VOL: 103, ISSUE: 37, PAGE NO: 30-31
Jean Bell, MSc, BSc, RN
Jean Bell is research nurse, Dumfries and Galloway NHS health board.
(2007) Nutritional screening during hospital admission. www.nursingtimes.net …
AbstractBell, J. (2007) Nutritional screening during hospital admission. www.nursingtimes.net
BACKGROUND: This article reports on a study on whether the mandatory requirements of NHS Quality Improvement Scotland’s (QIS) (2003) clinical standard 2 on nutritional care in hospital were being achieved. This standard, which covers assessment, screening and care planning, requires the mandatory nutritional screening of patients within 24 hours of admission into Scottish hospitals and the implementation of a nutritional care plan where necessary. The standard also recommends constant patient evaluation/reassessment and a discharge plan.
AIM: To investigate if the mandatory requirements of NHS QIS standard 2 were achieved and to identify the issues affecting nurses’ compliance with the standard.
METHOD: The study consisted of three stages: a casenote audit, which compared emergency medical with elective surgical patients; a nursing staff questionnaire; and two focus groups to investigate if the requirements of the standard were being met.
RESULTS: Few nurses were aware of the NHS QIS standard 2 and only a minority of surgical and medical patients were screened according to it.
CONCLUSION: There is a need to introduce a different validated and reliable nutritional screening tool. Further staff education is needed on nutrition.
This article, part 1, looks at the background and methodology, while part 2 looks at the results in detail.
Government bodies and professional groups recognise that some patients may not receive adequate nutrition and at-risk inpatients in UK hospitals may not be properly screened.
Patients’ nutritional status tends to deteriorate on admission and is associated with exacerbated disease and increased length of hospital stay. Some patients have a poorer nutritional state on discharge from hospital than on entry. It is predicted the decline in nutritional status could be largely prevented or treated with appropriate screening, assessment and management.
Nutritional care is a government priority after the results of national audits raised concerns. It is calculatedthat if patients were properly nutritionally screened and received adequate management, over £7.5bn per year could be saved for use in other areas of healthcare.
Scotland is leading the way in nutritional care, because it is the only country in Europe - despite these concerns - to develop monitored nutritional care standards.
A casenote audit that compared emergency medical and elective surgical patients, a nursing staff questionnaire and two focus groups aimed to investigate if the mandatory requirements of NHS QIS’s clinical standard 2 were being achieved. This is detailed in NHS QIS’s (2003) document Food, Fluid and Nutritional Care in Hospitals, clinical standard 2 - assessment, screening and care planning.
NICE has also published guidance on nutrition support in adults for practitioners in England and Wales (NICE, 2006).
Florence Nightingale (1860, cited in Richardson and Davidson, 2002) wrote: ‘Thousands of patients are annually starved in the midst of plenty, from want of attention to the ways which alone make it possible for them to take food.’ Hamilton (2000) added that patients should not become undernourished during a hospital stay as no illness or disease benefits from poor nutrition.
However, undernourishment affects one-third of care home residents in Britain, a quarter of GP and hospital outpatients and nearly half of surgical and medical admissions, with 12% severely undernourished and 75% of patients losing weight while in hospital (Elia, 2003).
It is now recognised that undernutrition begins in the community, and can continue throughout a hospital admission, requiring sustained treatment following discharge (NHS QIS, 2006).
NHS QIS (2006) highlighted thatScotland’s hospitals have over half a million admissions annually, which is approximately 10% of the population.NHS QIS (2006) acknowledged that undernutrition affects at-risk patients including children, older people and those with eating, drinking and/or communication problems.
Over 50 published nutritional screening tools are in clinical use (Malnutrition Advisory Group, 2003). Many of these have not been tested for validity or reliability and take between two and 30 minutes to complete (Best and Thomas, 2001).
The lack of a standardised approach to nutritional screening leads to inconsistency in the assessment and subsequent management of patients, with much being left to the nurse’s own judgement (Dempsey and Dempsey, 2000).
Butterworth (1974) highlighted the extent of unrecognised malnutrition in hospital patients. A King’s Fund report (Lennard-Jones, 1992) found that early identification and correction of malnutrition in hospitalised patients is essential, with mandatory recording of the nutritional screening score documented in the doctors’ and nursing notes.
