Nurse's perceptions of barriers to optimal nutritional therapy for hospitalized patients

Implementation of nutritional care in hospitals: A qualitative study of barriers and facilitators using implementation theory

BACKGROUND

Disease-related malnutrition is prevalent among hospitalised patients, but not all patients achieve the needed nutritional care. At a Danish University Hospital, focus has been on implementing nutritional practices based on clinical guidelines, but there is continuously variation between the wards regarding the quality of nutritional care.

AIM

The aim of this study was to identify the potential barriers and facilitators for implementation of the clinical guidelines for nutritional practices and to recommend suggestions for development of nutritional practices, using a theoretical implementation strategy.

METHOD

The design was a qualitative interview study of employees at a Danish University Hospital, using a semi-structured interview guide. The participants were nurses, nurse's assistant, nurse nutrition expert, head nurse and dieticians. We recruited 11 employees, representing eight different wards.

FINDINGS

The analysis identified six themes: (1) clear allocation of responsibilities and committed management enhances nutrition practices, (2) leadership support is essential, (3) physical settings and tools affect possibilities for action, (4) selection of equivalent staff is core, (5) teaching promotes the knowledge and skills and (6) a dietitian in the ward facilitates implementation of nutritional care. Barriers and facilitators among the themes were identified and has led to suggestions to strengthen nutritional care, based on implementation theory.

CONCLUSION

Various factors were identified as having impact on the implementation of nutrition practices and different suggestions have emerged to accommodate those factors, as well as to apply an implementation strategy to facilitate change in practice.

Malnutrition knowledge among nursing staff in four European countries: A cross-sectional study

BACKGROUND

Nursing staff must have sufficient knowledge in order to adequately prevent and treat malnutrition. However, only a marginal amount of information on this topic is available in the literature.

OBJECTIVES

This paper provides a comparison of the malnutrition knowledge among nursing staff in Austria, the Czech Republic, the Netherlands, and Turkey and presents factors associated with the malnutrition knowledge of nursing staff.

DESIGN

A cross-sectional study was performed.

SETTING AND PARTICIPANTS

Nursing staff from different care settings in Austria, the Czech Republic, the Netherlands, and Turkey participated in the study.

METHODS

The KoM-G 2.0 (Knowledge of Malnutrition - Geriatric) questionnaire was used for data collection.

RESULTS

In total, 2056 participants from different care settings took part in the study. Between 11.7 % (Turkey) and 32.5 % (Austria) of the participants had high levels of malnutrition knowledge. The country itself was the factor most strongly associated with malnutrition knowledge. The nurses' educational level and specialised training of nursing staff were also significantly (p < 0.001) associated with malnutrition knowledge. Questions about "factors that should be considered during older persons' food intake" were most frequently answered correctly, while questions about "different aspects of nutritional screening" were less often answered correctly in all four countries.

CONCLUSIONS

This study was one of the first to describe the rather low level of malnutrition knowledge among nursing staff in different countries. The country itself was identified as the factor most strongly associated with the nurses' knowledge of malnutrition, while the nursing staff's basic education as well as further training were also detected as significant factors. These results indicate that it is necessary to extend and improve (academic) nursing education and to offer specialised training programmes which may improve nutritional care across country borders over the long run.

Prevalence of hospital-acquired malnutrition and modifiable determinants of nutritional deterioration during inpatient admissions: A systematic review of the evidence

BACKGROUND

Malnutrition affects between 20% and 50% of hospital inpatients on admission, with further declines expected during hospitalisation. This review summarises the existing literature on hospital-acquired malnutrition that examines the magnitude of nutritional deterioration amongst adult inpatients and identifies preventable barriers to optimising nutrition support during episodes of care.

METHODS

A systematic review was conducted to answer the question: Among adult hospital inpatients, the presence of which modifiable factors contribute to hospital-acquired malnutrition? A database search was conducted between the 24 April and 30 June 2020 using CINAHL, MEDLINE, Scopus and PubMed databases according to a protocol registered with PROSPERO (CD42020182728). In addition, issues of the 10 top clinical nutrition journals published during the period of from 1 April 2015 to 30 March 2020 were hand-searched.

