Keywords nutrition assessment; malnutrition; nutrition screening; nurses; assistance with eating; hospitalized patients; nutrition education

Transcription

1 548227PENXXX / Journal of Parenteral and Enteral NutritionDuerksen et al research-article2014 Original Communication Nurses Perceptions Regarding the Prevalence, Detection, and Causes of Malnutrition in Canadian Hospitals: Results of a Canadian Malnutrition Task Force Survey Journal of Parenteral and Enteral Nutrition Volume 40 Number 1 January American Society for Parenteral and Enteral Nutrition DOI: / jpen.sagepub.com hosted at online.sagepub.com Donald R. Duerksen, MD 1 ; Heather H. Keller, PhD 2 ; Elisabeth Vesnaver 3 ; Manon Laporte, RD, MSc 4 ; Khursheed Jeejeebhoy, MBBS, PhD 5 ; Hélène Payette, PhD 6 ; Leah Gramlich, MD 7 ; Paule Bernier, RD 8 ; and Johane P. Allard, MD 9 Abstract Objectives: Given the high prevalence of malnutrition in hospitalized patients, nurses frequently encounter patients with significantly impaired nutrition status. The objective of this study was to determine nurses attitudes and perceptions regarding the prevalence, detection, and causes of malnutrition in Canadian tertiary care and community hospitals. Materials and Methods: In this descriptive study, a survey that focused on guidelines for nutrition support of hospitalized patients was completed by Canadian nurses working on medical and surgical wards in 11 hospitals participating in the Canadian Malnutrition Task Force study. Results: The survey was completed by 346 of 723 nurses (response rate 48%). Over 50% of nurses underestimated the documented prevalence of malnutrition in hospitalized patients. Nurses considered identification of malnourished patients very relevant (mean 8.4 on a 10-point scale) and would integrate a 3-question nutrition screen into their admission histories (92.5%). Nurses perceived lack of assistance with eating as a significant contributor to hospital malnutrition (17% felt this was a major contributor). While only 39% of nurses reported access to nutrition-related education, 92% were interested in receiving this form of updating. Conclusions: Nurses consider nutrition assessment important and relevant and require access to training to improve their capacity to detect malnutrition in their patients. Nurses are vital to the nutrition care of hospitalized patients and are well positioned to screen for nutrition risk and assist in nutrition management. The role of nurses in nutrition care needs to be linked to hospital policy. (JPEN J Parenter Enteral Nutr. 2016;40: ) Keywords nutrition assessment; malnutrition; nutrition screening; nurses; assistance with eating; hospitalized patients; nutrition education Clinical Relevancy Statement Nurses have an important role in the nutrition care of hospitalized patients. This survey demonstrated that nurses desire more nutrition-related education and are willing to participate in nutrition risk screening. Nurses perceive that lack of assistance with eating is an important problem for many hospitalized patients that contributes to malnutrition. Introduction Malnutrition is common in hospitalized patients and is associated with increased hospital stay, readmission rates, and mortality. 1 A recent study conducted by the Canadian Malnutrition Task Force (CMTF) demonstrated that 45% of patients admitted to medical and surgical wards in Canadian hospitals are malnourished. 2 Contributors to this malnutrition are many and include factors related to underlying illness, socioeconomic factors, and aging. 3,4 Once hospitalized, patients may not receive adequate nutrition because of medical tests scheduled during mealtimes; food not available when the patient is hungry; inability to reach the meal tray, open packages, or cut their food; and lack of awareness of medical professionals or lack of nutrition monitoring. 5 Due to these multifactorial From the 1 Department of Medicine, University of Manitoba, Winnipeg, Canada; 2 Department of Kinesiology, University of Waterloo, Waterloo, Canada; 3 Department of Family Relations & Applied Nutrition, University of Guelph, Guelph, Canada; 4 Clinical Nutrition Department, Vitalité Health Network, Campbellton, New Brunswick; 5 St Michael s Hospital, Toronto, Canada; 6 Faculty of Medicine and Health Sciences, University of Sherbrooke, Sherbrooke, Canada; 7 University of Alberta, Edmonton, Canada; 8 Jewish General Hospital, Montreal, Quebec; and 9 University of Toronto, Toronto, Canada. Financial disclosure: This study was supported with unrestricted research grants from Abbott Nutrition, Baxter, Pfizer, Fresenius Kabi, and Nestlé Health Science to the Canadian Nutrition Society. Conflict of interest: The following authors (D.R.D., H.H.K., J.A., L.G., M.L., H.P., P.B., and K.J.) have been part of a speakers bureau with Abbott Nutrition, a company that might have an interest in the submitted work; H.H.K. and J.A. have received honoraria for chairing the Canadian Malnutrition Task Force from the Canadian Nutrition Society. Received for publication May 1, 2014; accepted for publication July 16, This article originally appeared online on September 4, Corresponding Author: Donald R. Duerksen, MD, Department of Medicine, Division of Gastroenterology, University of Manitoba, C Tache Ave, St Boniface Hospital, Winnipeg, MB R2H 2A6, Canada. duerksn@cc.umanitoba.ca

