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Geriatr Gerontol Int 2016; 16: 374–379
ORIGINAL ARTICLE: EPIDEMIOLOGY, CLINICAL PRACTICE AND HEALTH
Nutritional care of elderly patients in acute care settings: A qualitative study Leila Gholizadeh,1 Khadijeh Yazdi,2 Nahid Dehghan Nayeri3 and Eesa Mohammadi4 1 Faculty of Health, University of Technology, Sydney, Sydney New South Wales, Australia; 2Nursing Research Center, Golestan University of Medical Sciences, Gorgan, 3Faculty of Nursing & Midwifery, Tehran University of Medical Science, and 4Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran
Aim: Poor nutritional status is common in older adult patients. The present study aimed to explore barriers and facilitators to nutritional care of elderly patients in acute care settings. Methods: Data were collected through individual face-to-face interviews with 12 registered nurses, and analyzed using interpretive description methodology. Results: Two core themes emerged from the analysis of data: (i) neglected care, with three subthemes of “support but also independence,” “unsupportive environment” and “responsibility of the family;” and (ii) a humanitarian ethic, with two subthemes of “respect and dignity” and “humanitarian care.” Conclusions: As an integral part of holistic care, elderly patient nutrition should be emphasised in health professional education, and promoted through managerial support, multidisciplinary collaborations, and implementation of appropriate monitoring and evaluation systems. Geriatr Gerontol Int 2015; 16: 374–379. Keywords: acute care setting, elderly, nursing, nutrition, qualitative study.
Introduction As the elderly population is growing globally, adjustments in provision of healthcare services are necessary to meet the special needs of older consumers. Older adults are the significant users of healthcare services. In the USA, people aged 65 years and over account for the highest percentage of hospitalizations.1 Similarly, in Australia, the number of hospital separations increased by 18% and 9% for people aged 55–64 years and ≥85 years, respectively, between years 2007–2012.2 Elderly patients have complicated care needs, and poor nutritional status is a common problem, with 90% of hospitalized older patients being malnourished or at risk of malnutrition.2 The causes of malnutrition are multifactorial, including physiological, psychological, cognitive and social factors related to aging.3 Acute illness episodes, disease symptoms and medications can
Accepted for publication 3 February 2015. Correspondence: Dr Leila Gholizadeh PhD MSc BSc, Faculty of Health, University of Technology, Sydney, Broadway, Sydney, NSW 2007 (PO Box 123), Australia. Email: [email protected]
374 |
doi: 10.1111/ggi.12532
also adversely affect the nutritional status of elderly patients. The condition is further worsened by hospitalization due to factors such as inadequate food supply, lack of food choice availability and disregarding the patient’s cultural or religious requirements or preferences. Some additional contributing factors include: interruptions to mealtimes by care providers, fasting for tests or procedures, inadequate staffing to assist with patient feeding and poor dining conditions.3,4 Maintaining and promoting patient nutrition is an important aspect of holistic nursing care, affecting patient recovery and outcomes.5 Poor nutritional status is associated with increased hospital stay, healthcare costs, and morbidity and mortality.4 Current standards recommend that the nutritional needs of patients should be met through provision of a healthy and balanced diet, and sufficient food and fluid intake be encouraged.6 This is particularly important in elderly patients because of the high impact of malnutrition on older patients’ general health status and ability to recover from illness.7 A poor nutritional status accelerates muscle tone loss, increasing the risk of instability and falls, and restricting the elderly patient’s ability to mobilize effectively. Weight loss is associated with increased risk of bone loss, hip fractures and pressure © 2015 Japan Geriatrics Society
Nutritional care of elderly patients
ulcers in this population group.4,8 A body mass index less than 22 kg/m2 at discharge is the predictor of developing a new disability in basic daily living activities in older patients.1 The important role of nutrition in health promotion and maintenance is increasingly being appreciated in healthcare systems, and strategies are implemented to improve the nutritional status of patients,9 but there exists a significant gap between the recommended nutritional care and actual practice in many healthcare facilities.5 Malnutrition in patients is not often identified, documented and treated by health professionals,3,10,11 with over half of the cases of malnutrition in elderly patients remaining undiagnosed in acute care settings.3,12 In a study, although nearly three-quarters of physicians felt that dietary counselling was important and was their responsibility, just two-thirds of physicians provided dietary counselling to 40% or less of patients, and spent 5 min or less on the counselling.13 In acute care settings, nurses are in unique positions to intervene at multiple levels to promote patient nutrition care. Because of their holistic care role, nurses have closer contact with patients and are considered as frontline caregivers.14–16 Thus, nurses have a wealth of experience, and can provide valuable first-hand information on the current practices in patient care, help identify facilitators and barriers, and cultivate strategies to optimize patient nutrition care. Furthermore, understanding the attitudes of nurses towards elderly patients and their nutritional care is important, and can affect the care provision. These attitudes are influenced by personal beliefs, knowledge and previous experiences, as well as social and cultural values.17 Similar to many healthcare systems, patient nutrition care has not been a focus of research and practice in Iran. One particular study reported that malnutrition was present in 52% of patients admitted to a general hospital in Tehran.18 Understanding the factors that contribute to nutrition care can help develop strategies to improve the care provision. The present study sought to explore the current practices, facilitators and barriers to the provision of nutritional care to elderly patients in acute care settings in Iran.
