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Nutrition support: a taste of the latest NiP survey results

Malnutrition in the UK does not receive the attention it deserves and is often overshadowed by the problem of obesity. In our latest survey, sponsored by Fresenius Kabi, we looked at your experiences of nutrition support and malnutrition. Here is a summary of the results…

Annika Magnusson
Supervising Editor
Nursing in Practice

In October last year the government unveiled plans to include nutrition as part of the nurse training programme with the aim of tackling malnutrition among elderly patients. Health minister Ivan Lewis warned that nurses who fail to help people eat and neglect older people should face disciplinary action.
Mr Lewis said: "There will be no overnight solutions or magic wands, but we somehow have to change the culture that says nutrition is not important. It is as important as access to the right medication."(1)
Many nurses reacted to this announcement and shared their thoughts with NiP: "Being of the old school training, I am appalled to find nutrition is not considered important enough to be in the nurse training at the moment," said one of our readers. Another reader added: "Nutrition is an essential part of individual daily living and should be taken seriously,
therefore by adding nutrition as a part of the nurse training programme it should increase individuals' involvement in the subject." "Nutrition is a basic principle of nursing. In the community nutrition is often neglected, with nurses forgetting that nutrition can aid wound healing, prevent/minimise the risk of pressure sores, and improve patient wellbeing," commented a registered dietitian from Southampton. "We should be encouraging the use of good, validated nutritional screening tools, with solid, evidence-based care plans to make nutritional screening and treatment something which is easy to achieve, and something which is considered to be as important as accessing the right medication."
So just how confident are primary and community care nurses in giving nutrition support and treating patients with reduced food intake? The latest Nursing in Practice online survey, sponsored by Fresenius Kabi, aimed to gauge the current level of knowledge and experience of nutrition support.

Training and education
NICE clinical guidelines for nutrition support in adults state that knowledge of the causes, effects and treatment of malnutrition among healthcare professionals in the UK is poor. All healthcare professionals who are directly involved in patient care should receive education and training, relevant to their post, on the importance of providing adequate nutrition, including:(2)

  • Nutritional needs and indications for nutrition support.
  • Options for nutrition support (oral, enteral and parenteral).
  • Ethical and legal concepts.
  • Potential risks and benefits.
  • When and where to seek expert advice.

It is therefore worrying, but perhaps not surprising, that almost 86% of the respondents said they have never had any training in nutrition support. Health visitors had the lowest training rates - only 9% said they had undertaken basic training in nutrition support. District nurses had the highest training rate with 30% (see Figure 1). "I feel we need more nutritional training and for every patient to be assessed/reassessed regularly," said a district nurse. "It would be very useful to have ongoing nutrition training embedded into nurse training," said another district nurse based in London. "I feel it is overlooked in many instances."

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"These results reflect what nurses have been telling us for some time - that they need more education and training in many aspects of nutrition," commented Sara Stanner, nutrition communications manager at the British Nutrition Foundation (BNF).
As a follow-up question respondents were asked whether they felt comfortable working with nutrition support. Only 24% said yes.
The most popular type of training proved to be inhouse training with no points or awards involved, and many of the respondents said sales representatives keep them up-to-date (see Box 1).

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Despite, or perhaps because of the lack of validated training 82% of our respondents keep their nutrition support knowledge up-to-date by reading professional journals, eg, Nursing in Practice, Nursing Times, Independent Nurse, Nursing Standard and Practice Nursing. Thirty percent get their information from the internet, including NHS, NICE, Diabetes UK and RCN - "Everything starts from Google…" said one nurse from London. Twenty-four percent of the respondents get their information from sales representatives such as Fresenius Kabi, Abbott, Nutricia, Flora, Roche and Sanofi-aventis, and many get advice from dietitians and other nursing colleagues.

Malnutrition
Malnutrition can occur in a variety of patient groups, such as pre- and postsurgery, oncology patients undergoing chemotherapy or radiotherapy, HIV patients, the elderly, those with mental health problems and those with a chronic illness. But it can also occur in "well" people who just can't find the time to eat a full and balanced diet - a busy modern lifestyles often means that meals and food become a low priority. Intensive athletic training programmes, heavy work schedules and periods of intense study can also lead to reduced food intake, and it is often at these times when good nourishment is really important.
The consequences of malnutrition include:(3)

  • Weakness and loss of muscle mass.
  • Apathy and depression.
  • Reduced immune response.
  • Poor healing of wounds.
  • Increased morbidity and mortality.

