Assistance at mealtimes in hospital settings and rehabilitation units for patients (>65 years) from the perspective of patients, families and healthcare professionals: A mixed methods systematic review

Identifying solutions to minimize meal tray waste: A mixed-method approach

BACKGROUND & AIMS

Over $150,000 are lost annually due to meal tray waste in a large hospital in the United States. This study aims to explore the root causes of meal tray waste within a decentralized foodservice model and strategies to mitigate waste.

METHODS

A mixed methods sequential explanatory design was used by first identifying hospital units high and low in meal tray waste using recorded food management data from January 2021 through September 2022, then conducting observations, mobile-interviews (n = 16), and in-depth interviews with hospital foodservice staff (n = 6) and nurses (n = 6) in each unit. Lastly, hospital and topic experts (n = 10) were engaged in strategizing solutions to reduce meal tray waste.

RESULTS

Findings indicate meal tray waste is increased when patients discharge and when standard trays (i.e., also known as house trays, which include items not requested by patients) are provided. Meal tray waste points to the unpredictability in a hospital that often arises due to patient circumstances, lack of coordination between nursing and foodservice staff, patients' food preferences, and the need for system and workflow improvements in a decentralized foodservice model.

CONCLUSIONS

Findings highlight considerations that may be applicable across diverse medical institutions seeking to reduce meal tray waste. Hospitals should choose the best foodservice model that suits their institution to manage operations efficiently, focusing on reducing waste, cost optimization, patient satisfaction, and sustainability.

Feeding Assistance Skill Score: development and verification of reliability and validity

PURPOSE

Feeding assistance should be safe and improve the assisted individual's ability to feed, yet objective tools for evaluating these skills are lacking. This study focuses on developing a tool for assessing feeding assistance skills.

METHODS

A group consisting of 25 experts employed the Delphi method to achieve a consensus on the essential items necessary for assessing feeding assistance skills. Subsequently, a draft score using a three-point scale was developed. To test the reliability of the draft scores, a group of 20 patients and 20 nurses was matched to record a meal assistance scene, which were independently evaluated by three raters. We computed the AC1 statistic to assess both intra- and inter-rater reliability, and further examined correlations between the Feeding Assistance Skill Score (FASS) scores and outcome items to verify validity.

RESULTS

Initially, an 18-item draft score was generated using the Delphi method. Subsequently, seven items were omitted from the intra- or inter-rater reliability analysis. Furthermore, after discussion, researchers removed one item that assessed food cognition, because the agreement score between the two items was 91%. Finally, the 10-item FASS was developed, showing a correlation with dietary intake upon validation.

CONCLUSIONS

We successfully developed a scoring system for peer evaluation of feeding assistance skills. Future studies should aim to validate the FASS. The implementation of the FASS aims to assess the effectiveness of feeding assistance training and care quality, potentially improving safety and satisfaction for those receiving feeding assistance.

Exploring hospital mealtime experiences of older inpatients, caregivers and staff using photovoice methods

AIM

To gather and understand the experience of hospital mealtimes from the perspectives of those receiving and delivering mealtime care (older inpatients, caregivers and staff) using photovoice methods to identify touchpoints and themes to inform the co-design of new mealtime interventions.

METHODS

This study was undertaken on acute care wards within a single metropolitan hospital in Brisbane, Australia in 2019. Photovoice methods involved a researcher accompanying 21 participants (10 older patients, 5 caregivers, 4 nurses and 2 food service officers) during a mealtime and documenting meaningful elements using photographs and field notes. Photo-elicitation interviews were then undertaken with participants to gain insight into their experience. Data were analysed using inductive thematic analysis, involving a multidisciplinary research team including a consumer.

RESULTS

Themes were identified across the three touchpoints: (1) preparing for the meal (the juggle, the anticipation), (2) delivering/receiving the meal (the rush, the clutter and the wait) and (3) experiencing the meal (the ideal, pulled away and acceptance). Despite a shared understanding of the importance of meals and shared vision of 'the ideal' mealtime, generally this was a time of tension, missed cares and dissatisfaction for staff, patients and caregivers. There was stark contrast in some aspects of mealtime experience, with simultaneous experiences of 'the rush' (staff) and 'the wait' (patients and caregivers). There was an overwhelming sense of acceptance and lack of control over change from all.

CONCLUSIONS

This study identified themes during hospital mealtimes which have largely gone unaddressed in the design of mealtime interventions to date. This research may provide a framework to inform the future co-design of mealtime interventions involving patients, caregivers and multidisciplinary staff, centred around these key touchpoints.

PRACTICE IMPLICATIONS

Mealtimes are experienced differently by patients, caregivers, nurses and food service officers across three key touchpoints: preparing for, delivering/receiving and experiencing the meal. Improving mealtime experiences therefore necessitates a collaborative approach, with co-designed mealtime improvement programs that include specific interventions focusing each touchpoint. Our data suggest that improvements could focus on reducing clutter, clarifying mealtime roles and workflows and supporting caregiver involvement.

IMPACT

What problem did the study address? Mealtimes are the central mechanism to meet patients' nutritional needs in hospital; however, research consistently shows that many patients do not eat enough to meet their nutritional requirements and that they often do not receive the mealtime assistance they require. Interventions to improve hospital mealtimes have, at best, shown only modest improvements in nutritional intake and mealtime care practices. Gaining deeper insight into the mealtime experience from multiple perspectives may identify new opportunities for improvement. What were the main findings? Patients, caregivers and staff have shared ideals of comfort, autonomy and conviviality at mealtimes, but challenges of complex teamwork and re-prioritisation of mealtimes in the face of prevailing power hierarchies make it difficult to achieve this ideal. There are three discrete touchpoints (preparing for, delivering/receiving and experiencing the meal) that require different approaches to improvement. Our data suggests a need to focus improvement on reducing clutter, clarifying mealtime roles and workflows and supporting caregivers. Where and on whom will the research have an impact? The research provides a framework for multidisciplinary teams to begin co-designing improvements to mealtime care to benefit patients, caregivers and staff, while also providing a method for researchers to understand other complex care situations in hospital.

REPORTING METHOD

This manuscript is written in adherence with the Standards for Reporting Qualitative Research.

PATIENT OR PUBLIC CONTRIBUTION

Patients and caregivers were involved in the conception and design of the study through their membership of the hospital mealtime reference group. A consumer researcher (GP) was involved in the team to advise on study conduct (i.e. recruitment methods and information), data analysis (i.e. coding transcripts), data interpretation (i.e. review and refinement of themes) and manuscript writing (i.e. review and approval of final manuscript).