Lennard-Jones et al (1995) conducted a study of 70 UK hospitals and discovered the nutritional screening of newly admitted patients was haphazard or nonexistent, with many doctors and nurses feeling nutrition screening was ‘unimportant’.
Gregory et al (1990) stated that malnutrition is multifactorial, often not identified and therefore not treated.
It is acknowledged that it takes a period of time for an individual to become undernourished. This usually starts in the community but, if it were recognised on admission to hospital, patient and family suffering could be avoided (British Association for Parenteral and Enteral Nutrition, 2005).
An estimated two million adults in the UK are affected by it, with the most vulnerable at-risk groups being elderly people, people with chronic disease, recently discharged patients and those who are poor or socially isolated.
Clinical factors can be combined with environmental and psycho/social factors, such as living alone, bereavement, memory loss, low income, disability and alcohol/drug dependency, all of which have a damaging influence on food intake (Hall et al, 2004).
Ballière’s dictionary (Weller, 2000) defined malnutrition as the condition in which nutrition is defective in quality or quantity, which can apply to under- or overnutrition. Therefore the term undernutrition is more accurate when applied to a poor nutritional state.
Undernutrition is the most common disease in the hospital setting. It improves by treating the disease and feeding the patient (Waitzberg and Correia, 2003). Patients over 65 years are at greater risk of entering hospital undernourished and therefore have a significant need for nutritional screening and assessment (Waitzberg and Correia, 2003).
Undernutrition can be acute (in hospitalised patients due to: reduced food/no food intake; hyper-metabolic state caused by surgery or trauma; drug therapy; or chronic (occurring in pre-hospitalised patients as a result of disease or medical conditions such as impaired gastrointestinal function); chemotherapy; respiratory disease; drug interactions leading to low protein intake; dementia; neurological disease; or poor food choices due to the inability to buy, prepare or eat foods independently) (Konstantinides, 1998).
Konstantinides (1998) explained that undernutrition has arisen when a patient’s body mass is less than it should be for their age, height, genetic base and activity. It is an inequality of energy and/or shortage in one or more nutrients such as proteins, vitamins or trace elements, reducing organ mass and function, except for the brain, which remains unchanged (Konstantinides, 1998).
Advanced surgical/medical procedures, drug regimens and highly skilled teams of staff are impeded by undernutrition. Acutely ill patients are more likely to die if undernourished (Holmes, 2003). Surgical patients develop more complications such as: poor wound healing and dehiscence, requiring further surgery; low resistance to infection; unsatisfactory response to medication; and prolonged recovery time (Holmes, 2003; Dudek, 2000).
Jordan et al (2003) questioned whether a care gap had developed in the prevention of malnutrition in hospital patients, as it lies on the boundaries of medical, nursing and dietetic practice, with each professional deeming it another’s responsibility. Medical and nursing staff need to be more aware of a requirement to improve their nutritional education, to question poor practice and improve quality of patient care (Best and Thomas, 2001; McWhirter and Penningham, 1994).
Corish et al (2004) advised nutritional screening tools were only of value if they constantly detected those at greatest risk, with accurate nutritional assessment requiring sequential measurements of nutritional status over a prolonged period of time.However, Wheatley (1999) warned that screening tool usage is variable, with fewer than half of all nutritionally deficient patients being referred to a dietitian.
The malnutrition universal screening tool (MUST) developed by BAPEN in 2003, is validated and reliable and the suggested NHS QIS tool of choice. It has been found to be very effective in detecting potential and actually undernourished patients. It is being introduced into hospitals and community settings across the country (NHS QIS, 2006).
Assessing the nutritional intake of a patient with a poor appetite may be difficult. Fluid/food charts are invaluable if correctly completed, as they should clearly identify missed meals or a poor fluid intake (Schenker, 2003). The at-risk patient needs to understand the reasoning behind and importance of adequate food and fluid intake. They need to know that if they decline a meal an alternative can be offered, and/or food supplements can be given (Schenker, 2003). The accuracy of the portion sizes can be assisted by the use of standard measuring spoons and portioning by the hospital kitchen staff, as well as a chart of commonly taken foodstuffs being present in patients’ bedside notes (Schenker, 2003).
