Oral nutritional supplements help to improve patients’ calorific intake. A poster campaign was launched to boost nurses’ knowledge of how to use these products
Citation: Harcourt Watkins C et al (2012) Raising nurses’ awareness of nutritional supplements. Nursing Times; 108: 25, 20-21.
Hospital patients are at increased risk of malnutrition and may need oral nutritional supplements.
Author: Claire Harcourt Watkins is staff nurse, Glangwili General Hospital; Linda Morgan is clinical nurse specialist nutrition; both at Hywel Dda Health Board.
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This article describes the development of a poster to raise nurses’ awareness of the importance of chilling supplements to encourage patients to take them and find out their preferred flavours.
Nurses are fundamental to influencing and implementing effective nutritional care (Jefferies et al, 2011). They have a pivotal role in ensuring that patients’ nutritional requirements are fully met by improving oral nutritional uptake and reducing the risk of malnutrition, which may have an impact on the length of hospital stay (Saunders et al, 2011).
Of patients admitted to an acute hospital setting, 28% are malnourished; without appropriate screening and assessment, this figure could rise for the most vulnerable people in hospital (British Association for Parenteral and Enteral Nutrition, 2010).
Effective nutritional screening for patients admitted to hospital can help in identifying those with or at risk of malnutrition. This information enables nurses to start a care plan for patients’ nutritional needs, using the multidisciplinary team when needed.
After the care plan is started, patients should be re-screened regularly so nurses can continue to plan their nutritional care, as advocated by the National Institute for Health and Clinical Excellence (2006) and detailed in the All Wales Food Record Chart and Nutritional Care Pathway (Welsh Government, 2009). Locally, screening is undertaken on all patients on admission, then weekly during their hospital stay.
After nutritional screening, nurses may need to consider the use of prescribed oral nutritional supplements (ONSs) to complement patients’ fortified diets and improve their overall calorific intake.
Patient consumption of ONS products can be improved by serving the supplements chilled and in their preferred flavour (Dunne, 2009).
There is evidence that patients do not always finish their ONS, which may be due to a change in their clinical condition or simply taste fatigue (Rahemtulla et al, 2005). Patients may not be able to manage the entire supplement at once, in which case the remainder can be labelled, dated, timed and refrigerated and consumed within 24 hours as recommended by the manufacturer. This may help to reduce waste and ensure that patients consume the maximum nutrients from the prescribed supplement (Gosney, 2003).
Background to the project
An observation of nursing practice identified variations in the way ONSs (specifically sip feeds and desserts) were served to patients in one clinical area.
This issue was identified as a result of ward observation and a mini-audit, which asked patients about their preferred flavour and whether they preferred supplements to be chilled.
The audit found patients preferred them chilled, saying they were more palatable, and this resulted in greater consumption. They also appreciated being given a choice of flavours.
The audit also found that a change in practice was needed for supplements to be stored and used correctly following manufacturers’ instructions.
I developed a poster in the clinical area and used it to raise awareness; it was headed: “We are best served chilled.” The poster also showed pictures of the main ONSs dispensed by Hywel Dda Health Board (Fig 1). Text balloons added impact with the phrases: “We come in many wicked flavours”; “We are all best served chilled”; and “We are wicked when served cold.”
I gained support for the poster project from the local hospital nutrition group and decided to use the poster in a variety of clinical areas.
I compiled questionnaires for audit before and after the posters were placed in each area. The questionnaire identified nurses’ existing knowledge base and whether this improved after the posters had been displayed.
Storage and refrigeration facilities in each area were also audited and various practices were identified. Some wards were sharing kitchen and fridge facilities while others were using small ward drug fridges.
The posters were displayed in 20 wards and the questionnaire was given to two members of staff on each of these wards; a total of 40 staff responded. The wards were revisited three weeks later and 40 staff members answered the questionnaires, following the display of the posters.
When the questionnaire was repeated after the poster placement, nurses’ awareness of supplements and their effective storage had increased. They recognised the need to date and label the fat-based emulsion supplement and there was a greater understanding of the need to assess patients’ choice to increase consumption. Many wards had also changed storage facilities for their supplements (Fig 2).
Storage facilities differ in each clinical area, which makes it difficult to offer the same guidance to all ward managers. However, the principle of chilled and correctly stored supplements remains; individual wards have established the best ways to achieve this.
This project provided the evidence that further work was needed to address the correct use of the fat-based emulsion supplement. As a result of this initiative, the pharmacy now dispenses the product with labels attached that are ready to be written on by the nurse once opened as well as a “refrigerate” label.
The poster has raised nurses’ awareness of taste fatigue in patients, the need to offer them a variety of flavours and t0 provide help to ensure they consume as much as possible.
This project has helped to inform the work plan for the health board and there is now an opportunity to extend the project across the board and in the community.
A teaching programme is raising awareness of the various ONSs available, highlighting the different nutritional content of each supplement. A tasting session for nurses is included to promote the importance of respecting patients’ preference of flavour, texture and temperature.
Nurses have a vital role to play in assessing patients’ nutritional needs and providing a care plan that takes into consideration their risk of malnutrition.
Audit has shown that the poster has proved a cost-effective way of raising nurses’ awareness at ward level of how simple changes in practice may improve patients’ consumption of ONS.
- Nurses play a pivotal role in screening and identifying patients’ nutritional needs
- Effective communication skills are needed to gain accurate and up-to-date information to develop a more personalised nutritional care plan
- Nursing documentation should inform ongoing nutritional care planning
- Practitioners should seek help from the multidisciplinary team to ensure patients receive the right level of nutritional assessment, care planning and evaluation
- A good variety of flavours of oral nutritional supplements, chilled and ready for use, encourages patients to take them
British Association for Parenteral and Enteral Nutrition (2010)Malnutrition Matters: Meeting Quality Standards in Nutritional Care. A Toolkit for Commissioners and Providers for England. Redditch, Worcestershire: BAPEN.
Dunne A (2009) Management of malnutrition in older people within the hospital setting. British Journal of Nursing; 18: 17, 1030-1035.
Gosney M (2003) Are we wasting our money on food supplements in elder care wards? Journal of Advanced Nursing; 43: 3, 275-280.
Jefferies D et al (2011) Nurturing and nourishing: the nurses’ role in nutritional care. Journal of Clinical Nursing; 20: 317-330.
National Institute for Health and Clinical Excellence (2006) Nutrition Support in Adults: Oral Nutrition Support, Enteral Tube Feeding and Parenteral Nutrition. London: NICE.
Rahemtulla Z et al (2005) The palatability of milk-based and non-milk-based nutritional supplements in gastrointestinal cancer and the effect of chemotherapy. Clinical Nutrition; 24: 1029-1037.
Saunders J et al (2011) Malnutrition and under-nutrition. Medicine: the Continuously Updated Review of Clinical Medicine; 39: 1, 45-50.
Welsh Government (2009)All Wales Food Record Chart and Nutritional Care Pathway.