Nursing Home Organization Mealtimes and Staff Attitude Toward Nutritional Care: A Multicenter Observational Study

OBJECTIVES

The aims of this study were to investigate the practices of registered nurses and nurse aides at mealtimes in nursing homes (NHs) and to evaluate the attitudes of health care staff toward the nutritional care of older people.

DESIGN

This is a multicenter cross-sectional study.

SETTING AND PARTICIPANTS

The study involved a convenience sample of NH health care staff: physicians, registered nurses, and nurse aides.

METHODS

Data were collected on characteristics of the dining environment, organizational and nutritional care practices, staff-resident ratio, and staff activities during meals, using 2 questionnaires and staff attitudes were assessed with Staff Attitudes to Nutritional Nursing Care Geriatric Scale (SANN-G). Total score ranges from 18 to 90 points, with the following cutoffs: ≥72, positive attitude; ≤54, negative; and 55-71 points, neutral attitude.

RESULTS

A total of 1267 workers from 29 NHs in northern Italy participated in the study. The most common nutritional assessment tool used by nurses was the Malnutrition Universal Screening Tool. A median of 4.0 and 4.2 people (family caregivers, volunteers and staff) were present for feeding support, respectively, at lunch and dinner. A median of 2.5 and 2.0 staff members at lunch and at dinner, respectively, fed residents. Overall, 1024 health care workers responded to SANN-G of which 21.9% showed a negative attitude, 57.2% neutral, and 20.9% a positive attitude. Nurse aides (190/714) showed worse attitudes compared with registered nurses (20/204) and physicians (2/36); differences were statistically significant. Overall, the best attitudes were toward "habits," "interventions," and "individualization" of nutritional care. Staff who had received nutritional training (29.2%) had best attitudes.

CONCLUSIONS AND IMPLICATIONS

The results suggest that NHs should ensure adequate staff-resident ratio during meals, involving trained volunteers and relatives. Moreover, health professionals' knowledge and attitude toward nutritional care should be improved through continuous training.

A Conceptual Study on Characterizing the Complexity of Nutritional Interventions for Malnourished Older Adults in Hospital Settings: An Umbrella Review Approach

INTRODUCTION

Malnutrition is a widespread and intricate issue among hospitalized adults, necessitating a wide variety of nutritional strategies to address its root causes and repercussions. The primary objective of this study is to systematically categorize nutritional interventions into simple or complex, based on their resource allocation, strategies employed, and predictors of intervention complexity in the context of adult malnutrition in hospital settings.

METHODS

A conceptual evaluation of 100 nutritional intervention studies for adult malnutrition was conducted based on data from a recent umbrella review (patient population of mean age > 60 years). The complexity of interventions was categorized using the Medical Research Council 2021 Framework for Complex Interventions. A logistic regression analysis was employed to recognize variables predicting the complexity of interventions.

RESULTS

Interventions were divided into three principal categories: education and training (ET), exogenous nutrient provision (EN), and environment and services (ES). Most interventions (66%) addressed two or more of these areas. A majority of interventions were delivered in a hospital (n = 75) or a hospital-to-community setting (n = 25), with 64 studies being classified as complex interventions. The logistic regression analysis revealed three variables associated with intervention complexity: the number of strategies utilized, the targeted areas, and the involvement of healthcare professionals. Complex interventions were more likely to be tailored to individual needs and engage multiple healthcare providers.

CONCLUSIONS

The study underlines the importance of considering intervention complexity in addressing adult malnutrition. Findings advocate for a comprehensive approach to characterizing and evaluating nutritional interventions in future research. Subsequent investigations should explore optimal balances between intervention complexity and resource allocation, and assess the effectiveness of complex interventions across various settings, while considering novel approaches like telehealth.

Exploring consumer beliefs about novel fortified foods: A focus group study with UK-based older and younger adult consumers

Consuming 'nutritionally-enhanced' food products (including those that are fortified or enriched to deliver nutritional and functional properties) may help to improve overall diet quality and combat risks associated with malnutrition. However, fortification can negatively impact consumer acceptance, particularly where expected sensory properties of 'delivery' foods are affected by target ingredients. Here, we explored factors influencing consumer acceptability for six novel food products that had been fortified, including both savoury and sweet meal components (e.g., high protein dumplings, probiotic yoghurt drink). In person focus groups (25 consumers aged between 22 and 76 years old) were conducted with two stages; firstly, participants completed a blind taste test of products without awareness of fortification. Secondly, participants discussed products with awareness of additional ingredients and food properties. Reflexive thematic analysis showed that liking of sensory properties differed between foods, but informing participants about the fortification of products highlighted potential trade-offs between taste, health, price, and familiarity. Though taste and texture were generally prioritised by participants, positive perceptions of health benefits increased consumer willingness to buy, whilst both cost and uncertainty about product use were potential barriers. Trust of information was a key concern for labelling and product claims. These results highlight product features that may be optimised to support the success of fortified foods. Greater transparency when building product brands and improving consumer knowledge of fortification may also be important for longer-term consumer acceptance.

Improving nutrition care and diet intake for hospitalised older people at risk of malnutrition through a nurse-driven mealtime assistance bundle

BACKGROUND

Poor dietary intake is common in hospitalised older people. A targeted mealtime intervention is needed to improve nutrition care and dietary intake, especially for those at risk of malnutrition.

OBJECTIVES

This quality improvement project designed, implemented and evaluated a mealtime assistance bundle consisting of care measures driven by the hospital nursing team. The aims were to improve the mealtime care process to promote dietary intake of the hospitalised older people and to improve nursing staff's knowledge, attitude and practice in malnutrition.

METHODS

This project adopted a pre-post design, targeting older people aged 65 years and above, who were admitted to a general medical unit in a regional hospital in Singapore. A mealtime assistance bundle consisting of seven care measures, using the acronym CANFEED, was implemented for older adults at risk of malnutrition. Outcome measures on the amount of dietary intake during meals through chart reviews and surveys of nursing staff using Malnutrition Knowledge, Attitudes and perceived Practices (M-KAP) questionnaire were performed before and after implementation.

RESULTS

There were fewer older adults with poor intake in the post-implementation group than the pre-implementation group. Among those at risk of malnutrition, older adults in the post-implementation group had higher average intake of all provided meals as well as the protein-dense main dish. Significant improvements were noted in the total scores rated by the nursing staff in both the Knowledge-Attitude subscale and Practice subscale of the M-KAP questionnaire.

CONCLUSIONS

Integrating a nurse-driven mealtime assistance bundle into usual care may have positive outcomes on nutritional intake of hospitalised older people at risk of malnutrition, and on knowledge, attitude and practice of hospital nurses in nutrition care.

