Improving food services for elderly,long‐stay patients in Australian hospitals: Adding food fortification,assistance with packaging and feeding assistance

Aim: The study aims to highlight barriers and feasible opportunities to enhance nutrition support of elderly, long‐stay patients in Australian hospitals. Methods: A total of 218 dietitians, nurse unit managers and food service managers from medical and rehabilitation wards of 184 hospitals completed a web‐based survey about current practices, perceived barriers and priority opportunities to enhance nutrition support in their context. Results: Cook‐fresh food was the most commonly reported food‐service system (50%). Eighty‐eight percent still used paper menus and one‐ or two‐week cycles were the most common menu cycle lengths. Lack of choice due to special diet, boredom arising from the length of stay, a lack of feeding assistance, limited variety and inadequate flexibility of food service were the key barriers identified. Food fortification, assistance with packaging, additional feeding assistance by nurses, non‐nursing feeding assistance and further nutrition assessment were key priorities for improvement. Conclusion: A ‘toolbox’ of strategies is needed as no one intervention will improve nutrition support of all patients. Further practice‐based outcomes and cost‐benefit studies are needed to enhance support and advocacy for feasible food service interventions in the future.     

Eating environment in the aged‐care residential setting in New Zealand: Promoters and barriers to achieving optimum nutrition. Observations of the foodservice,menu and meals

Aim: To investigate the foodservice, menu and meals in the aged‐care residential setting to identify promoters and barriers to achieving optimum nutrition. Method: An observational study conducted by the University of Otago Dietetic Training Programme. Rest home dietitians around New Zealand identified a final convenience sample of 50 facilities. Ten final‐year student dietitians each spent two days in their designated rest homes, administering a 19‐item questionnaire to ascertain practices relating to staffing, dining environment, menu, meals, snacks, feeding assistance, fluids, special diets, nutrition care, medications, nutrition policy and access to sunlight. Observations describing foodservice and meal‐related activities only are reported in this paper. Results: Most rest homes had the ability to provide for the needs of residents. Ninety per cent of facilities offered menu cycles of at least four weeks long. Potential barriers to meeting needs were inadequate amounts of protein‐rich food for numbers served and lack of perceived choice in menus and meal service. Lack of foodservice staff training and poor uptake of training opportunities contributed to these barriers. Conclusions: This is the first such study conducted in New Zealand. Results should be of interest to the Ministry of Health and district health boards that are charged with the responsibility to ensure that meals in long‐term care facilities meet the nutritional needs of this potentially vulnerable population. Shortcomings identified in the present study require a multidisciplinary approach that should include district health boards, auditing agencies, aged‐care organisations, training providers and dietitians.     

Partnership working by default: district nurses and care home staff providing care for older people

Older people residents in care homes that only offer residential care rely on primary healthcare services for medical and nursing needs. Research has investigated the demands that care homes staff and residents make on general practice, but not the involvement of other members of the primary healthcare team. This paper describes two consecutive studies completed in 2001 and 2003 that involved focus groups and survey methods of enquiry conducted in two settings: an England shire and inner London. The research questions that both studies had in common were (1) What is the contribution of district nursing and other primary care services to care homes that do not have on‐site nursing provision? (2) What strategies promote participation and collaboration between residents, care home staff and NHS primary care nursing staff? and (3) What are the current obstacles and aids to effective partnership working and learning? A total of 74 community‐based nurses and care home managers and staff took part in 10 focus groups, while 124 care home managers (73% of the171 surveyed) and 113 district nurse team leaders (80% of the 142 surveyed) participated in the surveys. Findings from both studies demonstrated that nurses were the most frequent NHS professional visiting care homes. Although care home managers and district nurses believed that they had a good working relationship, they had differing expectations of what the nursing contribution should be and how personal and nursing care were defined. This influenced the range of services that older people had access to and the amount of training and support care home staff received from district nurses and the extent to which they were able to develop collaborative and reciprocal patterns of working. Findings indicate that there is a need for community‐based nursing services to adopt a more strategic approach that ensures older people in care homes can access the services they are entitled to and receive equivalent health care to older people who live in their own homes.     

