The impact of nutritional care on patient outcomes
Why getting people eating well can be the key to getting everything right
Why getting people eating well can be the key to getting everything right
Whether care relates to falls or sepsis, long-term conditions or trauma, mental health or learning disability, patient nutrition and hydration should be at the very heart of it.
But despite the importance of getting this right – and numerous policies and drives to improve nutritional care – it is still seen too often as no one’s direct job or responsibility.
‘Nutrition spans everything,’ says Claire Campbell, chair of the National Nurses Nutrition Group (NNNG). ‘Good nutrition is vital for patients at home, in hospital, and everywhere in between. But although there’s been progress, there is still a lot of variation.’
Extent of malnutrition
The figures tell their own story. According to Age UK, there are an estimated three million malnourished people in the UK at any one time, a third of whom are aged over 65.
BAPEN (the British Association for Parenteral and Enteral Nutrition) reports that around a third of older people are at risk of malnutrition when they enter hospital, and England's Care Quality Commission says almost one in five patients in hospital who need help to eat do not always get it.
‘When someone comes to hospital it’s an opportunity to assess them and make sure they get the hydration and nutrition they need to get better’
Alice Roe, programme manager for professionals and practice, Age UK
It’s an issue that should cause concern, says Alice Roe, programme manager for professionals and practice at Age UK. ‘There have been improvements, but there are still patients who do not get the support they need to eat and drink, and their health and well-being suffers.’
Often, it’s not the hospitals’ fault, she says. ‘People are at risk of malnutrition in the community – at home, or in a care home – and that’s what brings them into hospital. It’s not that hospitals aren’t feeding them. But when someone comes to hospital it’s an opportunity to assess them and make sure they get the hydration and nutrition they need to get better.’
This chimes with the experience of Ms Campbell, who is a nutrition support nurse at Frimley Health NHS Foundation Trust. She stresses that getting nutrition right can actually save the NHS money as well as being good for patients.
‘There was one lady with COPD (chronic obstructive pulmonary disease) who, over the course of one year, had repeated, almost back-to-back hospital admissions,’ says Ms Campbell.
‘She had nasogastric food for a while because she wasn’t really able to manage both eating and breathing, and she went home in good health. She’d put on a bit of weight and so she had some reserves for the next time she was ill. We got her daughter on board and stressed the importance of keeping her weight up. That was four years ago, and in that four years I think she’s had two admissions – compared to the previous year, when it was every other month.’
Many NHS providers have nutrition nurse specialists in post – but that doesn’t mean they all do the same thing.
Some are specifically working with patients who require interventions such as nasogastric (NG) or percutaneous endoscopic gastrostomy (PEG) feeding, for example, while others have a wider remit and work closely with dietetics or catering teams. Some, like Ms Campbell, do all of these things. ‘Our roles are hugely varied,’ explains Ms Campbell, but that can also be a barrier ‘because there isn’t a consistent definition.’
Education is a hugely important part of her role, she adds, with on-the-ward roadshows being the most effective method. ‘Rather than sticking staff in classrooms and PowerPointing them to death, we’re showing them what’s relevant for the patient in front of them,’ she says.
A service that responds to patient preference
Good nutrition and a positive food environment are a priority for Calderdale and Huddersfield NHS Foundation Trust. Its approach includes mandatory training in nutritional screening for all nursing staff, an up-to-date food and drink strategy, and a nutrition steering group with two subgroups (nutrition and hydration, and artificial nutrition) led by senior management.
But while the governance and board involvement are impressive, it’s the human impact that has made the biggest impression on Janette Cockroft, matron for patient experience and patient services.
‘Our patients like the food in our hospitals,’ she says simply. ‘Patient feedback is really good, and in our PLACE (patient-led assessments of the care environment) report for last year we scored in the 90s for food presentation and organisation.’
The trust is part of the Soil Association’s Food for Life Network, but its efforts go beyond that. ‘We’ve done quite a lot of work in-house and we are constantly trying to improve,’ she says.
‘We have protected mealtimes but these are open to family carers, and we are working to promote social dining.’
The trust also has engagement support workers and runs themed celebrations, such as for Valentine’s Day.
‘Our service is very responsive,’ says Ms Cockroft. ‘If a patient doesn’t like the food, particularly someone who is staying with us for a long time, the catering manager will come and see them to find out about their likes and dislikes to see if we can find something to tempt them to eat.’