Methods The present qualitative study was part of a larger project that aimed to explore elderly care in Iran. The ethics committee of the participating university and hospital approved the study protocol. Participants received information about the study and provided informed consent. Using purposive sampling, 12 registered nurses with minimum of 6 months experience in elderly patient care were recruited from a tertiary general hos© 2015 Japan Geriatrics Society
pital in Tehran, Iran. Elderly was defined as age 65 years and older. Except for a nurse, all those invited agreed to participate in the study. Data were collected through individual interviews, which were carried out by one of the authors, scheduled at the participants’ convenience, carried out at the hospital and they took an average 40 min to complete. An interview guide was used to provide a rough structure to the interviews while allowing unanticipated themes to emerge. Participants were debriefed at the end of each interview to ensure accuracy and completeness of the provided data. Data saturation was achieved after 10 interviews; however, two further interviews were carried out to ensure that theoretical saturation had been reached. The interviews were recorded and transcribed verbatim, and data analysis commenced immediately after the first interview. Data were open-coded by one of the authors who also carried out the interviews, and categories were derived from the coded data. Codes and categories were reviewed and validated by other two authors, and analysis was guided by the interpretive description method.19,20 This method enabled the researchers to describe, interpret and develop a deeper understanding of factors that contribute to nutritional care of elderly patients in a hospital environment.19,20
Results Two themes representing the provision of nutrition care to elderly patients were identified from the interview data: (i) neglected care, with three subthemes of “support but also independence,” “unsupportive environment” and “responsibility of the family;” and (ii) a humanitarian ethic, with two subthemes of “respect and dignity” and “humanitarian care.”
Neglected care Support but also independence Nurses’ discussions on the nutritional care for elderly patients revolved around patient assessment and monitoring, physical support, encouragement, nutrition education, and dignity in care. A rich and nutritious diet was perceived to be vital to maintain the optimal health of an elderly patient and promote patient recovery. Nurses commented on their experiences of providing nutritional care to older patients, asserting that nutritional care begins with an assessment of the patient’s ability to eat independently, and assistance, education and encouragement are provided as required. They believed that elderly patients should be empowered through providing support and reinforcement to take more responsibilities for their health. They should be | 375
L Gholizadeh et al.
encouraged to self-feed themselves, and assistance provided if required. I help them with holding the glass when drinking water, so not to splash it on their clothes. At meal times, I give them a tissue and lift the head of the bed.You have to constantly remind them “Hold the spoon like this . . .” to encourage them to eat their food.
Unsupportive environment There was a perception that overall nutrition care failed to receive priority attention in clinical practice. Nurses criticized food service for inflexible meal times, limited food options, serving patients with monotonous and hard to chew and digest food, and not taking into account the elderly patients’ needs and preferences in preparing and serving meal. The same food every day: rice, stew and a bit of soup. They should get quality food. Elderly patients do not like butter, cheese or jam for breakfast, the same day after day. They should have some porridge with a glass of fresh milk for breakfast . . . but these are not served here.The patient cries “I cannot eat this food, I cannot swallow it” . . . They like soup and other soft foods. The issues related to food quality and quantity along with lack of an appropriate monitoring and evaluation system were perceived by nurses as having adverse effects on nutritional care of elderly patients. We have older patients who are lonely (without a family caregiver), nobody comes to visit them; nobody cleans them or helps with food. A novice nurse gives their medication. Well, the patient’s medications are given and documentation is complete. Everything looks OK legally . . . nobody monitors what the patient eats. Nurses collectively believed that patient nutrition care requires the collaboration of different sectors of the hospital, including the management, kitchen and nursing. They believed that changes for promoting patient nutrition care should start from a managerial level. Allocating an adequate food budget, staff nutrition education programs, and having in place an appropriate assessment and monitoring system could help improve the quality of nutritional care to patients. Sometimes I (nurse manager) say “Hey, let’s go and help out the patient with his food.” As soon as I intervene, the nurse starts assisting the patient. There was also a belief that the use of combined experiences and skills in each working shift can help improve patient nutrition care. It is more common to see patients’ meals are left on the tables untouched when novice nurses are rostered together. Usually, less experienced nurses are less keen to feed patients. Experienced nurses 376 |
are more likely to be involved in patient nutritional care; at least they know how to get someone to help out the patient. The presence of an experienced nurse in each working shift is very important, but this needs the manager’s cooperation of course.