2 Duerksen et al 101 causes, a multidisciplinary approach, led by dietitians, is required to prevent, detect, and treat malnutrition of hospitalized patients. 6 While dietitians are the clinical experts in identifying and treating malnutrition, nurses are often the first health professional to meet the patient at admission, 7 providing an ideal opportunity for nutrition screening, with those identified to be at risk referred for a more detailed assessment. Screening typically includes fewer than 5 questions that could be readily included in the nursing history. While the U.S. Joint Commission mandates nutrition screening within 24 hours of admission in the United States, there is no such regulatory requirement in Canada at this time. Furthermore, nurses are the direct-care staff on hospital wards who have the most day-today contact with patients. As such, they have important roles in the ongoing detection of patients who are at risk for malnutrition due to poor food intake and in the delivery of interventions that support nutrition for patients on their ward. For example, nurses could ensure that basic preventative practices, such as patients having ready access to their food trays, occur in a timely way. Nurses are also essential to management as they can monitor food consumption and body weight of hospitalized patients. Yet, nutrition education and nutrition knowledge of nurses have been noted to be suboptimal, 8 potentially limiting their effectiveness in the detection and management of malnutrition of hospitalized patients. 9 The purpose of this study was to determine nurses knowledge and attitudes with regard to malnutrition of hospitalized patients in Canada and to identify potential targets for nutrition education to promote quality nutrition care in hospitals. More specifically, the objectives were to determine (1) nurse perceptions of the prevalence of malnutrition of hospitalized patients, (2) the interest and relevance of nutrition assessment to nurses, (3) the willingness of nurses to participate in a nutrition screening process, and (4) nurse perceptions of the causes of hospitalassociated malnutrition. Methods Participants The CMTF conducted a prospective cohort study assessing the nutrition status of hospitalized patients in academic and community hospitals across Canada. In a separate cross-sectional study taking place from February 2012 through February 2013, nurses on the medical and surgical wards (registered nurses [RNs], registered practical nurses [RPNs], licensed practical nurses [LPNs], charge nurses, and nurse managers) from 11 hospitals involved in the CMTF malnutrition study were invited to complete a questionnaire regarding nutrition assessment and management of hospitalized patients. All study sites had the nursing survey protocol approved by their local research ethics board. A descriptive quantitative survey design was chosen to assess Canadian nurses attitudes and knowledge regarding malnutrition of hospitalized patients. As this was a descriptive study, the goal was to recruit as many nurses as possible from involved wards. Site coordinators provided paper copies of surveys to nurses at sites participating in the CMTF study. The study coordinators followed up with potential participants to promote completion and collected the surveys for central data entry and analysis. Survey Investigators adapted a physician/nurse questionnaire based on standards of nutrition care set by the European Society of Parenteral and Enteral Nutrition previously developed, pretested, and administered to these health professionals in Denmark. 10 A separate cross-sectional CMTF study, involving all 18 sites involved in the prospective cohort malnutrition study, recruited physicians for completion of a similar questionnaire; the results of this physician survey have been published recently. 