IMPLICATIONS FOR PRACTICE

Nurses play a critical role in nutrition care for hospitalised older people. Continuing efforts to improve nutritional intake of hospitalised older people should focus on staff education, building a multidisciplinary food-promoting culture and patient, family and community empowerment. More efficient clinical processes incorporating information technology with the EMR to support better nutrition care of the hospitalised older people are needed.

An Umbrella Review and Meta-analysis of Interventions, Excluding Enteral and Parenteral Nutrition, Initiated in the Hospital for Adults with or at Risk of Malnutrition

BACKGROUND

Multiple systematic reviews and meta-analyses (SRMAs) on various nutritional interventions in hospitalized patients with or at risk of malnutrition are available, but disagreements among findings raise questions about their validity in guiding practice.

OBJECTIVES

We conducted an umbrella review (a systematic review of systematic reviews in which all appropriate studies included in SRMAs are combined) to assess the quality of reviews, identify the types of interventions available (excluding enteral and parenteral nutrition), and re-analyze the effectiveness of interventions.

METHODS

The databases MEDLINE/PubMed, CINAHL, Embase, The Cochrane Library, and Google Scholar were searched. AMSTAR-2 was used for quality assessment and GRADE for certainty of evidence. Updated meta-analyses with risk of bias (ROB) by Cochrane ROB 2.0 were performed. Pooled effects were reported as relative risk (RR), with zero-events and publication bias adjustments, and trial sequential analysis (TSA) performed for mortality, readmissions, complications, length of stay, and quality of life.

RESULTS

A total of 66 randomized controlled trials were cited by the 19 SRMAs included in this umbrella review, and their data extracted and analyzed. Most clinical outcomes were discordant with variable effect sizes in both directions. In trials with low ROB, interventions targeting nutritional intake reduce mortality at 30 d (15 studies, n: 4156, RR: 0.72, 95% CI: 0.55, 0.94, P: 0.02, I2: 6%, Certainty: High), 6 mo (27 studies, n: 6387, RR: 0.81, 95% CI: 0.71, 0.92, P = 0.001, I2: 4%, Certainty: Moderate), and 12 mo (27 studies, n: 6387, RR: 0.80, 95% CI: 0.67, 0.95, P: 0.01, I2: 33%, Certainty: Moderate), with TSA verifying an adequate sample size and robustness of the meta-analysis.

CONCLUSION

Existing evidence is sufficient to show that nutritional intervention is effective for mortality outcomes at 30 d, 6 mo, and 12 mo. Future clinical trials should focus on the effect of nutritional interventions on other clinical outcomes.

TRIAL REGISTRATION NUMBER

The protocol is registered on PROSPERO (CRD42022341031).

Indirect Nutrition and Mobility Risks during Hospitalization: An Architectural Perspective on the nutritionDay Study Findings

Nutrition and mobility risks include complex and interrelated physiological, medical, and social factors. A growing body of evidence demonstrates that the built environment can affect patients' well-being and recovery. Nevertheless, the relationship between the built environment, nutrition, and mobility in general hospitals is largely unexplored. This study examines the implications of the nutritionDay study's results for the architectural design of hospital wards and nutrition environments. This one-day annual cross-sectional study uses online questionnaires in 31 different languages to collect ward-specific and patient-specific variables. The main findings relevant to the design of hospital wards were: (1) 61.5% of patients (n = 48,700) could walk before hospitalization and (2) this number dropped to 56.8% on nutritionDay (p < 0.0001), while the number of bedridden patients increased from 6.5% to 11.5% (p < 0.0001), (3) patients who needed more assistance had a much longer mean LOS than mobile patients, (4) mobility was associated with changes in eating, and (5) 72% of units (n = 2793) offered additional meals or snacks, but only 30% promoted a positive eating environment. The built environment may indirectly affect hospitalized patients' mobility, independence, and nutritional intake. Possible future study directions are suggested to further investigate this relationship.

Individual-Level Variables Associated with Self-Efficacy in Nutritional Care for Older People among Italian Nurses: A Multicenter Cross-Sectional Study

Malnutrition in older people is still an unsolved issue. Clinical nurses have a key role in malnutrition prevention. This study aims to describe the individual-level variables associated with self-efficacy in nutrition care for older adults among nurses. A cross-sectional descriptive observational study was performed involving nurses from four northern Italy hospitals. The self-efficacy scale for nursing nutrition care (SE-NNC) and Multiple linear regression (MLR) models were used, enrolling 305 nurses. The mean SE-NNC total score was 53.3 ± 19.7. Considering the three dimensions of the SE-NNC, mean scores were 45.9 ± 21.7 for boosting knowledge, 55.4 ± SD = 20.3 for assessment and evidence utilization, and 57.7 ± 21.1 for care delivery. To be a younger nurse, working in a chronic care setting, and being male were associated with a higher level of self-efficacy, both considering the SE-NNC total score and its dimensions. Working in acute care settings and being an older nurse was associated with lower nursing self-efficacy in nutrition care for older adults.

Experiences of mealtime assistance delivered by volunteers: an extended literature review

Trained mealtime volunteers are ideally situated to provide mealtime assistance to older patients in general hospital settings. Older patients are at risk of becoming undernourished and dehydrated while in hospital as a result of various factors, such as cognitive impairment and lack of mealtime assistance. This article details an extended literature review that was conducted to explore the lived experiences of older patients, staff, relatives and volunteers of mealtime assistance provided by volunteers. The findings suggest that continual use of mealtime volunteers in practice could improve the quality of care. Mealtime volunteers could be educated on the importance of communicating information pertaining to patients' food and fluid intake to enhance patient monitoring. Furthermore, additional training for mealtime volunteers could be streamlined and standardised to improve patient care and safety.

Dialogue is a prerequisite for the nurse-patient relationship in nutritional care: A secondary analysis using the fundamentals of care framework

BACKGROUND

Providing good nutritional care is complex as it goes beyond assessing and ensuring the patients' dietary needs. So far, nutritional research has mainly focused on establishing evidence for the nutritional treatment, while less attention has been on the complexity of providing nutritional care. The Fundamentals of Care (FoC) describes five elements (focus, knowledge, anticipate, evaluate and trust) essential for establishing a nurse-patient relationship as a foundation for quality care. By studying how these elements shape nutritional care and dialogue, we can explore and describe the complexity of nutritional care.

AIM

By using the FoC framework as an analytic framework, this study explores how the nurse-patient relationship shapes the nutritional care of orthopaedic patients.