Camberg et al (1997) highlighted that nearly 50% of readmissions are medical patients. Sullivan (1992) discovered that 30% of elderly patients admitted into a geriatric unit had at least one non-elective readmission within 90 days. Readmissions are due to: increasing age; a decrease in self-caring status; clinical deterioration (sometimes from an untreated problem); inadequate medical management; or rehabilitation and social problems. Readmission leads to a higher probability of becoming a nursing home resident within the following year (Wong et al, 2002; Covinsky et al, 1999; Sullivan, 1992).
Frequently admitted patients can be discharged with unrecognised, untreated or unsolved problems due to ‘yo-yoing’ between home and hospital.
A full assessment of individual patient care needs, including nutrition and post-discharge planning by nurses, has been identified as reducing the hospital readmission rate (Wong et al, 2002). Covinsky et al (1999) discovered patients’ nutritional status was an independent predictor of mortality one year after discharge.
Nurses’ concepts of nutrition vary greatly. Perry’s (1997) study found nurses with 10 years’ experience thought nutritional screening was more important than less experienced staff. Two-thirds of nurses felt healthy waiting list patients did not require nutritional screening (Perry, 1997). Kowanko et al (1999) and Perry (1997) discovered 12% of nurses thought malnutrition did not occur in hospital, with an overestimation of patients’ dietary intake occurring in one-third of assessments. Perry (1997) also discovered patient information was not always recorded. Nutritional assessment of patients was missed due to pressure of work, a shortage of time, limited dietetic education and patients’ diagnoses. Discrepancies occurred between the activities nurses stated they carried out when compared to the written documentation in patients’ casenotes (Perry, 1997).
Nurses may be unaware of patients’ needs (Kowanko et al, 1999). Clinical judgement can sometimes mean an overweight patient being perceived as not being at nutritional risk, as they need to lose weight anyway. A patient may also have a history of significant weight loss without dieting (Kowanko et al, 1999).
Wright et al (2003) identified changing nursing roles as possible reasons for nurses’ reduced involvement in screening, assessing and maintaining patient nutrition. There was an inconsistent/absence of nutritional documentation in patient notes. Staff were unaware of the patients’ dietary requirements and unsure of whom to contact if a nutritional need was identified. Nutrition was seen as a less valuable nursing task and patients were left to manage their meals themselves, because not enough nursing staff were available to assist patients at meal times. This was due to extended nursing roles constantly changing, with less experienced staff adapting their knowledge and skills base daily (Watson, 1997).
Hospital admission affects individual choice of what, when, where and how to eat. Patients requiring assistance at mealtimes had a higher incidence of undernutrition than independent patients. Difficult-to-feed patients provide little reward for the person tasked with feeding them and some nurses have raised the ethical dilemma of how to feed a patient who did not want to eat (Kowanko et al, 1999).
Nurses are at the forefront of improving nutritional care but need support from other members of staff to fulfil this role effectively (Agnew, 2005). Multidisciplinary team members are recognised as having important roles to play in patients’ nutritional support. The delegation of mealtime responsibilities from nursing staff has led to ward housekeepers, auxiliary and domestic staff commonly serving meals and feeding patients (Bradley, 2003). This leads to the healthcare assistants becoming very knowledgeable about patients’ daily intakes, likes and dislikes and it is they who are the first to notice patients’ nutritional intake problems (Green and Watson, 2005; Bradley, 2003; Hayward, 2003).
Undernutrition and dehydration due to inappropriate or repeated preparation for operations/procedures regularly occurs; for example, giving patients a bowel preparation causes dehydration as it draws fluid out of the body to stimulate bowel emptying for ease of examination by the surgical team (Jordan et al, 2003).
Patients can be fasted (to avoid the danger of aspirating stomach contents which might lead to pneumonia) for long periods so that procedures or surgery can be carried out (Watson, 1997). However, other patient emergencies occur, which cause cancellations to inpatient procedures/surgery, resulting in prolonged periods of fasting. Perry (1997) discovered that over one-quarter of nurses were happy to keep patients nil by mouth for 6-10 days and 9% of nurses for longer than 10 days.