One of the most positive things she has heard involved a patient who rediscovered an appetite and love of food during a hospital stay. ‘Around 60% of patients who come into hospital are nutritionally compromised. For someone to have their interest in food sparked while they were here, and to be determined to keep it up when they go back home, I think that’s a very good news story.’
Whole team responsibility
Ms Roe is wary of putting the entire responsibility for good nutrition on to nurses, specialist or not. ‘We want the whole multidisciplinary team to take this up,’ she says.
‘Nutritional care should be part of patient care. But it is nurses who are spending time with patients and they can make sure that they are getting the food they want, and can reach the plate, or lift a glass of water.’
Ideally, patients who need support to eat should receive one-to-one attention, Ms Roe adds, but she accepts that this can be difficult to achieve. ‘We understand there are staff shortages, which is why we say we need a whole-system solution.’
Initiatives such as the Hospital Food Standards have made a difference, she says. Many hospitals have a nutrition strategy, and this has led to improvements in patient satisfaction with hospital food. ‘But there is still variation,’ she adds. ‘We can’t put our feet up and say this has been solved.’
However, some measures to improve hospital nutrition are at risk of backfiring, depending on how they are implemented, Ms Roe warns. While protected meal times can help patients by ensuring they don’t coincide with medication rounds, for example, wards that interpret this to include banning visitors can shut out a relative or carer who could help their loved one to eat – and reduce the pressure on staff.
‘There is an assumption that because nutritional care is part of “basic care”, someone is doing it – but people rarely ask who that “someone” is’
Trevor Smith, president of the British Association for Parenteral and Enteral Nutrition
There are cultural barriers to overcome too – with patients, relatives, and even healthcare staff. ‘At Age UK we are still trying to raise awareness of the importance of stabilising weight. It’s about getting everyone on board,’ says Ms Roe.
This might mean promoting the use of full-fat cheese and yoghurt and whole milk – which goes against all the obesity-driven health messages we have been fed since childhood, she adds.
Trevor Smith, president of BAPEN, and a consultant gastroenterologist in Southampton, says nutrition is an essential part of good nursing and medical care. ‘The outcome benefits from getting nutritional care right are far better than any medicine we use, he says. ‘But the amount of training doctors and nurses get in nutrition is small. And there is an assumption that because it’s part of “basic care” that someone is doing it – but people rarely ask who that “someone” is.
He would like to see a transformation in the education and training of all healthcare professionals to put nutrition at its heart, with measurable standards for nutritional care, and some way of measuring nutritional care in hospitals. ‘We’re focused on screening, and auditing MUST (the Malnutrition Universal Screening Tool) is seen as a proxy [for measuring nutritional care] but it doesn’t tell you what actually happened,’ he adds.
He believes that no one should underestimate the value of food in overall care. ‘Getting nutritional care right is a good indicator of the overall quality of care,’ he says. ‘In clinical practice, getting people eating well is the key to getting everything right.’
Role for ward leaders
Dawne Garrett, professional lead for older people and dementia care at the RCN, believes nurses are well aware of the importance of nutrition. But she adds: ‘In order to deliver quality nursing care, of which nutrition is a cornerstone, you need the staff – and we are 41,000 nurses down [across England]. That is bound to have an impact.
‘Nurses are suitably trained but there are barriers. For example, ward leaders should have much more influence over what is served in their wards, but in many places, catering is outsourced and there is no connection with the wards. Boards should make sure ward leaders have a say.’
She also warns against making assumptions about people’s nutritional needs based on blunt measurements. ‘Someone who is obese can also be malnourished,’ she points out. ‘It’s important that people get the vitamins and nutrients they need, especially when they are unwell.’
Paying attention to special diets – ensuring those on plant-based diets are getting the right nutrition, for example, is also important, as is making provision for cultural or religious food requirements. If someone is observing Ramadan, for example, it will be difficult to make sure they are eating enough if the catering service closes at 10pm, adds Ms Garrett. ‘Eating is a very personal thing to do. It’s about pleasure, and about personhood, and it’s important that we get it right for patients.’
Advice from a nutrition support nurse
Claire Campbell, chair of the National Nurses Nutrition Group, says:
- Screening, for example using the MUST tool, and responding to the results is important, but it is not the whole story. Patients should be assessed in a holistic way that gives a fuller picture of their nutritional status and needs
- Nutrition and hydration are everyone’s responsibility, and are a key part of nursing
- Nutrition and hydration transcend all clinical specialties and should be part of all policies, for example, on falls prevention and in caring for people with long-term conditions
Jennifer Trueland is a health journalist