RESULTS

Fifteen articles were eligible for inclusion from a total of 5944 retrieved abstracts. A narrative synthesis of evidence was completed because of the high level of heterogeneity in methodologies. Nutritional deterioration is common among previously well-nourished and nutritionally compromised patients, with studies reporting that 10%-65% of patients experienced nutritional decline. Frequently reported barriers were mealtime interruptions, meal dissatisfaction, procedure-related fasting, effects of illness or treatment, chewing difficulties, poor appetite and malnutrition as a low clinical priority.

CONCLUSIONS

The findings of this review support the need for routine nutritional risk screening throughout each hospital admission with hospital-acquired malnutrition affecting up to 65% of inpatients. Clear establishment of the roles and responsibilities of each member within multidisciplinary healthcare teams in the provision of nutrition care and cost-benefit analyses are recommended to demonstrate the effectiveness of changes to models of care.

Mealtime and patient factors associated with meal completion in hospitalised older patients: An exploratory observation study

AIMS AND OBJECTIVES

To examine mealtime and patient factors associated with meal completion among hospitalised older patients. We also considered contextual factors such as staffing levels and ward communication.

BACKGROUND

Sub-optimum nutrition is a modifiable risk factor for hospital associated decline (HAD) in older patients. Yet, the quality of mealtime experiences can be overlooked within ward routinised practice.

DESIGN

Cross sectional, descriptive observation study.

METHODS

We undertook structured observation of mealtimes examining patient positioning, mealtime set-up and feeding assistance. The outcome was meal completion categorised as 0, 25%, 50%, 75% or 100%. Data were collected on patient characteristics and ward context. We used mixed-effects ordinal regression models to examine patient and mealtime factors associated with higher meal completion producing odds ratios (OR) and 95% confidence intervals (CI). The study was reported as per STROBE guidelines.

RESULTS

We included 60 patients with a median age of 82 years (IQR 76-87) and clinical frailty score of 5 IQR (4-6). Of the 279 meals, 51% were eaten completely, 6% three quarters, 15% half, 18% a quarter and 10% were not eaten at all. Mealtime predictors with a weak association with less-meal completion were requiring assistance, special diets, lying in bed, and red tray (indicator of nutrition risk), but were not statistically significant. Significant patient-level factors were higher values for frailty (OR 0.34 [0.11-1.04]) and Malnutrition Universal Screening Tool (OR 0.22 [0.08-0.62]). The average nurse-to-patient ratio was 1:5.5.

CONCLUSION

Patient factors were the strongest predictors for meal completion, but mealtime factors had a subtle influence. The nursing teams' capacity to prioritise mealtimes above competing demands is important as part of a comprehensive nutrition strategy.

RELEVANCE TO CLINICAL PRACTISE

Nurses are central to optimising nutrition for frail older patients. It requires ward leadership to instil a culture of prioritising assisted mealtimes, improved communication, greater autonomy to tailor nutrition strategies and safe staffing levels.

Trends and Novel Research in Hospital Nutrition Care: A Narrative Review of Leading Clinical Nutrition Journals

Hospital malnutrition is a longstanding problem that continues to be underrecognized and undertreated. The aim of this narrative review is to summarize novel, solution-focused, recent research or commentary to update providers on the prevention of iatrogenic malnutrition as well as the detection and treatment of hospital malnutrition. A narrative review was completed using the top 11 clinically relevant nutrition journals. Of the 13,850 articles and editorials published in these journals between 2013 and 2019, 511 were related to hospital malnutrition. A duplicate review was used to select (n = 108) and extract key findings from articles and editorials. Key criteria for selection were population of interest (adult hospital patients, no specific diagnostic group), solution-focused, and novel perspectives. Articles were categorized (6 classified in >1 category) as Screening and Assessment (n = 17), Standard (n = 25), Advanced (n = 12) and Specialized Nutrition Care (n = 8), Transitions (n = 15), Multicomponent (n = 21), Education and Empowerment (n = 9), Economic Impact (n = 3), and Guidelines (n = 4) for summarizing. Research advances in screening implementation, standard nutrition care, transitions, and multicomponent interventions provide new strategies to consider for malnutrition prevention (iatrogenic), detection, and care. However, several areas requiring further research were identified. Specifically, larger and more rigorous studies that examine health outcomes and economic analyses are urgently needed.

