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Focusing nursing care on the older person

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VOL: 98, ISSUE: 33, PAGE NO: 34

Angela Kydd, MSc (Gerontology), PGCE, RGN, RMN, is senior lecturer, School of Nursing, Midwifery and Health, University of Paisley, Scotland

Last week's article outlined the creation and maintenance of what is expected to become a centre of excellence in gerontological nursing (Kydd, 2002). This involves collaboration between the academic and the clinical sector with the aims of:
Last week's article outlined the creation and maintenance of what is expected to become a centre of excellence in gerontological nursing (Kydd, 2002). This involves collaboration between the academic and the clinical sector with the aims of:


- Improving care for older people;


- Enhancing the profile of the participating organisations;


- Identifying areas of good practice for wider dissemination;


- Using existing evidence-based work.


This week's article looks at two examples of how clinicians and academics can work together to improve patient care.


Nutrition for older patients in hospital
Brigeen Dyer is a nurse manager at Johnstone Hospital, a small rural unit for older people. Over the past four years she has been involved in a project looking at ways to improve nutrition throughout the hospital. Its review of catering services included exploring ways to improve the preparation, presentation, provision and quality of food. The subsequent work of Ms Dyer and her team has been cited as an example of good practice in the National Nursing, Midwifery and Health Visiting Report (2002) Promoting Nutrition for Older Adult In-Patients in NHS Hospitals in Scotland.


Nutrition is a fundamental physical requirement and an integral part of treatment (Allison, 1999), and all nurses have a responsibility to meet patients' nutritional needs (Bond, 1997). Service improvements may prevent the consequences of poor nutritional status, which include increased rates of infection, apathy, depression, and the development and delayed healing of pressure ulcers (Copeman, 1999).


Preparation and presentation


One of Ms Dyer's first steps, in cooperation with ward staff, was to persuade the trust to create a new position - ward hostess (Box 1). This role has improved meals for patients and enabled staff not to see mealtimes as a chore.


The hostesses I spoke to enjoy their jobs. They feel that their good relationship with the patients is rewarding. Mealtimes are not rushed and patients can have second helpings if they want. To ensure that patients get the help they need, staff do not take breaks during patients' mealtimes.


One problem with food that has to be delivered, in this case from a central kitchen about 50km away, is quality. For example, the fish was fairly dry. This was thought to be caused by the containers used to transport it, which prompted Ms Dyer and her team to investigate different methods of packaging the food before it leaves the central kitchen. In addressing this problem, communication between the kitchen and ward staff has been improved.


A cooked breakfast is offered twice a week. Cheese, butter and cream are used to increase the calorific value of suitable meals. Storing food on the ward had been banned, but Ms Dyer campaigned to reintroduce it and the ward is now able to store bacon and sausages, cheese, cream, bread, butter, gravy granules, fruit and canned food, so tasty snacks are available throughout the day. The availability of snacks helps to improve patients' nutritional intake (Jones, 1992) since, as Lennard-Jones (1999) points out, a low-fat low-sugar diet is often not appropriate for people who are ill and undernourished. They need sugar and fats to supply adequate calories in small volumes of food.


Ms Dyer has also ensured that ready-made sauces are available to patients if they ask for them with meals. In addition, some dishes need finishing touches before they are served to make them more appetising and the hostess takes care of this.


Lunch is usually the main meal of the day and the evening meal consists of soup and a sandwich filled with minced meat or cheese slices, as these are easier to eat than the slices of meat and grated cheese sandwiches that were previously provided.


Fruit used to be given to patients in the form of apple and orange slices, most of which were wasted. Staff requested that hard fruits be pureed and served with desert. Because this is part of the hostesses' remit, it is done daily.


Patients are often asked their opinions on the food and their preferred dishes are requested from the main kitchen. Seasonal and traditional foods are also requested for events such as Burns Night, pancake day and St Andrew's Day. This is not only fun but also serves to remind patients of the time of year. Cultural and religious dietary needs are catered for by liaising with the main kitchens and ordering dishes requested by particular patients.


Further provision is planned and the ward has applied for an extra £3 per patient per week to buy extra stock items. Other requests include a freezer to store bread and a soup cauldron so that soup can be served outside of mealtimes.


Many of the changes implemented have been inexpensive and there is now far less food wastage. Meals are definitely an occasion and patients' nutritional requirements are met in a non-medical way. The project has been in place since 1999 and Ms Dyer and her team continue to make changes and evaluate the service. The changes have been evidence-based and are endorsed by local dietitians. Training is high on the agenda.


Another example of excellent practice in this small hospital is the introduction of a tea room. This was set up so that the patients could entertain their visitors, as it is acknowledged that social activities involving food can improve nutritional intake (Molyneux, 1998). The hostesses help out in the tea room and a visitors' book serves as a simple but effective method of evaluating the service.


One patient summed up the appreciation of the new facility as follows: 'Visiting the tea room is the highlight of my week. We love the restfulness, the china cups, embroidered cloths and, of course, Rhona's [the hostess] presence, ever cheerful and helpful.'


Banishing routine from a ward
Donnie Cameron is a charge nurse on Bengullion ward, an elderly care ward at Campbeltown Hospital, which is situated in a rural area on the west coast of Scotland.