11 In addition to questions on current practices of nutrition assessment, nutrition management, nutritionrelated resources, and nutrition education in hospitals, this survey also asked about optimal and desired practices in these areas. The survey included questions assessing the nurses perceived knowledge, interest, and relevance of nutrition assessment in hospitalized patients. From a list of 11 choices, nurses were asked to select up to 3 reasons why hospitalized patients receive insufficient nutrition support and care. Demographics of participants were also collected and included age, sex, years since graduation, type of hospital (academic vs community), and primary ward of practice. With respect to questions relating to current nutrition practices, responses included yes in all patients, yes in >50% of patients, yes in <50% of patients, no, and don t know. For questions relating to optimal care of hospitalized patients, responses included entirely agree, largely agree, largely disagree, entirely disagree, or don t know. The European questionnaire was shortened and slightly modified to make it relevant to Canadian hospitals and nurses. Specifically, questions relating to nutrition support in a variety of clinical situations and relating to tube feeding were omitted, as these were repetitive and related to physician rather than nursing practice in Canada. In addition, questions relating to the Danish healthcare system were eliminated. Added questions included perceptions regarding the prevalence of malnutrition in hospitalized patients, willingness to integrate nutrition screening into nursing history, and barriers to providing adequate nutrition in hospitalized patients, including assistance with meals/eating. The original Danish questionnaire was initially revised by a physician on the CMTF team (D.R.D.), vetted by the rest of the CMTF team, and then distributed to a group of nurses from 4 centers (2 4 nurses from each site) that had already participated in the CMTF prospective cohort study to pilot the survey and provide feedback. Written feedback was obtained from these nurses, and based on this feedback, a

3 102 Journal of Parenteral and Enteral Nutrition 40(1) revised draft was reviewed by all members of the CMTF and further edited prior to finalizing the questionnaire. The final survey was 5 pages in length, included 56 questions, and took approximately minutes to complete. Statistical Analysis Descriptive analyses were conducted. Means, standard deviations (SDs), and proportions were used to describe the sample and compare responses with various questions. Many response categories were dichotomized to promote analysis and interpretation. Among the items on nutrition practices, responses were dichotomized as practiced (included responses yes in all patients and yes in >50% of patients ) and not practiced (included responses yes in <50% of patients and no ). For questions related to optimal care, responses were dichotomized as agreed ( entirely agree and largely agree ) and disagreed ( entirely disagree and largely disagree ). The response don t know was treated as missing data for the bivariate analyses. Statistical analyses were conducted using SPSS version 20 (SPSS, Inc, an IBM Company, Chicago, IL). Results Demographics Of the 723 surveys distributed, 345 were completed, for an overall response rate of 48%. Of those who completed the survey, 93% completed at least 90% of the questions. The demographics of the respondents are listed in Table 1. The age of respondents was equally distributed between 20 and 60 years, and most respondents were ward nurses (78%). There was similar representation from academic and community hospitals. The mean (SD) time from graduation was 11.9 (11.1) years. Nurses were asked whether they considered malnutrition a significant problem on the ward in which they worked. While the prevalence of malnutrition in the hospitals involved in the CMTF prospective cohort study was 45%, 2 more than 20% (73/338) of nurses stated that malnutrition was not a problem and 30% (101/338) stated that it was a problem in <25% of patients (Figure 1). This underappreciation of the high prevalence of malnutrition of hospitalized patients is discordant with nurses relatively high self-reported knowledge of nutrition assessment (mean 6.38 on a 10-point scale). As well, nurses were interested in the topic of nutrition assessment (mean 7.9 on a 10-point scale) and considered this of considerable relevance to them (mean 8.4 on a 10-point scale) (Figure 2). Despite this interest in nutrition, a large gap was identified between what nurses considered the optimal frequency of nutrition assessment and the frequency of nutrition assessment that they felt currently was practiced on their ward (Figure 3). For example, 94% of nurses felt that nutrition assessment should be performed on admission, but only 67% felt that this Table 1. Demographics of Nurse Respondents. a Characteristic % Age, y (n = 341) < >60 3 Province (n = 346) British Columbia 12 Saskatchewan 2 Ontario 30 Quebec 43 Nova Scotia 3 New Brunswick 10 Sex (n = 