METHOD

This study is a secondary analysis using deductive content analysis of interviews with patients undergoing major orthopaedic surgery, nursing staff and observations of interactions between nursing staff and patients. The core dimension of the FoC framework, 'Establishment of relationship,' was used as an analytic framework.

RESULT

The nurses perceived serving meals and providing nutritional supplements as an essential part of the nutritional care. Still, the nutritional care was organised as a routine task to be less time-consuming. Appropriate care was initiated when the nursing staff explored patients´ food preferences. When the nursing staff failed to familiarise themselves with the patient's preferences, the patients interpreted nutritional care as unrelated to their needs, resulting in a lack of trust.

CONCLUSION

The need for efficiency within nutritional care must not compromise the patients' need for dialogue with the nurse. Establishing a trusting relationship between nurses and patients prevents nutritional care from becoming a routine task unrelated to the patients' needs.

Managing ongoing swallow safety through information-sharing: An ethnography of speech and language therapists and nurses at work on stroke units

BACKGROUND

Speech and language therapists and nurses need to work together to keep patients with swallowing difficulties safe throughout their acute stroke admission. Speech and language therapists make recommendations for safe swallowing following assessment and nurses put recommendations into practice and monitor how patients cope. There has been little research into the everyday realities of ongoing swallow safety management by these two disciplines. Patient safety research in other fields of healthcare indicates that safety can be enhanced through understanding the cultural context in which risk decisions are made.

AIMS

To generate new understanding for how speech and language therapists (SLTs) and nurses share information for ongoing management of swallows safety on stroke units.

METHODS & PROCEDURES

An ethnographic methodology involving 40 weeks of fieldwork on three stroke wards in England between 2015 and 2017. Fieldwork observation (357 h) and interviews with 43 members of SLT and nursing staff. Observational and interview data were analysed iteratively using techniques from the constant comparative method to create a thematically organized explanation.

OUTCOMES & RESULTS

An explanation for how disciplinary differences in time and space influenced how SLT and nursing staff shared information for ongoing management of swallow safety, based around three themes: (1) SLTs and nurses were aligned in concern for swallow safety across all information-sharing routes; however, (2) ambiguity was introduced by the need for the information contained in swallowing recommendations to travel across time, creating dilemmas for nurses. Patients could improve or deteriorate after recommendations were made and nurses had competing demands on their time. Ambiguity had consequences for (3) critical incident reporting and relationships. SLTs experienced dilemmas over how to act when recommendations were not followed.

CONCLUSIONS & IMPLICATIONS

This study provides new understanding for patient safety dilemmas associated with the enactment and oversight of swallowing recommendations in context, on stroke wards. Findings can support SLTs and nurses to explore together how information for ongoing dysphagia management can be safely implemented within ward realities and kept up to date. This could include considering nursing capacity to act when SLTs are not there, mealtime staffing and SLT 7-day working. Together they can review their understanding of risk and preferred local and formal routes for learning from it.

WHAT THIS PAPER ADDS

What is already known on the subject It is known that information to keep swallowing safe is shared through swallowing recommendations, which are understood to involve a balance of risks between optimizing the safety of the swallow mechanism and maintaining physiological and emotional health. There is increasing appreciation from patient safety research, of the importance of understanding the context in which hospital staff make decisions about risk and patient safety. What this paper adds to existing knowledge The paper provides new empirical understanding for the complexities of risk management associated with SLT and nursing interactions and roles with respect to ongoing swallow safety. What are the potential or actual clinical implications of this work? Findings can underpin SLT and nurse discussion about how swallow safety could be improved in their own settings.

Investigating the patient food experience: Understanding hospital staffs' perspectives on what leads to quality food provision in Ontario hospitals

BACKGROUND

Food quality influences patient food satisfaction, which may subsequently affect food intake and recovery, influencing hospital costs. The present qualitative study aimed to gain an understanding of hospital staff/volunteers experiences of serving food in Ontario hospitals, perceptions of food quality and challenges to quality food provision.

METHODS

Sixteen Ontario hospitals participated. Semi-structured interviews (n = 64 participants) and focus groups (n = 24; 150 participants) were conducted. Transcripts were analysed using inductive thematic analysis.

RESULTS

Four themes emerged: (1) Providing Good Quality Food (e.g., attributes that comprise the construct of meal quality, patients' expectations and desires from meals); (2) Individualising the Food and Mealtime Experience (e.g., processes to identify and cater to patients' needs and preferences); (3) Acknowledging Organisational Constraints (e.g., staffing, budget, etc.); and (4) Innovating Beyond Constraints (e.g., identifying innovation within potential modifiable and unmodifiable organisational constraints).

CONCLUSIONS

Serving meals in hospital is complex because of organisational and patient factors; however, current efforts to serve quality food despite these complexities were uncovered in our investigation. Discussions highlighted current practices that promote food quality and strategies for improvement. Improving food quality and the hospital meal experience can support food intake and patient outcomes, as well as reduce waste and hospital associated costs. The findings can be used to support quality improvement measures aiming to serve high quality food that meets patients' expectations and nutritional needs.

Canadian Hospital Food Service Practices to Prevent Malnutrition

Purpose: The study aimed to determine current practice, barriers, and enablers of foodservices in Canadian hospitals relative to guiding principles for best practice to prevent malnutrition.Methods: Foodservice managers completed a 55-item cross-sectional, online survey (closed- and open-ended questions).Results: Survey responses (n = 286) were from diverse hospitals in all Canadian regions; 56% acute care; 13% had foodservices contracted out; and 60% had a reporting structure combined with clinical nutrition. Predominantly, foodservice systems were 43% in-house versus 41% pre-prepared, 46% cook-serve food production, 64% meals assembled centrally (on-site), and 40% non-selective menus with limited opportunities for patient choice in advance or at meals. The "regular menu" (44%) was most commonly served as 3 meals, no snacks at specific times. Energy and protein-dense menus were available, but not widespread (9%). Daily energy targets ranged from 1200 to 2400 kcal and 32% of respondents viewed protein targets as important. The number of therapeutic diets varied from 2 to 150.Conclusions: Although hospital foodservice practices vary across Canada, the survey results demonstrate gaps in national evidence-based practices and an opportunity to formalize guiding principles. This work highlights the need for standards to improve practice through patient-centered, foodservice practices focused on addressing malnutrition.

