Prioritising mealtime care, patient choice, and nutritional assessment were important for older inpatients’ mealtime experiences
Dr A Dickinson, University of Hertfordshire, Hatfield, UK;
Action research study using a qualitative, interpretative, inductive approach to explore the mealtime environment before (phase 1) and after (phase 3) facilitation of changes in staff practice (phase 2).
Purposive sample of older patients (6 in phase 1, 4 in phase 3) who had stabilised after an acute admission and needed complex nursing and medical care, and ward staff (19 in phase 1, 15 in phase 3), including healthcare assistants, nutrition assistants, qualified nursing staff, occupational therapists, and physiotherapists.
In phases 1 and 3, 6 mealtimes were observed (including breakfast, lunch, and supper), 3 focus groups were conducted with ward staff, and patients participated in semistructured interviews with staff nurses. Focus groups and interviews were audiotaped, transcribed verbatim, and analysed thematically. Data from phase 1 informed the focus of phase 2.
3 themes affected patients’ experiences of mealtimes on the ward: nursing care and priorities, eating environment, and institutional and organisational constraints. Only the first theme, with 3 categories, was described. (1) In phase 1, mealtime care and organisation was provided in a routine and ritualised way. It had low social and skill status and did not generally involve qualified nurses. Patients were aware that a limited number of staff was available to assist them. In phase 3, mealtimes were considered less chaotic. By changing nursing practice (eg, time of evening drug round), qualified nurses could help at mealtimes. (2) Patient choice. Although patients had some flexibility in choice of food and portion size in phase 1, staff and patients commented that patients were generally not involved in decision making at mealtimes and were not offered choices (eg, whether to go to the dining room). In phase 3, staff indicated that patients were now a focus of work at mealtimes; a patient noted, “They try to give you something that you like.” (3) In phase 1, nutritional assessment of patients was not systematic, and qualitative aspects of nutrition, such as patient likes and dislikes, were often neglected. For example, one patient was repeatedly served shepherd’s pie, although she thought that nurses should know she did not like it because she did not eat it. In phase 3, nutritional care and a formal assessment of nutritional risk was prioritised, including use of multiple measures and tools, some of which staff found “too complicated to use in practice.” The involvement of all staff at mealtimes allowed for a shift in care toward getting to know patients, spending time with them, and focusing on their needs. One staff member stated, “If you sit and be patient and have the time to do it, then that person will actually eat.” Staff found they had more opportunities to observe and monitor patients’ eating habits and to identify specific difficulties. Other important aspects of assessment included working with patients’ families, particularly for patients with cognitive impairment, and sharing and reflecting on practice with colleagues, which included formal opportunities for safe, open, and honest discussions.
Prioritising mealtime care, patient choice, and nutritional assessment were important for older inpatients’ mealtime experiences.
Dickinson A, Welch C, Ager L. No longer hungry in hospital: improving the hospital mealtime experience for older people through action research. J Clin Nurs 2008;17:1492–502.
Source of funding: Nutricia Clinical Care and Foundation of Nursing Studies in association with Pfizer.
The study by Dickinson et al reminds us that many older people are still at risk of malnutrition simply because they are in hospital; it should prompt gerontological practitioners to re-examine their own practices.
Some studies have examined specific interventions for improving food intake in older people. 1 2 However, the study by Dickinson et al highlights the complexity and time associated with effecting and sustaining changes to mealtime practice in a system that doesn’t always prioritise the needs of older patients. This evidence can be useful for planning many practice development activities, including “Essence of Care” benchmarking, 3 or for discussions with nursing and service managers who may expect, perhaps unrealistically, a single intervention to transform complex aspects of practice such as mealtimes and nutrition.
The multiple interventions used in this study illustrate the many facets that need to be considered (including time scale) to enable staff to change their practice. Although an action research design was used, where explicit practice development principles were drawn on, it is unfortunate that the ward context was not specifically explored in this publication.
The qualitative aspects of this study show that nurses can make a difference in the way that mealtimes are organised and managed. When this contribution is combined with specific service delivery and organisational interventions, it can help to improve the nutritional status of older people.