Some 16-67% of hospital food is wasted, with 11-27% of patients regularly missing meals for various reasons (Hospital Caterers Association, 2004). These include: a lack of appetite; requiring assistance with eating; disruption due to ward rounds; staff carrying out clinical procedures/surgery; poor food choices/portion sizes; and others’ clinical conditions putting patients off eating (Holmes, 2003).
Jordan et al (2003) identified a lack of awareness of patients who needed help with menu selection, eating or adapted utensils. Meals were not at an edible consistency or acceptable temperature for patients and trays were taken away before they had finished eating. Bedside tables were cluttered, at the incorrect height or positions and there was not enough space to place the meal tray down (Jordan et al, 2003). Staff placed the tray down on the patient’s bed, often out of their reach. Frequently, staff put one dish from the tray in front of the patient, leaving them to call for assistance to reach the other items of food.
Wright et al (2003) found a lack of communication between ward staff and catering staff when ordering/cancelling meals. There was also poor communication between the consultant responsible for the patient’s care and ward staff, causing problems and delays in making the clinical decision to introduce enteral/parenteral feeding (Green and Watson, 2005).
Serving food on red or different coloured trays to identify nutritionally at-risk patients at mealtimes could lead to improvements in patients’ nutrition (Bradley, 2003). The red tray is seen as an ‘alert’ to highlight that the patient has been assessed as being at nutritional risk. This informs the kitchen staff who put the food on the tray, the serving staff and the ward staff who collect the tray for return to the kitchen that this patient either needs assistance with feeding or their dietary intake needs recording.
The Hospital Caterers Association (2004) Protected Mealtimes project is being phased in nationally. It aims to stop unnecessary ward activities of multidisciplinary team members and visitors, when appropriate, to allow patients to enjoy their meals without unnecessary interruption (Holmes, 2003).
Nursing screening may be an unimportant extra piece of paper to fill out. Walton (1986) questioned whether the nursing process asks too much of nurses. Comments such as nurses drowning in paperwork, with more patients seen if there was less to write, are common (Allen, 1998).
However, nurses are aware of the accountability involved in care planning and documentation, but an inadequate knowledge of documentation skills, nursing care and education can lead to reluctance to record information on paper, with the implied role change from nurse to administration secretary (Allen, 1998).
Nurses may be frustrated by constant interruptions disrupting lines of thought, such as telephone calls and patient/relative/other members of staff queries while they are trying to complete documentation (Bjorvell et al, 2003).
Documentation takes time, which brings feelings of guilt on a busy, understaffed ward with high patient turnover. Extended nursing roles add a heavy workload burden for nursing auxillaries. Therefore nursing staff often stay behind at the end of a shift to complete paperwork so the new shift does not have unfinished documentation to complete. This in itself can lead to poor job satisfaction, and high stress and staff turnover rates (Bjorvell et al, 2003).
Due to the different workload during the night, nutritional screening may not be viewed as a priority, as staff admit relatively few patients and do not see patients eating (Watson, 1997). Night-time nursing tends to be carried out by permanent night staff. Night staff tend to lack the facilities for continuing education programmes and miss out on study days (Claffey, 2006). They have lower levels of supervision but higher levels of job responsibility and tiredness, which can lead to poor patient documentation; this can affect patient care (Claffey, 2006).
Implications for practice
- Some 40% of NHS expenditure is presently used to treat the elderly, who are living longer but in imperfect health (Department of Health, 1999).
- Scotland’s poor health figures are attributed to: bad diet; poor housing; lack of opportunities; low self-esteem/self-confidence; high rates of smoking; poverty; a high rate of long-term disability; working in lower-paid, high-risk jobs; and long-standing health problems that are slowly improving. Poor diet remains a concern in this vulnerable group (The Scottish Office, 1999).
- When comparing Scotland’s health figures to those of Western Europe, Scotland’s still remain unsatisfactory.
- With an increasing elderly population and the possibility of a poor dietary intake, the need for accurate assessment and management of all elderly patients entering hospital is particularly important.