Nutritional care of older people: Investigating nurses' attitudes in medical and surgical units

Background: Malnutrition in older people in hospitals leads to negative patient outcomes. Nurses often underestimate the problem, showing negative attitudes.Aims: To compare nurses' attitudes towards nutritional care of older people in surgical and medical wards. Design: Multicentre cross-sectional survey, conducted in January 2015.Methods: All nurses in surgical and medical wards in 10 hospitals in northern Italy were surveyed using the Staff Attitudes to Nutritional Nursing Care Geriatric Scale (SANN-G scale).Results: 799 out of 1,293 questionnaires were returned (61.8%). 23.2% (185) had a negative attitude, 56.6%(452) had a neutral attitude, and 20.2%(162), positive. Multivariate analysis showed no significant differences between medical and surgical wards (OR = 1.298; CI95% = .883-1.886, p = .18).Conclusions: It is necessary to raise nurses' awareness of poor nutritional care in both settings. More research is needed within the barriers to nutritional care.Impact statement: Strategies such as education and more clearly defined nutritional responsibilities are needed to improve nurses' attitudes.

The role of non-dietetic healthcare professionals in managing interventions among adults at risk of malnutrition: A systematic review

BACKGROUND

Malnutrition is estimated to affect over three million people in the UK resulting in serious consequences on both the individuals' health and healthcare system. While dietitians are uniquely qualified to provide nutritional interventions, they have one of the lowest workforce numbers in the NHS making it difficult to tackle the malnutrition burden alone. Thus, innovative ways of working are needed. Non-dietetic health care professionals are often involved in the identification, assessment and treatment of malnutrition and research has shown benefits of their involvement in identification and management of nutritional issues, however their role in delivering nutritional interventions has not yet been evaluated. The aim of this systematic review is to collate evidence on the potential roles and effectiveness of non-dietetic healthcare professionals in providing nutritional interventions and their impact on patient-centred outcomes in malnourished or at-risk individuals.

METHODS

Three electronic databases were searched on 10th October 2019. Titles and abstracts were initially screened, followed by full texts, against inclusion criteria and included/excluded studies by two authors independently. Data were extracted and tabulated where possible and grouped according to type of intervention and outcomes. Risk of bias and quality of evidence was assessed using the GRADE approach. Data were combined in the form of a narrative synthesis.

RESULTS

Eighteen eligible studies were included; five involved feeding assistance, 10 involved implementing individualised nutrition monitoring or care plans and three were multi-factorial interventions. Interventions took place in a range of settings including hospital and long term care facilities. Very low and low quality evidence suggests that non-dietetic HCP interventions may improve weight, percent of patients reaching estimated energy requirements, quality of life, falls and frailty rate and patient satisfaction. Very low quality evidence suggests that non-dietetic HCP interventions may not improve mid-arm circumference, energy or protein intake, activities of daily living, handgrip strength or length of hospital stay. Low quality evidence suggests that non-dietetic HCP interventions have no effect on mortality.

CONCLUSIONS

A lack of good quality evidence on the effectiveness of non-dietetic HCP delivered interventions on the management of malnutrition in adults makes it difficult to draw conclusions. However, this review has highlighted the types of interventions and potential roles of non-dietetic HCPs, providing a groundwork for further high-quality research such as feasibility studies in this area, for the effective management of malnutrition within clinical and community practice.

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.

Older Adults' and Their Informal Caregivers' Experiences and Needs regarding Nutritional Care Provided in the Periods before, during and after Hospitalization: A Qualitative Study

To enhance prevention and treatment of malnutrition in older adults before, during and after hospitalization, deeper understanding of older adults' and informal caregivers' perspective on nutritional care is important. One-time in-depth interviews were conducted with 15 older adults who had been discharged from hospital, and seven informal caregivers. We explored their experiences and needs regarding nutritional care provided in the periods before, during and after hospitalization. Five themes emerged from the data: (1) dietary intake, (2) food service during hospitalization, (3) nutrition-related activities, (4) whose job it is to give nutritional care, and (5) competing care priorities. Further, several opinions about nutritional issues were identified. Older adults and informal caregivers did not always experience optimal nutritional care. When discussing nutritional care, they mainly focused on the in-hospital period. When providing nutritional care and developing guidelines, older adults' and informal caregivers' perspective on nutritional care should be incorporated. Here, the periods before, during and after hospitalization should be taken into account equally.

Protein-energy malnutrition in older Australians: A narrative review of the prevalence, causes and consequences of malnutrition, and strategies for prevention

ISSUE ADDRESSED

Protein-energy malnutrition (PEM) is a condition of involuntary weight and muscle loss caused by inadequate nutritional intake. In Australia, it is predominantly associated with chronic diseases, as are common in the older population. Given the ageing population of Australia, and the poor outcomes associated with PEM, there is a need to identify the contributing factors, and to explore strategies to prevent PEM.

METHODS

Two databases were searched for pertinent keywords, including malnutrition, Australia and elderly, with relevant articles selected for inclusion. The citations and references of these articles were also searched for further articles.

RESULTS

PEM is associated with increasing age and institutionalisation. The contributing factors are multifactorial, and include physiological, pathophysiological and structural causes. PEM is a significant public health issue for Australia, in terms of its consequences on both quality of life for older adults, and the burden on the healthcare system. However, there are strategies that can be implemented at the community, organisation and policy level to prevent PEM.

CONCLUSION

PEM is a common problem for older Australians, and this has important physiological and public health consequences, especially in the context of the ageing Australian population. However, there is significant scope for preventing PEM. SO WHAT?: Readers can be advised that PEM is a significant public health issue that will increase in importance as the population continues to age. It is important that communities, organisations and governments develop strategies to prevent PEM.

Meals beyond the bedside: An ethnographic exploration of staffs' perspectives and experiences of communal dining in subacute care

Communal dining offers multiple benefits for hospital patients, yet dining rooms may be underutilized in practice. This study aimed to understand and explore staffs' perspectives and experiences of communal dining in subacute care, and the impacts on staff mealtime practice. Using qualitative, ethnographic methodology, 94 hours of fieldwork were conducted across two subacute care wards. Participants were staff involved in nutrition care or present on the ward at mealtimes. Ninety-one semistructured and ethnographic interviews were conducted with 59 staff, and 54 episodes of observation captured more than 190 staff. Interviews and field notes were thematically analyzed using an inductive approach. Three themes were identified: (i) benefits to patients; (ii) logistical and practical challenges; and (iii) supportive cultural factors. While staff recognized how communal dining benefited patients, logistical and practical challenges impacted their ability to facilitate it in practice. Healthcare organizations seeking to embed communal dining into the mealtime routine should recognize that clear delineation of staff roles and responsibilities, and cultural change involving normalization, setting expectations, and collective advocacy may be needed to optimize benefits for patients.