Effectiveness and cost-effectiveness of early screening and treatment of malnourished patients

BACKGROUND: About 25-40% of hospital patients are malnourished. With current clinical practices, only 50% of malnourished patients are identified by the medical and nursing staff. OBJECTIVE: The objective of this study was to report the cost and effectiveness of early recognition and treatment of malnourished hospital patients with the use of the Short Nutritional Assessment Questionnaire (SNAQ). DESIGN: The intervention group consisted of 297 patients who were admitted to 2 mixed medical and surgical wards and who received both malnutrition screening at admission and standardized nutritional care. The control group consisted of a comparable group of 291 patients who received the usual hospital clinical care. Outcome measures were weight change, use of supplemental drinks, use of tube feeding, use of parenteral nutrition and in-between meals, number of consultations by the hospital dietitian, and length of hospital stay. RESULTS: The recognition of malnutrition improved from 50% to 80% with the use of the SNAQ malnutrition screening tool during admission to the hospital. The standardized nutritional care protocol added approximately 600 kcal and 12 g protein to the daily intake of malnourished patients. Early screening and treatment of malnourished patients reduced the length of hospital stay in malnourished patients with low handgrip strength (ie, frail patients). To shorten the mean length of hospital stay by 1 d for all malnourished patients, a mean investment of 76 euros (91 US dollars) in nutritional screening and treatment was needed. The incremental costs were comparably low in the whole group and in the subgroup of malnourished patients with low handgrip strength. CONCLUSIONS: Screening with the SNAQ and early standardized nutritional care improves the recognition of malnourished patients and provides the opportunity to start treatment at an early stage of hospitalization. The additional costs of early nutritional care are low, especially in frail malnourished patients.     

Food work and feeding assistance on hospital wards

Approximately 60 per cent of UK patients aged 65 years or older are at risk of malnutrition or their situation worsening while in hospital. We report the results of a qualitative study embedded in research to prevent malnutrition in older people in hospital (the mappmal study). Our aim was to understand and describe processes that promote or inhibit nutrition in hospital. Throughout 2009 we examined meal services at four UK hospital sites across two regional locations, focusing on older patients admitted with dementia, for stroke or for fractured neck of femur. Data were collected through semi‐structured interviews with National Health Service staff (n = 54), stakeholders (n = 6), and a focus group with former patients and carers (n = 5). We identified ward‐based food work as a technical and interpersonal challenge in narratives around malnutrition. Food work constituted two overlapping spheres of activity: interpersonal engagement through feeding assistance and reassurance and the arrangement of resources that facilitate meals such as the preparation of food trolleys. Our analysis is framed by the literature on emotional labour, dirty work and the professionalisation of nursing. We demonstrate how food work is overlooked by being conceptualised as common sense and as one of the most mundane and elementary tasks in hospitals.     

Factors determining inpatient satisfaction with care

The objective of the study was to identify factors associated with satisfaction among inpatients receiving medical and surgical care for cardiovascular, respiratory, urinary and locomotor system diseases. Two weeks after discharge, 533 patients completed a Patient Judgments Hospital Quality questionnaire covering seven dimensions of satisfaction (admission, nursing and daily care, medical care, information, hospital environment and ancillary staff, overall quality of care and services, recommendations/intentions). Patient satisfaction and complaints were treated as dependent variables in multivariate ordinal polychotomous and dichotomous logistic stepwise regressions, respectively. Patient sociodemographic, health and stay characteristics as well as organization/ activity of service were used as independent variables. The two strongest predictors of satisfaction for all dimensions were older age and better self-perceived health status at admission. Men tended to be more satisfied than women. Other predictors specific for certain dimensions of satisfaction were: married, Karnofsky index more than 70, critical/serious self-reported condition at admission, emergency admission, choice of hospital by her/himself, stay in a medical service, stay in a private room, length of stay less than one week, stay in a service with a mean length of stay longer than one week. The factors associated with inpatient satisfaction elucidated in this study may be helpful in interpreting patient satisfaction scores when comparing hospitals, services or time periods, in targeting patient groups at risk of worse experiences and in focusing care quality programs.     

Developing and validating a novel staff questionnaire to identify barriers and enablers to nutrition and mealtime care on hospital wards

Aims

Improving hospital nutrition and mealtime care is complex and often requires multifaceted interventions and implementation strategies to change how staff, wards and systems operate. This study aimed to develop and validate a staff questionnaire to identify multilevel barriers and enablers to optimal nutrition and mealtime care on hospital wards, to inform and evaluate local quality improvement.

Methods

Literature review, multidisciplinary focus groups and end-user testing informed questionnaire development and establishment of content and face validity. To determine the construct validity, the questionnaire was administered to ward staff working in five wards across two facilities (acute hospital, rehabilitation unit). Exploratory factor analysis was used to estimate the number of factors and to guide decisions about whether to retain or reject individual items. Scale reliability was assessed using Cronbach's alpha.