The Scottish Report -Scotlandthe Grave? (Scottish Executive, 2003)estimates by 2028 one-quarter of the Scottish population will be over 65 and one in 12 will be over 80. When this is combined with a falling birth rate and an expanding rich/poor health gap, it is clear more emphasis has to be made on preventative, anticipatory care rather than reactive management (Kerr, 2005).
The main aims of this study were: -
- To investigate if the mandatory requirements of NHS QIS Food, Fluid and Nutritional Care in Hospitals standard two were achieved;
- To identify the issues affecting nurses’ compliance with NHS QIS standard two.
Deductive reasoning was used for this study, as the investigator started with the general idea that a high percentage of patients had not been nutritionally screened by nursing staff on admission to hospital. This idea was tested by analysing the data collected (Bowling, 2002).
Local ethical and management approval was granted for this study. As this project required a baseline of current practice, management approved a case note audit without alerting staff, as awareness of audit may have changed practice.
Casenote audits carried out retrospectively look at previously conducted events, endeavouring to ally present data with what has previously happened (Cormack, 2000; Parahoo, 1997). An advantage of a casenote audit is that the researcher relies on existing data being in the casenotes and not subject to changes in practice such as the ‘Hawthorne effect’, when staff become aware and interested in a study being carried out, resulting in them altering their normal behaviours and actions (Parahoo, 1997). However, using retrospective data may mean some information may be absent, difficult to read or to make sense of (LoBiondo-Wood and Haber, 2002).
Casenote audit sample
- One hundred case notes, identified from a medical records computer printout, comprising notes of 50 medical emergency and 50 surgical elective patients admitted into hospital for seven days or more, were randomly selected from those available in the file room.
- Medical emergency and surgical elective case notes were selected for investigation to enable a direct comparison of nursing procedures, to evaluate if different types of patients were assessed differently. Historically, surgical patients were often perceived as healthy patients requiring surgery, whereas medical patients tended to have chronic conditions leading to recurrent admissions (Anderson et al, 1996).
- All medical admissions were admitted directly to the medical admission ward. A nurse completed all assessments and paperwork there. The patients were then transferred to a suitable medical ward within 48 hours of admission.
- From Monday to Friday, all surgical elective admissions reported to a dedicated admission/discharge lounge. Routine blood tests, electrocardiograms and X-rays were carried out there and a nurse completed the ward paperwork. The patient then waited to be allocated a bed. Elective surgical patients admitted for seven days or more were highly likely to require major surgery which involved being nursed in surgical high-dependency or intensive care units post theatre, then transferred back to their ward of admission, beds allowing, once suitably recovered to prepare for discharge home.
Nursing staff questionnaire
The questionnaire had 10 mainly closed questions. It was quick and easy to answer and analyse, in clear typeface, to encourage responders to complete and return the questionnaire (Bowling, 2002). The focus, content and wording of the questions were formulated to avoid unintentionally biasing the answers. It aimed to be attractive, practical and non-threatening, using tick boxes and spaces for comments. It was estimated that it would take approximately 5-10 minutes to complete.
The questionnaire took a filter-then-funnel approach, beginning with a broad general question, leading to a very specific point. Questionnaires were coded to allow follow-up of non-responses; two mailings were carried out, as postal questionnaires generally have a low response rate (Parahoo, 1997).
Topics included in the questionnaire were: the demographics of the sample; years of nursing experience; compliance and barriers to compliance; awareness of QIS standard 2; use of care plans; reassessment on transfer/after seven days in hospital; and knowledge of nutrition.
In order to include all relevant staff, the sample was identified from the duty rota for the week of distribution. Some 324 nursing staff working with inpatients were identified. Each potential participant received a personally addressed letter of invitation, information sheet and questionnaire, with a return addressed envelope sent via internal mail, inviting them to participate in the study.
A pilot study assessed the content and validity of the questionnaire by assessing if the respondents understood the question in the same way, if the question format was suitable, if the instructions were easily understood and the relevance of the questions was carried out.
Opinions vary on acceptable response rates for questionnaires from 20% (Burgess, 2001) to the ‘rule of halves’ with a 45-55% return for the initial mailing, then approximately half this amount for the first reminder and then half again for the second reminder (Breakwell et al, 1995).