Barriers to Delivery of Enteral Nutrition in Pediatric Intensive Care: A World Survey

OBJECTIVES

To explore the perceived barriers by pediatric intensive care healthcare professionals (nurses, dieticians, and physicians) in delivering enteral nutrition to critically ill children across the world.

DESIGN

Cross-sectional international online survey adapted for use in pediatric settings.

SETTING

PICUs across the world.

SUBJECTS

PICU nurses, physicians, and dietitians.

INTERVENTIONS

The 20-item adult intensive care "Barriers to delivery of enteral nutrition" survey was modified for pediatric settings, tested, and translated into 10 languages. The survey was distributed online to pediatric intensive care nurses, physicians, and dieticians via professional networks in March 2019 to June 2019. Professionals were asked to rate each item indicating the degree to which they perceived it hinders the provision of enteral nutrition in their PICUs with a 7-point Likert scale from 0 "not at all a barrier" to 6 "an extreme amount."

MEASUREMENT AND MAIN RESULTS

Nine-hundred twenty pediatric intensive care professionals responded from 57 countries; 477 of 920 nurses (52%), 407 of 920 physicians (44%), and 36 of 920 dieticians (4%). Sixty-two percent had more than 5 years PICU experience and 49% worked in general PICUs, with 35% working in combined cardiac and general PICUs. The top three perceived barriers across all professional groups were as follows: 1) enteral feeds being withheld in advance of procedures or operating department visits, 2) none or not enough dietitian coverage on weekends or evenings, and 3) not enough time dedicated to education and training on how to optimally feed patients.

CONCLUSIONS

This is the largest survey that has explored perceived barriers to the delivery of enteral nutrition across the world by physicians, nurses, and dietitians. There were some similarities with adult intensive care barriers. In all professional groups, the perception of barriers reduced with years PICU experience. This survey highlights implications for PICU practice around more focused nutrition education for all PICU professional groups.

Food and heart-the nutritional jungle: Patients' experiences of dietary habits and nutritional counselling after coronary artery bypass grafting

AIMS AND OBJECTIVES

The aim of the study was to examine patients' experience of dietary habits and nutritional counselling in the early period during hospitalisation after coronary artery bypass surgery (CABG).

BACKGROUND

Undergoing CABG, patients have two different nutritional needs, extra proteins and calories for the first period after surgery and a heart-healthy diet when the recovery period is over. These needs can be difficult to manage for the patients.

DESIGN

Qualitative study.

METHODS

Interviews were conducted and analysed within a phenomenological-hermeneutic frame inspired by the French philosopher Paul Ricoeur. Patients undergoing CABG were interviewed 4-5 days after surgery at Odense University Hospital from March to May, 2017. The study adhered to the COREQ guidelines.

RESULTS

In total, 15 patients were interviewed (mean age 65 years, 87% men). After analysing the interviews following themes emerged, "Different needs-the nutritional jungle", "Food and heart-the lacking attention," and "The force of habits-being under the influence from spouses on dietary habits".

CONCLUSION

The interviewed patients had no or only a little knowledge about how to eat after heart surgery. In general, they experienced a lack of attention to nutritional counselling by the nursing staff during hospitalisation. Furthermore, the health behaviour of men seems to be different from women's, and therefore, interventions aiming at optimising men's health might be prioritised. Finally, spouses have a great influence on eating habits, why they should be involved in nutritional counselling.

RELEVANCE TO CLINICAL PRACTICE

This study provides important and relevant knowledge about patients' lacking knowledge about nutrition. When planning nutritional measures, whether it is promoting healing after heart surgery or preventing progression of arteriosclerosis, the study contributes with suggestions as to which factors should be considered in this process-men's health behaviour and spouses' influence on dietary habits in the household.