environment. By meeting this aim, staff are able to devote time to the meal service and assist those patients needing help to eat. The trust introduced the protected mealtime initiative and a recent pilot audit tool demonstrated that 93% of patients had uninterrupted mealtimes. Patient views were sought, which resulted
    in 88% of patients agreeing with the concept of protected mealtimes.

  • Training In order to enhance the patient experience and promote evidence-based practice, the NSG ensures a structured and consistent approach to all aspects of nutritional care. This is achieved through a coordinated approach to in-house staff training and education programmes for all groups of workers. The trust provides nutrition training through the newly qualified programme, NVQ courses, Fundamentals of Care course and a junior doctor programme. Teaching sessions have been introduced on nutrition and swallowing difficulties for registered nurses, healthcare support workers and junior doctors.

A training programme has been developed for registered nurses on insertion of fine-bore nasogastric tubes for enteral feeding. A pilot of a nurse competency-based programme for swallowing assessment of patients with acute stroke has also
been introduced.

The trust nutrition policy is continually reviewed and amended, and has been presented to the trust board. The policy
has been disseminated to all staff through various formats including ward meetings
and drop-in days. The policy was disseminated more widely at a national conference and the initiatives will be publicised in the local press.

Work in progress

In response to NICE’s Nutrition Support in Adults clinical guidance the NSG has developed an action plan that is regularly reviewed.
Working in partnership with dietitians, speech and language therapists, and senior nurses, care plans were developed. These incorporated nursing diagnosis and patient outcomes to meet the patients’ nutritional needs, for example dietary intake and swallowing problems.
These care plans are currently being introduced throughout the trust.

Find out more

If you would like to have additional information on this project, contact Janet Thomas or Sarah Davies

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