Approximately 5% of the UK adult population has a body mass index (BMI) less than 20 (an indication of malnutrition) and studies have revealed that patients receiving district nursing care are significantly more likely to be malnourished.(4) The prevalence of malnutrition in hospital and the community affects more than three million patients and costs the NHS £7.3bn a year.(5) However, it is estimated that 70% of malnutrition in the UK goes unrecognised and untreated.(6)
NICE guidelines recommend that screening should take place on initial registration at general practice surgeries and when there is clinical concern. Body mass index (BMI) is the most used tool but there has been a lot of discussion about its inadequacy recently and a range of other screening tools is now available, including the Malnutrition Universal Screening Tool (MUST) and the Mini-Nutritional Assessment (MNA), both developed for use in older adults in community settings.
Despite the wide range of screening tools available, 64% of the respondents reported using common sense for assessing undernutrition. A community nurse from the West Midlands shared her concerns about the tools available: "There seems to be an overreliance on nutritional tools and an underplaying of experience - it seems that there will soon be a 'tool' for everything which replaces education and knowledge. There is a place for guidance, but the knowledge of the individual practitioner must not be overlooked or dismissed. If there is a 'tool' for each activity of living, the danger is that less importance could be placed on some screening guides, and they may be seen as a paper exercise."
According to Sara Stanner: "Nurses need to be confident in the use of appropriate screening tools to identify and monitor those at risk and have a good understanding of nutritional support and practical measures for helping to treat loss of appetite or poor food intake."
About 35% of the respondents said they routinely screen for malnutrition with a majority of those doing so when there is clinical concern, eg, unintentional weight loss, fragile skin and poor wound healing. Respondents also screen for malnutrition on initial GP registration and some take the opportunity to screen at other occasions, eg, health checks and flu injections.
However, this left 65% of respondents who said they don't routinely screen for malnutrition, and when asked if someone else was doing it, 56% responded they didn't know.
Respondents were then asked what tools they use for screening. The answers seen in Figure 2 are just examples of the many tools that can be used for screening and some respondents shared examples of other tools, such as these given by a community nurse in West Midlands: "Many years of experience and holistic assessment, ie, loose clothing, ketones in urine, poor access to shops, lack of foods in cupboards, evidence of poor diet around home and low income."

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If a patient screens positive for malnourishment 37% of respondents would refer them to their GP, 30% would refer them to a dietitian and 26% would discuss lifestyle factors.
Sarah Schenker, dietitian at the BNF, explained: "Recognising the risk of malnutrition and then acting quickly is paramount. We do not have to turn our nurses into nutritionists but there must be a mechanism in place to take action that is simple and effective."

Dysphagia
Only 6.8% of our respondents said they had had training in the diagnosis, assessment and management of swallowing disorders. As with nutrition support, training and education in swallowing disorders is mostly done inhouse with no award or credit points. Summarising the feelings among many of our respondents a practice nurse from East Midlands said: "I used to work on a stroke unit for a year as a newly qualified nurse and had two placements on a stroke unit as a student, so I do have experience, but I have not had official training to do the screening."
Not surprisingly only 12% said they felt confident working with patients with swallowing disorders, whereas 44% said they don't work with these conditions at all.

Tube feeding
People requiring enteral tube feeding should have their tube inserted by healthcare professionals with the relevant skills and training.(2) An encouraging 72% of respondents have had training in inserting nasogastric tubes, but when asked if they were confident inserting tubes, only 30% said yes.

Sip feeds
A wide range of dietary supplements is available and used in both hospitals and the community when food intake is reduced. Healthcare professionals should choose a well-formulated dietary supplement containing a mix of protein, fat and carbohydrate to provide energy, as well as a range of vitamins and minerals to make up for the lack of these nutrients in the diet.(7)
Respondents were asked why their patients were using sip feeds and the answers are seen in Figure 3. Other reasons included:

  • "As a top-up for malnourished and palliative patients. Also at the recovery stage for patients who have been ill for long and are just getting their appetite back slowly."
  •  "When additional protein is required for wound healing or oedema."
  • "When recommended after dietitian assessment."
  • "Substance misuse, asylum seekers."
  • "Endstage chronic obstructive pulmonary disease and heart failure."
  • "Postoperatively."

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The amount of feed required depends on the patient's nutritional requirements and actual food intake. Murphy recommends prescribing small quantities of sip feeds at first, to establish whether the patient finds the product palatable. When the patient's preferred supplement has been chosen, a supply sufficient to last four to six weeks only should be given, because the patient should be reassessed after that time. It is also helpful if the prescriber specifies the patient's favourite flavours on the prescription.(3)
Respondents were asked what, in their opinion, is important to their patients in a sip feed. Taste, nutritional profile and a variety of flavours were most important factors in choosing sip feeds (see Box 2). One practice nurse said: "Often the flavours are quite 'sickly' and if nauseous, they do not lend themselves easily to frequent use." Another nurse shared some useful advice: "I allow patients to taste the samples of supplements and their choice enables me to advise the GP on which ones to prescribe."
Respondents also indicated what is important to them when choosing a sip feed for their patients (see Box 3).