Results

The questionnaire was completed by 138 staff, with most respondents being nurses (57%) and working in the acute care facility (76%). Exploratory factor analysis supported construct validity of four of the original seven subscales. The final questionnaire consisted of 17 items and 4 sub sub-scales related to (1) Personal Staff Role; (2) Food Service; (3) Organisational Support, and (4) Family Involvement; each sub-scale demonstrated good reliability with Cronbach's alpha values all >0.70.

Conclusion

This novel and brief questionnaire shows good reliability and preliminary evidence of construct validity in this small sample. It provides a potentially useful instrument to identify barriers and enablers to nutrition and mealtime care from the staff perspective and inform where improvement efforts should be focused.     

Staff perceptions of end-of-life care in long-term care

OBJECTIVE: Although residential care/assisted living facilities and nursing homes have increasingly become a significant site of death for older Americans, little is known about staff perceptions of end-of-life care, perceived need for improvement in care, and differences by type of setting. DESIGN, SETTING, AND PARTICIPANTS: Ninety-nine staff provided their perceptions of end-of-life care for 99 decedents from 74 residential care/assisted living facilities and nursing homes in four states as part of a larger cohort study. Staff were interviewed retrospectively regarding care provided during residents' last month of life. MEASUREMENTS: Staff reported on 11 areas of end-of-life care, describing the importance of each area and the level of improvement they felt was indicated. Weighted "need for change" scores were calculated as the product of perceived importance and need for improvement. RESULTS: Both residential care/assisted living and nursing home staff reported a need for more staff education and nursing assistant time, as well as more use of volunteers. The two lowest ranked items for both facility types were involvement of hospice and encouragement for staff to attend funeral services. Nursing home staff perceived a greater need for improvement than residential care/assisted living staff in all 11 areas. CONCLUSION: Results underscore the staffing demands of end-of-life care across facility types, and staff desires to be able to provide quality care throughout the dying process.     

Why are newly qualified doctors unprepared to care for patients at the end of life?

Medical Education 2011: 45 : 389–399 Context Death and dying occur in almost all areas of medicine; it is essential to equip doctors with the knowledge, skills and attitudes they need to care for patients at the end of life. Little is known about what doctors learn about end‐of‐life care while at medical school and how they learn to care for dying patients in their first year as doctors. Methods We carried out a qualitative study using face‐to‐face interviews with a purposive sample of 21 newly qualified doctors who trained in different medical schools. Results Data were analysed using a constant comparative approach. Two main groups of themes emerged. The first pertained to medical school experiences of end‐of‐life care, including: lack of exposure; a culture of ‘clerking and signs’; being kept and keeping away from dying patients; lack of examinations; variable experiences, and theoretical awareness. The second group of themes pertained to the experiences of recently qualified doctors and included: realising that patients really do die; learning by doing; the role of seniors; death and dying within the hospital culture; the role of nursing staff, and the role of the palliative care team. Conclusions Undergraduate medical education is currently failing to prepare junior doctors for their role in caring for dying patients by omitting to provide meaningful contact with these patients during medical school. This lack of exposure prevents trainee doctors from realising their own learning needs, which only become evident when they step onto the wards as doctors and are expected to care for these patients. Newly qualified doctors perceive that they receive little formal teaching about palliative or end‐of‐life care in their new role and the culture within the hospital setting does not encourage learning about this subject. They also report that they learn from ‘trial and error’ while ‘doing the job’, but that their skills and knowledge are limited and they therefore seek advice from those outside their usual medical team, mainly from nursing staff and members of palliative care teams.     

Creating Potential for Common Ground and Communication Between Early Childhood Program Staff and Parents About Young Children’s Eating

ObjectivesTo explore child care staff and parent perspectives and communications about children’s eating in child care.DesignFocus groups (FGs) conducted with child care staff and parents.SettingFour Western states in the United States.ParticipantsThirty-nine child care staff in 7 FGs and 25 parents in 6 FGs.Phenomenon of InterestThoughts and concerns about children’s eating and opportunities to improve communication between staff and parents.AnalysisContent analysis (FG coding inter-rater reliability: staff = 0.74; parents = 0.81) and identification of meta-themes.ResultsThree meta-themes were identified: (1) recognition of positive influences of the child care setting in children’s development of healthy eating; (2) concerns about children’s eating in child care and at home; and (3) strategies to improve communications and transactions related to children’s eating.Conclusions and ImplicationsStaff reported that their roles included informing parents about food at mealtimes in child care (eg, menus, recipes) but also educating parents about child nutrition and feeding. Parents valued daily information about their child’s eating to adjust home mealtimes and to feel connected to their child. Barriers to effective communication included limited time and concerns regarding parent reactions and defensiveness. Staff requested training about child nutrition and feeding and about sensitive communications with parents.     

