Can nurses do to Reduce Malnutrition in Hospitals

Reducing the incidences of malnutrition that often occurs during admission to hospital has been a priority within the nursing care profession for many years. There have been various explanations for this such as lack of staff, patients not able or are unwilling to admit they require assistance, poor use of assessment tools and care pathways. A key factor in the prevalence of patients presenting with malnourishment is the disturbances patient’s endure during mealtimes, such as ward rounds, non urgent medical interventions, housekeeping activities and visitors. This essay will explore the incidences of malnutrition, and those who are most at risk and the changes that have been made to reduce such incidences.

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Change management should be regarded as an ongoing process, which requires good communication, planning, positive leadership and cooperation. This essay will endeavor to explore the change management processes, leadership and team management skills used in the implementation of protected mealtimes. It will explore the negative aspects and problems encountered when implementing a change and the ongoing management skills required to maintain such changes.

For many patients admitted to hospital, in particular the elderly, malnutrition is a common occurrence. It is the nurse’s fundamental duty of care to provide patients with the highest of care possible, a major requirement for any human being to survive and live a healthy life is the intake of a healthy nutritious diet, be that by conventional methods or artificial measures suitable for the patient’s state of health at that time (Royal College of Nursing 2007). Studies into hospital malnutrition show that as many as four out of ten elderly patients admitted to hospital are already malnourished and as a result of a hospital admission as many as six out of ten elderly patients, become malnourished, their situation worsens and their illness very often escalates (Age Concern 2006; BAPEN 2007). The NHS Improvement Plan (2004) set standards to deal with the increasing incidences of malnutrition within hospital settings; it has become apparent that these examples of good practice recommendations have not been implemented in every hospital in the country, as incidences of malnutrition continue to exist. Davidson and Scholefield (2005) reports that inadequate nutrition can lead to longer hospital stays, impairs the recovery of patients and increases financial costs; several hospitals have indeed planned and implemented changes to reduce such incidences but on the whole have had limited success. The authors found that constant interruptions from drug, rounds, clinical activities and lack of nursing staff being on the ward at mealtimes (due to lunch breaks coinciding with mealtimes) all accounted for patients being provided with very little or on occasion no nutritional intake at any given mealtime. Savage and Scott (2005) does agree with this statement to some extent but argues that it is all to easy to blame nursing staff alone, it is the responsibility of each individual NHS trust to implement managerial changes and policies and ensure that they are monitored, evaluated and improved to provide the best care possible for each patient. Mamhidir et al (2007) argues that since the implementation of protected mealtimes in some hospitals there is substantial evidence to suggest that patients, particularly the elderly benefit immensely; patients gained weight, healing time reduced, were discharged earlier and mealtime experiences were a more pleasant experience for patients as well as nursing staff. Mooney (2008) argues that there is evidence to suggest even after hospital trusts have been presented with unarguable evidence that malnutrition is a major problem and a catalyst for longer hospital stays, only 43 percent of those trusts have not yet provided evidence that they have implemented schemes in order to reduce hunger and malnutrition. The Hospital Caterers Association (2004) further comment that mealtimes should not primarily focus on the provision of nutrition, it also makes way for social interaction between patients and carers, they further comment that in general the quality of the food provided is not the issue, the inability of the patient to be able to feed themselves is far more the worrying issue. Council of Europe (2003) comment that hospitals should be designed to be patient centred, ensuring that the delivery of nutrition is flexible and all deliverance of care is set within a framework; all staff should work together in partnership to ensure that incidences of poor nutrition are dealt with. Repetitive reports of malnourishment is evidence enough to suggest that current practices are no longer working, change is a necessary force to ensure incidences are reduced. It is the responsibility of the leader to ensure this is tackled (Age Concern 2006).