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Respondents were asked why certain brands of sip feeds were used in their practice. Here are a few of the responses:

  • "Only available."
  • "Company rep has been proactive in promoting product and supplying samples."
  • "Habit."
  • "Doctors prefer it. Don't know why."
  • "Range of flavours. Convenience of bottle."
  • "Cost-effective."
  • "Partly because of the multifibre option, the choice of flavour and base, and PCT directive."

Half of the respondents said that juice-based sip feeds were most popular with their patients. Milk-based sip feeds are also popular; however, a community nurse said: "Not all patients like milk-based products - the soups and fruit desserts make a popular change." "Patient compliance is challenging," commented another nurse.
Sip feeds are mostly used in addition to meals with patients taking sip feeds in between meals. One of the respondents commented: "I feel it is important that sip feeds are used only when necessary and regularly reviewed. Patients should be encouraged to have a regular diet where possible as well and not become dependant on sip feeds alone."

Prescribing
Sixty percent of respondents refer to a GP for prescriptions and only 8% make decisions about prescribing nutrition support themselves. Many respondents would also refer to a dietitian and liaise with colleagues: "I would discuss with my dietitian colleagues and then I would prescribe using their advice." Another nurse commented: "I would discuss nutrition prescriptions before issuing them as I have limited knowledge of the subject."
However, a major problem appears to be the cost and getting the GP's approval:

  • "GPs are reluctant to script for nutritional support products due to the cost involved. As nurses I think we would prescribe more than GPs."
  • "Problems getting GPs to prescribe for patients, as they say it's either not required/expensive/will not be taken."
  • "I am not involved in supplementary nutrition. I think it has to be authorised by the dietetics department as it is so expensive."
  • "Not all GPs like to use supplements."

Supporting patients in the community
Healthcare professionals should ensure that patients with nutrition support and their carers are kept fully informed and have access to appropriate sources of information, eg, individualised care plans, emergency telephone numbers and contact details for relevant support groups, charities and voluntary organisations. Consideration should be given to cognition, gender, physical needs, culture and stage of life.(2)
The majority of respondents said they offered individualised care plans, and many provide patients with contact details for relevant support groups, including:

  • "Contact with daycare centre and rehabilitation centre providing the necessary training and explanation to carers if needed."
  • "Local 24-hour service teams."
  • "Local district nurse team."
  • "Nutrition company that has a helpline."
  • "Young adults with eating disorders will have the support group info of psychologist, and the NHS facilities where they could be inpatients or supervised outpatients."
  • "MS society, young disabled unit."
  • "Macmillan nurses."

Conclusion
The main message from this survey is quite obvious - more training is required in primary and community care specific to nutrition support. NICE claims that healthcare professionals in both hospital and community settings have a poor knowledge of nutrition, which is partly due to receiving a minimal amount of education in nutrition during their undergraduate or basic training.(2) Lynn Young, primary care adviser at the RCN, commented: "We know very well at the RCN that working conditions can sometimes be very discouraging for nurses to be able to spend the time with patients to ensure good nutritional levels need."
Finally some respondents pointed out the importance of nutrition in their own practice. "Nutrition should be a prime factor," commented a healthcare assistant from London, and a nurse practitioner added: "Doing this survey has made me aware that this is an area I need to research more fully and increase my knowledge."

This nutrition support survey took place from 7 July to 25 July 2008. A total of 640 primary care nurses completed the survey - 42% practice nurses, 13% nurse practitioners, 10% community nurses, 5% district nurses, 5% health visitors and 25% others. Eighty-four percent of the respondents have been qualified nurses for more than 10 years. The survey was sponsored by Fresenius Kabi.

References

  1. Nurses to get nutrition assessments. 2007. Available from: /article_5925
  2. National Institute for Clinical Excellence. Nutrition support in adults. London: NICE; 2006.
  3. Murphy P. Enteral feeds explained. The Pharmaceutical J 2001;267:297-300.
  4. Rollins H. Treating malnutrition in primary care. NiP 2001;2:105-6.
  5. RCN. Improving nutritional care: evidence for practice. Available from: http://www.rcn.org.uk/newsevents/event_details/rcn_events/rcn_improving_...
  6. Schenker S. Undernutrition in the community. NiP 2006;30:76-80.
  7. Daniels L. Undernutrition in the community. NiP 2003;11:65-6.