343) Female 89 Male 11 Hospital setting (n = 340) Academic 56 Community 44 Ward (n = 336) Internal medicine 45 General surgery 28 Specialty medicine 15 Specialty surgery 13 Nurse type (n = 344) Ward 78 Unit manager 4 Charge nurse 5 Clinical nurse specialist 2 Other 10 a The number differs as some respondents did not answer all of the questions was being done in at least 50% of admitted patients. A similar gap was noted for weighing patients. Nurses felt that nutrition assessment and weighing of patients should be done not only on admission but also during hospitalization and at discharge. While 68% (201/296) of respondents felt that dietitians or diet technicians should be primarily responsible for nutrition screening, 91% (303/333) of nurses reported that they could incorporate a 3-question nutrition screen into their daily work plan for all patients. Nurses were asked to choose from a list the reasons for insufficient nutrition support and nutrition care for patients on their ward. While they perceived that many factors contribute to malnutrition, the most common reasons given were insufficient assistance with eating, lack of documentation of nutrition needs, lack of time for providing quality care, no definition of responsibility for nutrition care, and lack of knowledge on how to manage nutrition problems (Table 2). They did not perceive any major differences between their

4 Duerksen et al 103 Is malnutri on a significant problem in pa ents on your ward? Do not know Malnutri on in > 50% of Pa ents Malnutri on in 25-50% of Pa ents Malnutri on in < 25% of Pa ents Malnutri on not a problem Figure 1. Nurses perception of the prevalence of malnutrition in hospital wards in which they work. Self-reported knowledge, interest and relevance of nutrition assessment Knowledge Interest Relevance Figure 2. The self-reported knowledge, interest, and relevance of nutrition assessment to nurses (based on a 10-point scale). hospital and other Canadian hospitals in general. Almost half of respondents (47%, 156/335) felt that at least 25% of patients on their ward required assistance with eating (Table 3). However, only one-third of respondents (111/333) felt that 75% or more of the patients who required assistance with feeding actually received it. In general, nurses felt they had ready access to resources for enteral and parenteral nutrition (Table 4), but only 48% (162/337) of nurses stated that they had protocols available for identifying patients at nutrition risk. A perceived need was additional nutrition training (92%, 98/107). Continuing nutrition education for ward nurses was available to only 39% (121/308) of respondents. Discussion While malnutrition is common in hospitalized patients, 2,12,13 in this survey, nurses underestimated this prevalence. Accurate nutrition assessment is best accomplished through the Subjective Global Assessment, 14 a history and physical

5 104 Journal of Parenteral and Enteral Nutrition 40(1) Weight on discharge Weight during hospital Current Prac ce (%) Op mal Prac ce (%) Weight on admission NA at discharge NA during hospital NA on admission Figure 3. Nutrition assessment (NA) and patient weights in practice compared with nurses perception of optimal practice. Table 2. Nurses Perception of the Reasons for Insufficient Nutrition Support on Their Ward and in Canadian Hospitals. a Reason Ward, % Canadian Hospitals, % Lack of knowledge Indifference 6 7 Lack of documentation Too many complications 7 7 Time-consuming No definition of responsibility Technically difficult 3 3 Hard to identify relevant patients 7 7 Too expensive 3 8 Insufficient assistance with eating a In total, 330 participants provided 1 3 reasons for their wards (n = 845); 270 participants provided 1 3 reasons for Canadian hospitals (n = 728). examination classifying patients into well-nourished, moderately malnourished, and severely malnourished categories 15 ; this standardized assessment is consistent with the current recommendations. 16 Malnutrition is not always easy to detect, particularly in obese individuals and older adults who are frail and frequently have significant muscle wasting. Given that Canadian nurses are not trained in comprehensive nutrition assessment techniques such as Subjective Global Assessment ( it is not surprising that they might underestimate the prevalence of malnutrition. A comprehensive assessment requires not only the collection of data but also its analysis and interpretation, skills specifically within the scope of dietetic practice. Table 3. Nurses Perceptions of the Proportion of Patients Requiring and Receiving Assistance With Meals and Eating. Characteristic % Proportion of patients requiring assistance with meals/eating (n = 335) None 2 <25% 52 25% 50% 35 51% 75% 10 76% 100% 2 Proportion of patients receiving assistance with meal/eating when needed (n = 333) None 1 <25% 30 25% 50% 16 51% 75% 20 76% 100% 33 In most acute care settings, it would not be expected for nurses to perform a detailed nutrition assessment. Rather, a more relevant role for nurses would be the identification of patients at nutrition risk. Nutrition risk screening involves asking validated, simple questions to determine whether a more detailed nutrition assessment is needed. 