Change Management can be described as the process of developing a planned approach to change within an organisation. The objective should be to maximise the collective benefits for all stakeholders involved in the change and minimise the risk of failure implementing the change. Change involves assessment, planning and evaluation; changes in which people are nursed should always be focused on the benefits patients will receive if change is implemented (National Institute of Health and Clinical Excellence, 2007). Welford (2006) writes that there are many theories which explore the need for change; the goal should be the provision of the highest quality of care, each individual involved in the delivery of such care should work together, be committed and supportive of each other during times of change. Change within a team which leads to new practices and ideas affects each individual differently; it can be a very daunting task for some and for others it is embraced to allow for personal development and the sharing of knowledge (Murphy 2006). There are many theories which uses steps or phases that can evaluate if a change is needed and if the changes that are implemented work. For the purpose of this essay the author refers to a popular theory developed by Lewin in the 1950’s which requires three stages to implement effective change the acceptance and participation of all those involved in the area requiring change. The first phase, commonly referred to as the ‘unfreezing’ stage of this theory requires the participants to acknowledge the need for change; evidence should be provided to encourage new thinking and beliefs about current practices. Hallpike (2008) writes that there is evidence to suggest that teams can be divided into groups who have their own individual opinion on certain regimes, practices and care deliverance. This can be said for the provision of nutrition to patients. In this particular study the author reports that some team members did not think there was a problem with the current provision, some were not convinced that changes would be made and others did not have faith in a holistic approach across the team. In this situation it is the responsibility of the team leader to persuade all the team members that the need for change is necessary in order to provide the best service possible, that the whole team work towards a common goal. Welford (2006) discusses the second phase of Lewin’s theory; describing this stage as the moving stage, allowing individuals to voice their own ideas, experiment with different regimes, it allows time for reflection, to discuss positive or negative findings. Past practices may have seen some team leaders adopt the belief that employees were seen to work better when the leader provided strict job descriptions and a clear plan of what was expected of them; their opinions and ideas were not of value to the overall success of a team. Major (2002) argues that for a leader to adopt such thinking will only lead to flaws and a feeling of negativity within a team; the leader should adopt good communication skills and openness to allow for effective team building, positive group dynamics, all working efficiently and productively. Dennis and Morgan (2008) suggests that although change is the responsibility of the service provider, input from the service user is without doubt a valuable tool in assessing if a change is working for the greater good. Feedback, regardless of being positive or negative ascertains if the change has been a positive one. If the new change has a detrimental affect to the service user then the change has been a negative one, this requires a return to the freezing stage to allow the team to make further changes to increase the benefits to the service user. The authors’ further comment that managers should be seen as advocates for the service user; it should be the responsibility of the manager to challenge team members over poor practice, poor attitudes and resistance to change for the better. Conflict within a team leads to unrest, a disbelief that change is for the greater good leading to a dysfunctional team. The third phase of Lewin’s theory can be commonly referred to as the ‘refreezing’ stage, where new ideas and behaviours become a new or common practice. Pearce (2007) argues that to name this phase as such denotes that the change remains static, leaders should continuously strive to make changes for the better, communication across the whole team allows for individual’s points of view to be exposed and discussed; feedback on how a new change is working is necessary in order to achieve the highest levels of quality care.

Leadership styles become a key issue when developing, implementing and upholding change. Motivation of staff also plays a key role in the acceptance of change; leaders should demonstrate that they are a good role model, adopt a friendly attitude towards team members, accepting of criticism and be willing to provide positive feedback, when the team endeavour to believe in and implement the change (Darlington 2006). Corkindale (2009) argues that leaders need balance their role within a team to ensure that they do not become too over familiar with individual team members, as this may lead to team members relying too heavily on the leader to make all the decisions and authority may be compromised.

Murphy (2006) writes that leaders need to adopt a style of leadership that suits the workforce; a laissez-faire approach can be seen as the leader not taking into account individual team member’s ideas, work ethics and commitment seriously, it can lead to a team feeling devalued and unorganised. The National Institute for Mental Health (2007) further suggests that leaders who show their commitment, by working alongside their colleagues, adopting and maintaining the changes themselves demonstrates a leader who is at the forefront in the deliverance of quality care. They further suggest that each leader will bring their own set of ethics, life experiences and education to a team, will often adopt their own style of leadership that may be a mixture of several styles moulded to suit the team and the area of practice they are employed to manage. Opportunities for team members to voice their opinions and concerns are invaluable; they are after all the main implementers of the change and will have be the first to recognise if the change has gained positive or negative results. The change can only work if leaders allow for reflection, discussion and adaptation of the change to suit each individual involved in the change process. A change that is difficult to implement or maintain will end in failure, this leads a team adopting negative feelings and a resistance to change in the future.

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Goleman (2000) suggests that to adopt an authoritarian approach, can at times be a positive approach to leadership especially if some team members resist change or there is a need to produce quick results. Goffee and Jones (2000) disagree with this statement and suggest that a good leader is someone who other people want to follow without bullying, threats or the fear of reprisals; they lead by communicating effectively and adopt a style of leadership that allows the team to understand what is expected of them.

RCN (2007) writes that the only way malnourishment can be identified and managed effectively is with effective use of recognised screening tools.Perry (2009) argues that in many cases nursing staff are given the means and tools to assess a patient, but many are inadequately trained to understand the findings of the assessment or are unwilling to involve other health professionals in the care of the patient. A multidisciplinary approach to tackle such problems should be used. Protected mealtimes have been proven to be useful to not only the patient but to the whole care team, it allows for assessment in areas such as speech and language, mental health issues and other physical problems which can affect the nutritional intake of individuals. South Staffordshire Primary Care Trust (2009) reports that protected mealtimes affects and involves all staff within in the organisation from physiotherapists, domestic staff, maintenance staff through to outside professionals such as social workers. It involves all areas of clinical practice where patients require nutritional intake, not only for patients who are unable to feed themselves but for those patients who require and deserve a quiet, interruption free period to eat, drink and relax.

To maintain and monitor the change process and may require several attempts before the target is reached. takes time and may not always be successful first time. National Patient Safety Agency (2008) states that many clinical staff referred to the implementation of protected mealtimes as a hindrance to their daily routine, but once the benefits for patients as well as the staff members were explained they became more compliant and understanding for the need to change.