The nurse’s role in keeping patients nourished

Liz Evans. Nutrition Nurse Specialist – Bucks Healthcare NHS Trust.

Chair - NNNG

Who are the NNNG? We are a group of nurses

dedicated to promoting excellence in all aspects of nutritional care and promoting good nutritional practice for nurses across all specialities.

Established in 1986 our membership stands at nearly 300 at present but is ever expanding.

We believe that good nutrition needs nurses!

http://www.nnng.org.uk/

What is the nurse’s role in nutrition and hydration? A brief history

1980’s (Ref http://www.dailymail.co.uk/news/article-2082883/NHS-care-David-Cameron-says-nurses-told-talk-patients-hospital-wards.html)

Today ( Ref http://www.bbc.co.uk/news/health-11097822

The story so far….

Late 19th and early part of the 20th century Matron and senior nursing staff were in charge of the kitchen and domestic staff.

Post 1948, the NHS developed strong functional management structures in hospitals and hospital groups. Senior nurses began to change their ideas about roles and responsibilities of nurse managers.

1960’s-70’s

1968 – the Standing Nursing Advisory Committee declared that..

It was no longer appropriate for ward sisters to directly manage non- nursing staff on the wards, nor for nurses to spend time on “hotel services” to the detriment of their rapidly- developing “therapeutic role” and “technical nursing” skills.

Hotel services included

Preparing patients’ food and drinks ( except special diets).

Distributing food and drinks, including special diets, at mealtimes.

Collecting and clearing meals Preparing trays and setting up bed tables

Recommendations included

Introduction of housekeeper teams to be managed by senior grade housekeeper not ward staff

A formal career structure and standardised national syllabus for housekeeping staff.

1980’s

Hospital catering services contracted out. Nurses’ were limited in influencing standards in

these areas. The role of the nurse in feeding patients was

no longer clearly defined. Student nurses no longer rostered as part of

the ward team which led to a decrease in the numbers of staff carrying out care on wards.

1990’s 1994 McWhirter and Pennington report that

40% of patients were undernourished on admission and two thirds of all patients lost weight during their stay.

The Community Health councils for England and Wales (1997) suggest that no one is taking responsibility for ensuring that patients are fed or investigating why some patients are not eating and drinking.

The UKCC remind trained nurses that it is their responsibility to ensure that the nutritional needs of their patients are met.

2000 -2006 Essence of Care (2001) highlights food and nutrition

as one of the 8 fundamental aspects of care. Modern matrons are introduced (2001) to improve

not only the quality of nursing care but the total environment for in patient care. This includes ensuring that “patients’ nutritional needs are met.”

The Department of Health recommends that all Trusts should appoint ward housekeepers.

National organisations such as BAPEN, Age Concern, RCN, all highlight nutritional care as a concern.

2006-present (1) Age Concern releases “Hungry to be Heard” RCN launch Nutrition Now campaign with Age

Concern and NPSA support. NPSA highlights poor nutritional care as a safety

issue. Government issues the Nutrition Action Plan. Patient Environment Action Team recommends

that all Trusts should have Protected Mealtimes.

2006- present (2) Department of Health release new standards

for Care settings to be compliant with. (Care Quality Commission 2010). Nutrition and hydration is high on the list – standard 5.

Nutrition education is brought back into pre registration nurse training.

BAPEN nutrition screening week 2007-2011 indicates that 1 in 4 people admitted to a care setting is malnourished.

Malnutrition Task Force is launched.

CQC Dignity and Nutrition for Older People.

• A targeted inspection of 100 NHS hospitals

• Older people ‘’dignity, food and drink’’ • Commenced in February 2011 and

carried out over 4 months • Gives a snapshot of findings at the time of

the visit. • Final report released states that 1 in 5

hospitals are failing to meet this standard.

So why are we still not getting it right? What are the barriers?

Attitudes

Common excuses

It’s not my job I have the drugs to do I have to finish this.. The housekeeper should know “Not relevant”

Retorts

Hospital Acquired Infections cost the NHS 7.3billion pounds a year. Malnutrition costs 13 billion pounds a year.

You have time to do dressings, drug rounds, why is food less important?

You may know what the patient is eating but this may not be sufficient to reassure relatives and other members of the MDT.

Poor nutritional care causes harm or has the potential to cause harm to patients.

So whose job is it?

However

Three out of four nurses say they have no time to talk to older hospital patients and many are so rushed they can’t help them to eat.

Typically, one registered nurse is expected to look after nine elderly patients who may be frail, acutely ill and have complex medical needs. (Ref Safe Staffing for Older People RCN 2012)

How can we overcome these barriers? Senior nurses at board level should make nutritional

care a priority and support protected mealtimes and mandatory nutrition training.

Ward routines should be re assessed to ensure that patients are given the help they need at all times, not just lunchtime.

Trust boards should recognise that food is part of treatment and allow time on the wards for staff to ensure patients are helped to eat. We should be caring for people – not caring about targets.

Effective leadership!

We need Dynamic nursing managers Supportive matrons An organisation that sees the bigger picture and

supports good practice.

How can this be achieved?

Education Education Education

Who needs educating?

Hospitals – nutrition training should be mandatory in all organisations for all levels – not just nursing.

It should be on level footing with infection control and pressure area care

It should not be seen as a hotel service but as an essential part of treatment and care.

How should nutritional care be organised in hospitals?

Nutritional care is a multi-disciplinary responsibility, and an integration of workforce activities is absolutely essential. BAPEN 2007

All hospitals Trusts should have a nutrition steering committee working within the clinical governance framework NICE 2006

Who is involved?

Allied Health Profs

Trust board

Matrons and Senior nurses

Relatives And

carers pharmacists

dietitians

Nutrition nurse specialist

Medical staff

Speech and Language therapists

Catering Partners and Soft facilities

manager

Patient

Florence Nightingale 1860

Every careful observer of the sick will agree in this that thousands of patients are annually starved in the midst of plenty, from want of attention to the ways which alone make it possible for them to take food.

The Mid Staffordshire NHS� Foundation Trust Inquiry 2010. Admitted to hospital in March 2005 for open

surgery for a cholecystectomy the patient was expecting a short stay. The surgery went well but her recovery was poor as she was not eating or drinking. Her family were concerned that she was dehydrated as she was not being given regular fluids and there was no luid chart even though she was on IV. Her nutrition was also poor and caused her weight to plummet.

This lady ended up going into a nursing home with Clostridium Difficile

And finally…..the future

Will this be the only way we can get patients fed?

Thank you for listening

Any comments/questions?

References..

Age Concern (2006) Hungry to be Heard BAPEN (2010) Malnutrition Matters. Meeting Quality

Standards in Nutritional Care. BAPEN (2009) Combating Malnutrition –

Recommendations for Action. BAPEN (2007) Organisation of food and nutritional

support in hospitals. NCEPOD (2010) An Age Old Problem. A review of the

care received by elderly patients undergoing surgery. NICE (2006) Nutrition Support in Adults. Savage J,Scott C,(2005) Patient’s Nutritional Care in

Hospital. RCN Institute.