17 Screening tests are typically designed to be more sensitive than specific, and a negative screen means that nutrition compromise is unlikely and further detailed nutrition assessment unnecessary. Nurses are in an ideal position to perform nutrition screening in that they assess all admitted patients and care for these patients on a daily basis. 7 On the basis of our survey, frontline nurses appear willing to integrate nutrition screening into their daily routine, and this

6 Duerksen et al 105 Table 4. Nurses Perceptions of Ward Resources Related to Clinical Nutrition. Currently Available Interested in Having Available a Ward Resource % n b % n b Established nutrition support team Resource person with nutrition expertise Protocols/guidelines on identifying patients at nutrition risk Protocols/guidelines on tube feeding Protocols/guidelines on parenteral nutrition Nutrition education for medical staff Nutrition education for nursing staff / / / / / / / / / / / / / /107 a Only includes responses from nurses who did not have that resource available. b The number differs as some respondents did not answer all of the questions. could assist in detecting malnourished hospitalized patients. A recent systematic review that included 11 published studies examining the role of nurses in nutrition risk screening of hospitalized patients identified 5 barriers to nurse implementation. 7 These included lack of organizational culture, competing priorities, valuing clinical judgment over using clinical tools, lack of training and education, and discrepancy between attitude and practice. This review emphasized the complexity of incorporating nutrition screening into nursing function and concluded that routine screening for malnutrition will not take place unless it is considered an integral part of nursing assessment that is required by policy and resourced appropriately. 7(p211) In a recent U.S. survey given to American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) members as well as members of the Academy of Medical-Surgical Nurses and the Society of Hospital Medicine (31% of respondents were nurses and 62% were dietitians), 82.7% of respondents stated that nurses were involved in nutrition screening. 18 The screening tools used varied, with 38.5% reporting use of a validated nutrition screen. Thus, in many hospitals in the United States, nurses are already involved in nutrition screening, and it appears that further education is required to ensure that validated screening tools are used. Detailed nutrition assessment, including the measurement, analysis, and interpretation of nutrition information, is not emphasized in current nursing training programs, 8,19 potentially translating into inadequate nutrition knowledge of practicing nurses. In a cross-sectional survey of nurses caring for hospitalized patients, overall, there was very poor nutrition knowledge of ward nurses, and the level of knowledge was positively correlated with the importance they placed on nutrition. 20 A lack of training is one of the barriers for nursing involvement in the malnutrition screening process. 7 A low level of nutrition knowledge has also been demonstrated in intensive care nurses. 21 Similar to the results of our survey of Canadian nurses caring for patients on medical and surgical wards, a survey from nurses working in general practice clinics in Australia demonstrated a need for more nutrition education. 22 In this Australian study, 98% of surveyed nurses perceived that additional nutrition education would help them in their role of caring for patients with chronic disease. The need for nutrition knowledge to enhance the effectiveness of nurses in caring for patients has also been demonstrated in oncology. 