Much has been written about the issue of nursing rituals, but another aspect of nursing that is detrimental to individualised care is routine. This is often ingrained, not only in the psyche of nurses but also in the way wards are organised. The provision of individualised nursing and care tailored to the needs and wishes of the individual is at the forefront of the Draft National Care Standards (Scottish Executive, 2001).


In acknowledging the right of the individual to make choices, it was clear to Mr Cameron and his team that staff often persuaded patients to fit in with the ward routine. In some cases this is unavoidable as the ward has to fit in with the routines of other departments, but the day-to-day care provided to most patients is a different matter. For example, why should patients get up at 7.30am for breakfast? Why should they have a bath or shower in the morning if they are accustomed to bathing before going to bed? Why should they go to bed early to enable staff to spread their workload? These were issues the team felt they needed to address, but were prevented from doing so by institutional constraints in the way the ward was staffed.


The opportunity arose when three posts became vacant at the same time, giving the ward 108 nursing hours to fill. The three positions were divided into three 16-hour and three 20-hour posts, allowing the introduction of family-friendly policies. Three new members of staff would work from 9am to 1pm four days a week, and three would work from 4pm to 9.30pm, with a half-hour break, four days a week. This allowed a more flexible approach to patient care - following patients' wishes as opposed to giving them care that suited the routine of the ward.


It was not an easy change. The ward routine had to be altered and instead of the rush to get patients up and washed before breakfast, the few patients who wished to get up were helped to do so while most had breakfast in bed or slept on. This meant that the morning shift had two fewer staff from 7.30am until 9am, after which the numbers were made up. Patients now take priority and it is not unusual for staff to be making beds until almost lunchtime. However, patients are usually in the sitting area by then, so this does not cause problems.


Some staff initially felt stressed by the new way of working. One key factor in this, suggested by Ford and Walsh (1994), is that the culture of nursing and health care is resistant to change. In this case, the charge nurse involved the team and they examined the results together in the light of their acceptability and applicability to their own area.


Patients are now able to choose their own routine, which has the additional benefit of freeing staff to provide individualised care. For example, one member of staff takes a patient out to bingo on Wednesday evenings. This kind of activity reflects the ideology of holistic care, providing social support to patients in long-term care (Dalley, 1997).


The shortfall of staff between the hours of 1pm and 4pm has not been detrimental to care and Mr Cameron is running a second project - which he refers to as 'the reverse of a day hospital'. Patients who wish, and have the support of relatives, can go home for parts of the day.


No formal evaluation has taken place, but staff report that although they are as busy as they were before the changes, they feel that the quality of what they do has improved. They all report that patients are extremely happy with the changes. Regular staff meetings take place to re-evaluate care in line with Dalley (1997), who recommends that staff should 'self-audit'.


As their mentoring educator, I have visited the ward and talked to staff about the project. We are currently looking at establishing a video-conference link between the ward and the university to improve communication between the two environments. It will also be used for in-service training.


These changes are part of a continuing programme that will, hopefully, gain momentum, with participation in the project supported by the University of Paisley.


Conclusion
The examples cited in this article show that research evidence can not only identify problem areas but also provide effective interventions to resolve them. Funk and Tornquist (1992) point out that such evidence can suggest strategies to promote function and provide a better understanding of the patient's perception of the experience.


Yet there remains a sizeable gap between research and practice (Kirchhoff, 1982; Brett, 1987; Moore, 1995; Pediani and Walsh, 2000). To be effective, changes in health care, including the reorganisation of the NHS, need to be underpinned by education and training. With the introduction of primary care groups and primary care trusts, as part of the implementation of The New NHS: Modern, Dependable (Department of Health, 1997), there is now the potential to involve nurses to a much greater extent than in previous NHS reorganisations.


One of the main implications of this is that nurses, midwives and health visitors have become involved in strategic planning and decision-making for health and social care in the NHS. However, to provide a patient-focused and health-needs-oriented service (Department of Health, 1997), nursing education needs to focus on providing and facilitating skills.


Implementing Fitness for Practice (UKCC, 1999) and Making a Difference (Department of Health, 1999) require those involved in nursing education to provide relevant support to clinicians. They also require clinicians to update their knowledge and skills regularly. We hope that in working together, clinicians and academic staff can make a difference to the quality of patient care. The work of clinicians demonstrates the amount of dedication and commitment such a project entails. We hope that by sharing ideas and expertise we can provide best practice without reinventing the wheel.


The project is not currently funded and relies on people's goodwill and enthusiasm. We have applied for research funding as we feel it is important to evaluate the work formally. In the meantime, all the clinicians involved intend to write up their projects in conjunction with mentors from the university.


BOX: THE ROLE OF THE WARD HOSTESS


  • Preparing the serving area for food;
  • Preparing the patients ' dining area,,to include cloths,condiments and individual aids for eating;
  • Updating the menu board;
  • Liaising with named nurses;
  • Serving food with each patient 's preferences in mind,for example,portion size and presentation
  • Responsibility for the storage of food on the ward;
  • Preparing snacks using knowledge of patients ' dietary requirements.
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