Food and Nutrition Care in Long-Term Care Facilities: Examining the Perspectives of Frontline Workers

Abstract

Malnutrition in older adults residing in long-term care facilities continues to be a problem in the United States. Existing research has identified a list of possible contributing factors, including staffing problems. Few studies on food and nutrition care have attempted to gain the perspectives of nursing or dietary aides (henceforth, aides), the frontline staff who work most closely with the residents of long-term care facilities. The current study takes a qualitative approach grounded in a theoretical perspective based on Total Quality Management (TQM) to increase understanding of the interpersonal and management practices that affect resident wellbeing, health, and nutrition. Four focus groups (n?=?24) were conducted with aides working in long-term care facilities. Aides expressed emotional closeness with residents and provided detailed knowledge about food and nutrition care. They reported both compassion fatigue and satisfaction. An element of dissatisfaction related to aide relationships with management and other employees who did not actively solicit their perspectives and knowledge on resident feeding. The knowledge and experience of aides could be better utilized by shifting management strategies to focus on employee empowerment and training. Principles of TQM could be applied to improve food and nutrition care in long-term care facilities.     

Nutritional care in care homes: experiences and attitudes of care home staff

Background: The Food Award Barnsley (FAB) is organised for care homes that meet nutritional criteria based on national recommendations. Research (Thompson, 2003) highlighted that meeting FAB criteria is not an assurance that residents are receiving adequate nutrition. This is supported by studies demonstrating multiple individual/organisational factors influencing rates of malnutrition in care establishments (Abbasi & Rudman 1994; Health Advisory Services, 2000). To develop a training intervention to support FAB, an understanding of the role, perceptions and attitudes of care staff in the process of nutritional care was required. The main research aims were to describe staff's experiences of nutritional care of service users, to explore staff's attitudes towards nutritional care of service users and to highlight issues relating to nutritional care which could be considered when developing training programmes or provide the basis for future research. Methods: A care home that held the silver FAB, offered nursing and residential care and had more than 20 beds was chosen. Maximum variation sampling was used to select a cross‐section of staff in terms of position, level of education and length of service. Twelve semi‐structured interviews were recorded, transcribed and analysed using the template approach as developed by King (1998). The process from which the conclusions of the study were drawn was made clear through documentation. The audit trail within the final report demonstrates dependability and confirmation and hence the rigour of the study. Results: In general staff felt they were effective in identifying and addressing issues of malnutrition. However, from a dietetic perspective there was a fragmented approach to nutritional care. At all levels ‘confused role expectations’, lack of clear action planning, poor communication and attitudes towards malnutrition represented a significant barrier to good nutritional care within the home. Despite using a nutritional screening tool, staff relied more heavily on their own subjective judgement to identify residents who they thought were malnourished. Care home staff at all grades considered a poor appetite to be a ‘normal’ part of ageing and some felt that in conditions such as Parkinson's Disease it was expected that residents would lose weight. Portion sizes were reduced regardless of the need for compensation for reduced nutritional intake. Discussion: The lack of a coherent approach to nutritional care coupled with poor communication at all levels resulted in the risk that residents were not receiving appropriate nutritional care. Staff relied on their own judgement, not an objective measure; to identify residents they thought were at risk of malnutrition. These problems were compounded by attitudes of staff at all levels to nutrition, weight and ageing which resulted in lack of intervention in residents who were malnourished or at risk of malnutrition. Conclusion: This study highlights barriers to changing the process of nutritional care within the home which should be addressed through training, whilst ensuring national nutritional standards for provision of food are met. References Abbasi, A. & Rudman, D. (1994) Under nutrition in the nursing home: Prevalence, consequences, cause and prevention. Nutr. Rev. 52, 113–122. Health Advisory Services. (2000) “Not Because they are Old”. An Independent Inquiry into the Care of Older People on Acute Wards in General Hospitals. London: Health Advisory Services. King, N. (1998) Template analysis. In Qualitative Methods and Analysis in Organisational Research. eds C. Cassell & G. Symons, pp. 118–134. London: Sage. Thompson, L. (2003) Nutritional Perceptions among Staff Working in a Care Home for Elderly People and the Potential for Nutrition Education. BSc thesis, Leeds Metropolitan University.     