Patient-reported experiences of mealtime care and food access in acute and rehabilitation hospital settings: a cross-sectional survey

BACKGROUND

Nutrition and mealtime interventions can improve nutritional intake amongst hospital inpatients; however, patient-reported experience is rarely considered in their development and evaluation. The present study aimed to measure patient-reported food and mealtime experience to evaluate and inform continuous quality improvement of hospital nutrition care.

METHODS

A cross-sectional survey with inpatients in seven acute care and rehabilitation wards was conducted. A 27-item validated questionnaire measured five domains of patient experience: food choices, organisational barriers, feeling hungry, physical barriers to eating and food quality. Responses were summarised descriptively and compared between settings (acute versus rehabilitation), patient demographics (age, gender) and time in hospital.

RESULTS

Responses from 143 participants (mean age 67 years, 57% male, 28% rehabilitation, median 6 days into hospitalisation) showed that 10% or fewer respondents reported difficulties with food choices, feeling hungry or food quality. The most common difficulties were opening packets (36%), insufficient menu information provided (29%), being interrupted by staff when eating (28%), being disturbed when eating (27%), being in an uncomfortable position when eating (24%) and difficulty reaching food (21%). There were no significant differences in domain patterns by sex, age group or time in hospital. Organisational barriers were reported less frequently amongst rehabilitation participants compared to acute care (P = 0.01).

CONCLUSIONS

This survey highlights areas of positive patient-reported experience with nutrition care and suggests that local improvement efforts should focus on physical assistance needs and organisational barriers, especially in acute care wards. The questionnaire may be useful for informing and evaluating systematic nutrition care improvements.

Mealtime care and dietary intake in older psychiatric hospital inpatient: A multiple case study

AIMS

To investigate the energy and protein adequacy of meals and dietary intake of older psychiatric inpatients and describe patient and mealtime factors potentially influencing intake.

DESIGN

Multiple case studies.

METHODS

Psychiatric inpatients aged 65 years and older, admitted to a single mental health ward during the 6-week study period (April-May 2019) were eligible for inclusion. Dietary intake was observed for two consecutive days each week (minimum four observation days). Visual plate waste methods were used to estimate patients' dietary intake at mealtimes, with energy and protein intake calculated using known food composition data and compared with estimated requirements. Medical records were reviewed weekly to collect information on potential factors related to intake and mealtime care. Data from all sources were first summarized in a case record for within-case analysis using descriptive statistics, followed by cross-case analysis.

RESULTS

Eight participants (five men, age 67-90 years, two underweight and one overweight, and four requiring some mealtime assistance) had 5-12 days of observation data recorded. Three met their estimated daily energy and protein requirements throughout the study period, while the remaining five participants did not. The main barriers identified as contributing to insufficient energy and protein intake were as follows: missing meals (asleep and treatment); inadequate food provided (insufficiency of the standard hospital menu); and need for increased mealtime assistance.

CONCLUSION

Poor dietary intake may be common among older psychiatric patients, suggesting that they may also need nursing and multidisciplinary nutrition care interventions shown to effectively prevent and treat malnutrition in other older inpatient groups.

IMPACT

Older psychiatric patients experience similar nutrition and mealtime issues to other older inpatients. This study highlights the need for nurses and the multidisciplinary team to ensure patients order and receive adequate food, especially when they miss meals and that they receive proactive mealtime assistance.

The perspectives of health professionals in Denmark on physical exercise and nutritional interventions for acutely admitted frail older people during and after hospitalisation

Frailty is associated with several negative health outcomes, such as readmissions to hospital. Physical exercise, including strength training and nutritional optimisation are essential parts of documented interventions for frail older people in preventing or minimising frailty. Further knowledge is necessary to ensure feasible and successful interventions encompassing both physical exercise and nutritional optimisation. The aim of this qualitative study was to investigate the perspectives of health professionals on which factors may affect interventions, including physical exercise and nutrition, for frail older people in relation to discharge after acute admission to hospital. Data were gathered in two semi-structured focus groups, totalling 11 health professionals working with frail older people in a Danish university hospital and a municipality. The sampling of participants was purposive and the interviews were facilitated by a semi-structured interview guide. Data were analysed applying a six-step data-driven thematic analysis. Findings showed that health professionals experienced working with nutritional optimisation and physical exercise within a frail older population as challenging, and they mostly used extrinsic motivation, such as incentives, deals or intensified messages, as external factors in their approaches as to affect specific behaviours. A discourse on the importance of activity- and functional training was prevalent, while diverging perspectives were present in relation to strength training, which was considered less feasible or meaningful in a community-dwelling setting. Organisational barriers such as communication between sectors and time limitations affected negatively the work of health professionals, as they hindered co-ordinated and adequate interventions from the health professionals. Findings and theory-based knowledge indicate that health professionals should work towards a person-centred approach, which includes goal-setting, to improve physical training and nutritional interventions for frail older people. Furthermore, health professionals may need more support in order to incorporate strength training in interventions. In addition to this, improved co-ordination between sectors is warranted.

Older patients' perspectives on mealtimes in hospitals: a scoping review of qualitative studies

The increasing age of populations throughout the world means that healthcare services are faced with new challenges, not least regarding the provision of food during hospital stay. There is a lack of knowledge of how hospital mealtimes are experienced by older patients, and so the aim of this article was to review current knowledge regarding mealtimes in hospitals from the perspectives of older patients. A literature search was performed using seven databases: PubMed, Web of Science, Scopus, Sociological Abstracts, SweMed+, ASSIA and CINAHL with no limits regarding publication date. The inclusion criteria were peer-reviewed articles in English or Swedish that used qualitative methods to examine older patients' (>65 years) mealtime experiences. The Five Aspect Meal Model (FAMM) served as a framework for understanding the complexity behind a mealtime experience. Qualitative content analysis was used as a guide when analysing the material. The search produced 415 studies, 14 of which were included in the review. The findings generated three main themes for understanding how older patients experience mealtimes while in hospital: (1) the food and the food service, (2) mealtime assistance and commensality during mealtimes and (3) the importance of retaining one's independence. The review also clearly indicated a shortage of studies that solely focus on older patients' experiences of their mealtime. More research is therefore needed to be fully able to understand the complex task of providing meals in hospitals.

Process of implementing and delivering the Prevention of Delirium system of care: a mixed method preliminary study

BACKGROUND

Delirium is a frequent complication of hospital admission among older people. Multicomponent interventions which can reduce incident delirium by ≈one-third are recommended by the National Institute of Health and Care Excellence. Currently, a standardised delirium prevention system of care suitable for adoption in the UK National Health Service does not exist. The Prevention of Delirium (POD) system of care is a theory informed, multicomponent intervention and systematic implementation process which includes a role for hospital volunteers. We report POD implementation and delivery processes in NHS hospital wards, as part of a feasibility study.