23 While our survey included nurses working in acute care settings, many patients do have chronic disease and cancer that could lead to nutrition risk at admission and prolonged stays that influence nutrition status. Because nurses have more direct patient contact than other healthcare professionals, they are in an ideal position to participate in nutrition risk screening and reinforce important nutrition concepts that are part of the care plan developed by the dietitian. Training is required to facilitate this knowledge translation. In our study, nurses identified assistance with eating as one of the barriers to achieving adequate nutrition for hospitalized patients. Many hospitalized patients are elderly and are unable to open packages, are in a poor position to eat, or are unable to feed themselves. In an intervention study that explored the role of 3 mealtime assistance interventions in the hospitalized elderly, patients were more likely to achieve adequate energy intake after an intervention that included healthcare professional (including nursing) education as well as mealtime assistance and protected mealtimes. 24 Other barriers to achieving adequate nutrition in hospitalized patients include lack of definition of responsibility for nutrition care and intervention, lack of continued risk screening of patients while in the hospital, and provisions of food that is culturally appropriate and available to patients when they desire it. 6 Further studies are needed to determine optimal interventions to support nutrition in malnourished hospitalized patients and the roles that nurses can play in treatment and management. With respect to nutrition assessment of hospitalized patients, our survey results are similar to the research conducted with nurses and physicians in Norway, Denmark, and Sweden, on which this Canadian survey was based. 25 This European survey included 2749 nurses (61% of total persons surveyed) and also found a significant discordance between the perceived current nutrition practice and optimal nutrition practice. 25 For example, although nurses felt that nutrition assessment on admission (26%) and during hospitalization (27%) was infrequently performed, over 80% of nurses felt that nutrition assessment should be performed on admission and during hospitalization. This discordance was also similar to the results obtained from the nutrition survey given to Canadian physicians. 11 These

7 106 Journal of Parenteral and Enteral Nutrition 40(1) results suggest that nutrition screening and assessment require a higher priority in hospitalized patients; this requires training, resource allocation, and designation of responsibilities. There are several limitations inherent to this descriptive study. While the response rate was reasonable at 48%, respondents are likely to have been those more interested in nutrition, which could bias the results, particularly with respect to the interest and relevance of nutrition to nurses. In this survey, we did not collect information related to the education background of the nurses and also did not distinguish between RNs and RPNs/LPNs. There is a significant difference in the educational background and responsibilities of these 2 types of nurses. Their training may have influenced their ability to recognize malnutrition of hospitalized patients, as well as their knowledge of current processes and protocols. Finally, this survey asked questions relating to perceptions of nurses, such as causes of malnutrition in hospitalized patients. This survey did not address the actual causes or their significance. In conclusion, the successful management of malnutrition of hospitalized patients requires a multidisciplinary approach with clearly defined roles. 6 Roles need to be defined for nurses as well as other members of the healthcare team. Nurses can have a significant impact on the successful detection of atrisk patients through nutrition screening. Their role in ensuring access to hospital food and monitoring intake and body weight during hospitalization needs to be better defined to optimize the management of patients with malnutrition. Further education in the nursing curriculum and postcertification is required in Canadian hospitals. Hospitals require interdisciplinary nutrition protocols and guidelines available that assist with the identification and nutrition management of inpatients. The role of nurses in optimizing nutrition of hospitalized patients needs to be clarified and systems set in place that ensure that nutrition is a significant part of nursing function. Statement of Authorship D. R. Duerksen, H. H. Keller, M. Laporte, H. Payette, K. Jeejeebhoy, L. Gramlich, P. Bernier, and J. P. Allard contributed to the conception/design of the research and contributed to the interpretation of the data; E. Vesnaver contributed to the analysis and interpretation of the data. D. R. Duerksen drafted the manuscript. All authors critically revised the manuscript, agree to be fully accountable for ensuring the integrity and accuracy of the work, and read and approved the final manuscript. References 1. Lim SL, Ong KC, Chan YH, Loke WC, Ferguson M, Daniels L. Malnutrition and its impact on cost of hospitalization, length of stay, readmission and 3-year mortality. 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