Multidisciplinary evaluation of a critical care enteral feeding algorithm

Aim: Feeding algorithms have been demonstrated to improve nutrition delivery and influence primary outcomes in critical care units. Most feeding algorithms assist decision‐making related to initiation of enteral nutrition, use of prokinetics and the mode of delivery of feeding. The algorithm that is the subject of this evaluation enabled nursing staff to select type of feed and target feeding rate for enterally fed patients. The aims of this evaluation were to assess acceptance of the algorithm across disciplines, and to determine if energy and protein intakes achieved were comparable with data reported in an international multi‐centre observational study. Methods: Semistructured interviews were conducted with eight nurses, three doctors and three dietitians, to gauge their attitudes towards usefulness of the algorithm. Data on energy and protein intakes was collected for 108 patients using nursing observation records of volume of feed delivered with deductions for discarded aspirates. Results: Positive feedback on usability of the algorithm was given by all interview participants. Common themes from the interviews were that the algorithm ‘enabled feeding to start earlier’, ‘was simple to use’ and ‘ensured consistency of approach’. Greater than 80% of estimated nutritional targets were achieved, and enteral feeding commenced on average within 8 hours. Conclusions: Evaluation of the new feeding algorithm indicated that it was well accepted by users, ensured a consistent approach to enteral feeding delivery and enabled feeding to start earlier within an intensive care unit.     

The nurse and the nursing staff according to mothers of hospitalized children

This study was carried out at the Pediatrics Unit in a School Hospital of the city of S?o Paulo during the second semester of 2000. This is a qualitative research with the following objectives: (1) to understand how mothers with a child in hospital identify the nurse as well as other components of the nursing Staff (technicians and assistants) and (2) to learn about their perceptions about the care provided by the nursing staff. Eight mothers with a child hospitalized were individually interviewed. Speeches were submitted to a thematic analysis of the content. Two categories were observed: Identification of the nurse/nursing staff by mothers with a child in hospital and the perception of these mothers about the nursing staff. In the first category, the difficulty to identify the components of the nursing staff was observed. In the second, it was observed that the nursing activity is seen as subordinated to the medical area. Eventually, mothers have difficulty to distinguish what is performed by the nurse or by the other members of the staff but the entire nursing care is evaluated as very good. Besides, the nurse is considered as the one who solves the problem. Nursing is seen by these mothers as an activity mediated by the representation of motherhood. The care performed by this staff in spite of being considered as very good, still needs to be presented to mothers as professionals and self-employed in order to change a stereotyped view of nursing.     

Management of pain in older people within the nursing home: a preliminary study

The provision of continuing care for older people has largely shifted from the hospital setting to the community, and nursing homes increasingly provide support for older people, many of whom exhibit multiple pathology and complex health and social care needs. However, the quality of pain management within this setting has been identified as an issue of concern. It has been estimated that approximately two-thirds of people aged 65 years and over experience chronic pain, and that the prevalence of chronic pain in nursing home residents is between 45% and 80%. However, there exist a number of barriers to the identification and management of chronic pain among older people resident in nursing homes, including sensory impairments in older people themselves and educational deficits among professionals. Such barriers need to be overcome if pain management is to be improved. The present study involved administering a pre-piloted postal questionnaire to the managers of 121 nursing homes within a geographically defined area. Sixty-eight (56%) were completed and returned. The questionnaire broadly covered the following: prevalence of chronic pain and use of interventions; assessment and management strategies; education and training; and communication barriers. Overall, 37% of nursing home residents were identified as experiencing chronic non-malignant pain (pain lasting longer than 3 months not caused by cancer) and 2% were reported as experiencing chronic malignant pain (pain lasting for more than 3 months caused by cancer). Paracetamol was identified as the most 'often' used analgesia for both pain modalities. Sixty-nine per cent of nursing homes did not have a written policy regarding pain management and 75% did not use a standardised pain assessment tool. Forty-four per cent of nursing homes provided education or training sessions for qualified staff and 34% provided this for care assistants. Forty per cent of qualified staff and 85% of care assistants had no specialist knowledge regarding the management of pain in older people. The present study confirms the need for the development of effective pain management strategies underpinned by appropriate training and education in order to meet the particular needs of older people.