METHODS

A comparative case study design and participatory, multi-method evaluation was performed with sequential six month preparatory and six month delivery stages. Six wards in five hospitals in Northern England were recruited. Methods included: facilitated workshops; observation of POD preparatory activities; qualitative interviews with staff; collection of ward organisational and patient profiles; and structured observation of staff workload.

RESULTS

POD implementation and delivery was fully accomplished in four wards. On these wards, implementation strategies informed by Normalization Process Theory operated synergistically and cumulatively. An interactive staff training programme on delirium and practices that might prevent it among those at risk, facilitated purposeful POD engagement. Observation of practice juxtaposed to action on delirium preventive interventions created tension for change, legitimating new ways of organising work around it. Establishing systems, processes and documentation to make POD workable in the ward setting, enhanced staff ownership. 'Negotiated experimentation' to involve staff in creating, appraising and modifying systems and practices, helped integrate the POD care system in ward routines. Activating these change mechanisms required a particular form of leadership: pro-active 'steer', and senior ward 'facilitator' to extend 'reach' to the staff group. Organisational discontinuity (i.e. ward re-location and re-modelling) disrupted and extended POD implementation; staff shortages adversely affected staff capacity to invest in POD. Findings resulted in the development of 'site readiness' criteria without which implementation of this complex intervention was unlikely to occur.

CONCLUSIONS

POD implementation and delivery is feasible in NHS wards, but a necessary context for success is 'site readiness.'

Hospital Volunteering Experiences Suggest that New Policies are Needed to Promote their Integration in Daily Care: Findings from a Qualitative Study

OBJECTIVE

To explore Hospital Volunteers' (HVs) motivations and experiences, as well as the strategies they adopt to overcome challenging situations during volunteering and the needs they perceive.

METHODS

Eleven Italian HVs were purposively approached between January and July 2016, using face-to-face semi-structured interviews. The interviews were audio-recorded, transcribed verbatim and analysed using the descriptive phenomenological approach.

RESULTS

Hospital volunteering emerged as a complex experience characterised by five themes: (a) becoming a volunteer; (b) developing skills; (c) experiencing conflicting emotions; (d) overcoming role difficulties by enacting different resources and strategies; and (e) addressing emerging needs.

CONCLUSIONS

According to the findings, hospital policies aimed at promoting volunteer integration in daily care are needed and should be based on (a) a shared vision between the hospital and the volunteer associations regarding the HVs' role and skills; (b) the development of integrated models of care combining different workforces (i.e. professionals and volunteer staff); (c) appropriate training of HVs at baseline; (d) individualised continuous education pathways aimed at supporting HVs both emotionally and in the development of the required skills; and (e) tailored education that is directed to health-care staff aimed at helping them to value the service provided by HVs.

The effect of volunteers' care and support on the health outcomes of older adults in acute care: A systematic scoping review

Aim

To examine the available evidence on the effects of care and support provided by volunteers on the health outcomes of older adults in acute care services.

Background

Acute hospital inpatient populations are becoming older, and this presents the potential for poorer health outcomes. Factors such as chronic health conditions, polypharmacy and cognitive and functional decline are associated with increased risk of health care‐related harm, such as falls, delirium and poor nutrition. To minimise the risk of health care‐related harm, volunteer programmes to support patient care have been established in many hospitals worldwide.

Design

A systematic scoping review.

Methods

The review followed the PRISMA Extension for Scoping Reviews (PRISMA‐ScR) (File S1). Nine databases were searched (CINAHL, MEDLINE, EMBASE, Cochrane, Scopus, Web of Science, PubMed, ScienceDirect and JBI) using the following key terms: ‘hospital’, ‘volunteer’, ‘sitter’, ‘acute care’, ‘older adults’, ‘confusion’, ‘dementia’ and ‘frail’. The search was limited to papers written in English and published from 2002–2017. Inclusion criteria were studies involving the use of hospital volunteers in the care or support of older adult patients aged ≥ 65 years, or ≥ 50 years for Indigenous peoples, with chronic health conditions, cognitive impairment and/or physical decline or frailty, within the acute inpatient settings.

Results

Of the 199 articles identified, 17 articles that met the inclusion criteria were critically appraised for quality, and 12 articles were included in the final review.

Conclusions

There is evidence that the provision of volunteer care and support with eating and drinking, mobilising and therapeutic activities can impact positively upon patient health outcomes related to nutrition, falls and delirium. Further robust research is needed to determine the impact of volunteers in acute care and the specific care activities that can contribute to the best outcomes for older adults.

Relevance to clinical practice

Volunteers can play a valuable role in supporting care delivery by nurses and other health professionals in acute care services, and their contribution can improve health outcomes for older adults in this setting.

Acute stroke patients not meeting their nutrition requirements: Investigating nutrition within the enriched environment

BACKGROUND & AIMS

Malnutrition is common after stroke. We investigated the impact of environmental enrichment strategies on dietary intake and rates of malnutrition in an acute stroke unit.

METHODS

We performed a before-after study. In standard care, meals were delivered to participants' rooms whilst in the enriched environment, communal meals with assistance were offered and nutritional intake reminders were placed at the patient bedside. Nutrition supplementation was provided to both groups if indicated. Breakfast and lunch meals were directly observed while remaining intake was calculated using food charts. Nutrition requirements were calculated for energy (ratio method), protein (1 g/kg) and proportion of requirements met. Malnutrition was assessed using the Subjective Global Assessment and body weight. ANCOVA adjusting for stroke severity was used to determine between group differences. Stepwise multivariable logistic regression was performed to assess predictors of nutritional outcomes, adjusting for intervention group, demographic, clinical and baseline nutritional factors.

RESULTS

Neither standard care (n = 30, age 76.0yrs ± SD12.8) nor enriched environment (n = 30, age 76.7yrs ± SD12.1, p = 0.84) met daily requirements for energy (70.7% ± SD16.8 vs. 70.7% ± SD17.3, p = 0.94) or protein intake (73.2% ± SD18.6 vs. 69.8% ± SD17.3, p = 0.70). Mean body weight dropped: standard care 0.92 kg ± SD2.47 vs. enriched 0.64 kg ± SD3.12 (p = 0.53) and malnutrition increased: standard care 3.3%-26.6% vs. enriched 6.6%-13.3% (p = 0.07). Predictors of malnutrition on discharge in logistic regression models were: length of stay (p < 0.01) and protein (p < 0.01) or energy intake (p = 0.02).