From the findings of the casenote audit and nursing questionnaire, several areas were identified for further exploration. Separate medical and surgical focus groups were held to ensure a homogeneous group (Parahoo, 1997).
Parahoo (1997) explained that focus groups are unstructured interviews with small numbers of a purposive (when the researcher intentionally chooses who takes part in the study) sample of people to interact with each other and the group leader, by using personal experience to comment on investigation topics (Polit and Tatano Beck, 2004; Bowling, 2002). The key to a successful focus group is the interaction between contributors, empowering participants and extracting members’ attitudes, feelings, beliefs, experiences and reactions by drawing out multiple views and emotion processes from the group (Bowling, 2002; McNamara, 1999; Luntz, 1994).
The disadvantages of focus groups are that they may be intimidating and discouraging for less articulate or shy individuals if one dominant personality is allowed to stifle open, honest discussion by browbeating other participants. Members may not express their own personal view, with perhaps some individuals not trusting other members to keep personal or sensitive information anonymous and confidential. The researcher has less control over the data produced than in quantitative studies or one to one interviews, but must allow participants to talk, question, challenge and express doubts to one another (Bowling, 2002; Talbot, 1995).
Aims of the focus group
The aims were:
- To explore in depth reasons why nutritional screening was not always completed;
- To determine factors influencing completion;
- To look at the issue of referral to the dietitian;
- To examine the start of nutritional support.
A week before the focus groups, the researcher contacted the staff on duty for every ward with inpatients, to inform and invite a staff member to attend. An hour before the focus groups, the researcher visited every ward again, to remind staff and to confirm a staff member would be available to attend.
The focus groups took place in the ward day room, in the early afternoon, at the overlap period between the early and late shifts, when the maximum numbers of ward staff were on duty (McNamara, 1999).
Focus group ground rules explained that everyone’s contribution, views and experiences were important. There were no right or wrong answers and all information and opinions heard during the meeting would be kept confidential by the members of the focus group and not repeated outside the group. One person spoke at a time to enhance the quality of the tape.
An independent facilitator chaired the discussion. All staff present gave permission for the conversations to be taped and a scribe took notes verbatim throughout the session (McNamara, 1999).
The surgical focus group comprised eight nurses, ranging from ward managers to newly qualified staff nurses from all specialties except ear, nose and throat. Three senior staff nurses took part in the medical focus group, representing medical rehabilitation, care of the elderly, stroke and dermatology specialties. The acute medical wards were not represented. The focus groups produced significant data, with different and varied comments/issues raised.
The researcher avoided focusing on emotional content and data depicting personal interest (Polit and Tatano Beck, 2004). Key themes were identified with care taken to avoid data being placed in the wrong section.
The data gathered by the focus groups was analysed using a thematic approach. The data collected was carefully read, marked and broken down into sub-scenes. A list of key opinions were compiled with overlapping ideas put in clusters or separated into categories and subcategories (Polit and Tatano Beck, 2004). Patterns, topics, words, phrases and themes became apparent; these were then compared, reviewed and explored further (Parahoo, 1997).
Results from the case note audit indicated that, in the surgical and medical settings, a minority of patients - only 22% of surgical and 30% of medical patients - were nutritionally screened as per the standard.
Results from the questionnaire and focus groups found few nurses were aware of NHS QIS clinical standard two. Some 27% of staff always nutritionally screened patients, with 28% usually, 35% sometimes and 10% never doing so. Repeat screening of transferred patients did not occur routinely on transfer to another ward; neither did it for patients with hospital stays of seven days or more. Care plans were not used regularly but fluid balance charts were readily used for the surgical patients. Emergency medical patients were more often nutritionally screened than the elective surgical patients. The majority (72%) of nurses who completed the questionnaire were interested in finding out more about nutritional issues.
Although significant progress has been made in the approach to nutritional care, this study finds that there is a need to introduce a different validated and reliable nutritional screening tool. Further staff education is needed to highlight the importance and management of nutrition.
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The dissertation from which this article was developed was supervised by Dr Valerie Blair, Senior Lecturer School of Health Studies, Bell College, Hamilton.