CONCLUSIONS

Acute stroke patients were not meeting nutritional requirements and losing body weight. The enriched environment showed no effect on nutritional intake. Malnutrition was associated with lower energy and protein intakes and increased length of stay.

Health practitioner practices and their influence on nutritional intake of hospitalised patients

Objectives

In the hospital setting, poor dietary intake interacts with disease and represents a major and modifiable cause of malnutrition. Understanding barriers to adequate dietary intake is an important strategy to guide the development of interventions to improve nutrition intake. The aim of this study reported in this paper was to explore patient, family and health care professionals' perceptions of barriers to and enablers of adequate nutrition care and dietary intake of medical inpatients.

Methods

An exploratory qualitative study design incorporating group and individual interviews of patients (n = 14), their family members (n = 4), and health care professionals (n = 18) was undertaken. Participants were recruited pragmatically, using a mix of convenience and purposive sampling. A theoretically informed, semi-structured interview schedule was based on observations of practice and the Theoretical Domains Framework. Interviews were audio-recorded, transcribed verbatim and analysed inductively using a general inductive approach.

Results

Three key themes emerged from analysing participant interviews. Siloed approaches to nutrition care reflected the diverse range of health care professionals responsible for nutrition care but who often worked in isolation from their colleagues. Competing work priorities for nurses reflected the challenge in prioritise nutrition care which was often constrained because of other care needs or work-related pressures. Helping patients to eat highlighted that nurses were often the only health care professional who would provide assistance to patients at mealtimes and lack of available staff could negatively influence patients' nutrition intakes.

Conclusions

We have identified many complex and interrelated barriers which preclude adequate dietary intake in acute medical patients. These predominantly reflect issues inherent in the hospital culture and environment. Multi-faceted and sustainable interventions that support a facilitating nutrition culture and multidisciplinary collaboration, inclusive of patients and families, are needed to address these underlying barriers.

Swallowing function in advanced age

PURPOSE OF REVIEW

To present current literature regarding swallowing function in advanced age, including healthy ageing, dysphagia and trends in multidisciplinary team service delivery.

RECENT FINDINGS

Normative studies support swallowing efficiency but greater variability in healthy advanced age, through to 100 years old. Deviations from normative data and symptoms of dysphagia leading to aspiration or nutritional risk, imply swallowing disorder, rather than simply the ageing process. Quantitative and qualitative studies are emerging that promote management of swallow dysfunction for an ageing society, including innovative assessment, home treatment, swallowing exercise and optimized mealtimes.

SUMMARY

Current literature on swallowing function in advanced age provides multidisciplinary perspectives and initiatives, with clear commitment to improving quality of life for older adults. The diversity of the older population and serious consequences of swallowing difficulties calls for routine screening tools for swallowing impairment and malnutrition risk. Representation of 'oldest old' in future normative studies is essential to guide swallowing management in adults over 85 years old.

Exploring staff perceptions and experiences of volunteers and visitors on the hospital ward at mealtimes using an ethnographic approach

AIMS AND OBJECTIVES

To explore multiple perspectives and experiences of volunteer and visitor involvement and interactions at hospital mealtimes. In addition, to understand how the volunteer and visitor role at mealtimes is perceived within the hospital system.

BACKGROUND

Mealtime assistance can improve patients' food intake and mealtime experience. Barriers to providing mealtime assistance include time pressures, staff availability and inadequate communication. Volunteers and visitors can encourage and assist patients at mealtimes. There is a lack of evidence on the relationship between hospital staff, volunteers and visitors.

DESIGN

A qualitative, ethnographic approach.

METHODS

Sixty-seven hours of fieldwork were conducted on two subacute wards within an Australian healthcare network in 2015. Mealtime practices and interactions of hospital staff, volunteers and visitors were observed. Sixty-one staff, volunteers and visitors were interviewed in 75 ethnographic and semi-structured interviews. Data were inductively and thematically analysed.

RESULTS

Three key themes emerged as follows: "help"-volunteers and visitors were considered helpful when they assisted patients at mealtimes, supported well-being and aided staff-patient communication; "hindrance"-staff perceived visitors as negative presences when they inhibited patient progress and impacted staff work practices; and "reality of practice"-visiting hours, visitor engagement in patient therapy and communication between staff, volunteers and visitors were important practical considerations of mealtime involvement.

CONCLUSIONS

The findings show how and why volunteers and visitors can be helpful and unhelpful at hospital mealtimes on subacute wards. More research on the role and contribution of volunteers and visitors on hospital wards will inform future practice in healthcare settings.

RELEVANCE TO CLINICAL PRACTICE

This healthcare organisation should continue to encourage volunteer and visitor involvement at hospital mealtimes. More effort is needed to educate visitors about patients' therapeutic goals and the importance of nutrition. The working relationship between hospital staff, volunteers and visitors should be strengthened to improve nutritional care.

An integrative review: Developing and measuring creativity in nursing

OBJECTIVE

To analyze and synthesise the existing evidence on creativity in nursing.

DESIGN

An integrative review.

DATA SOURCES

A systematic search was conducted using seven English databases (PubMed, Science Direct, Web of Science, Cochrane, EBSCO, Wiley, and Medline) and the top three best Chinese databases (CNKI, Wanfang Data, and VIP).

REVIEW METHODS

The combined keywords, creativity and nursing/nurse, were used to search for relevant journal articles that were written in English or Chinese from January 1995 to December 2016. The components of articles, i.e. title, abstract, full-text and the cited reference, were screened, filtered, evaluated and recorded according to the PRISMA statements and Joanna Briggs Institute Checklists. Thematic analysis was performed to synthesise evidence from the full-texts of studies.

RESULTS

Fifteen quantitative and seven qualitative studies were included in this review. A joyful affective perspective enriched the conceptualization of creativity in nursing. Many intrinsic factors (e.g. learning styles, thinking styles, intrinsic passion, interest in nursing and achievement motivation) or extrinsic factors (mostly workplace problems and nurses' shortage) could influence nurses' and nursing students' creativity. Artistic expressions (e.g. painting, music, and pottery), self-directed learning and group/team work were reported to have a positive effect on creativity enhancement. None of existing instruments can adequately measure nurses' or nursing students' creativity.

CONCLUSIONS

The concept of creativity requires an explicit definition, which is essential to the development and evaluation of creativity in nursing education and practice. Many factors influencing nurses' and nursing students' creativity can be implemented to achieve positive outcomes through efforts at artistic expressions, self-directed learning and teamwork. An instrument with satisfactory psychometric properties should be available for monitoring creativity development among nurses and nursing students.