Responsibility of the family Because of factors including high nursing workload, involvement of the family in care giving to elderly patients seemed imperative. Families were often involved in providing nutritional care to elderly patients, such as assisting the patient at meal times, and they were encouraged by nurses to bring in the patient’s favorite foods and between-meal snacks. Nevertheless, patient nutrition care was compromised at times if the family caregiver was not present. In the handover, sometimes I ask why the patient’s food is left on the table; they (nurses) say “Her family caregiver is not here to help.”
Humanitarian ethic Respect and dignity Nurses believed that not only was nutrition important for maintaining physical health, it could also affect elderly patients’ overall well-being. There was a belief that nutrition care entails respect and dignity for an elderly person. Food and mealtimes were perceived to be important for the elderly, and quality food could help improve the general health and well-being of older patients. Taking into consideration the patient’s food preferences and their eating habits, and providing patients with timely assistance were perceived to be the important aspects of respecting the dignity of elderly patients. We should be careful not to spill the food on their clothes when feeding them. They (elderly patients) are very irritable and get offended quickly. Although the importance of high-quality food intake for older patients was acknowledged by the nurses, this aspect of patient care was more likely to be overlooked in a busy shift. A sense of remorse and guilt, however, was described by some nurses who were not able to adequately meet the care needs of older adult patients. We are Muslim, right! But I am sorry I have to say that we often don’t even have enough time to properly check the patients’ vital signs. It is a shame to be a nurse and see patients’ foods left untouched on the tables.
Humanitarian care Lack of time was the most frequently mentioned barrier to the provision of nutritional nursing care in the © 2015 Japan Geriatrics Society
Nutritional care of elderly patients
hospital setting. Furthermore, managers and accordingly nurses placed a high priority on nursing procedures, such as dressing, administering patient medications and attending to doctors’ orders, while they failed to pay attention to patient nutrition care. In view of this, nurses who were engaged in the provision of nutritional care for elderly patients seemed to be rather motivated by sympathy than viewing this aspect of care as a necessary part of professional nursing practice. They (older patients) are helpless and rely on us. I feel sorry for them; so despite my heavy workload, I try to help them at meal times.When caring for older adults, you have to consider humanity. You know, there is not enough recognition for the work you do. Some nurses say there is no salary difference between a dodgy nurse and a nurse who puts her heart and soul into the work.
Discussion Important initiatives are being undertaken at the government level to improve geriatric care in Iran through stimulation of specialty studies. Hence, exploring the current practices in elderly care including patient nutrition is a timely research topic and could inform the development of educational curriculums for geriatric specialties. Training of health professionals in nutrition care is imperative, and helps promote the nutritional assessment and management in elderly patients in acute care settings.21,22 In the current study, nurses expressed positive attitudes towards improving nutritional care for hospitalized patients. Their involvement in nutritional care of elderly patients included providing the patients with physical support, education and encouragement. However, there were cited barriers that interfered with the nurses’ desire to provide optimum nutrition care to patients, including lack of time, shortcomings of the hospital’s food production or delivery processes, and lack of recognition and an appropriate monitoring and evaluation system. Yet, nurses made efforts to compensate for the care deficit by improving the self-care abilities of patients to be able to eat their meal independently and involving family caregivers in elderly patient care. They encouraged families to bring in quality and favorable homemade food, and assist the patient at mealtimes. Although engaging the family in the care of hospitalized patients, particularly activities of daily living, has been documented in the literature,23 and it might help improve the nutritional care of elderly patients, the desire of the family to become involved in patient care should be discussed, and appropriate guidance and supervision provided.24 More importantly, the family’s involvement in patient nutrient care should not replace © 2015 Japan Geriatrics Society
the nurses’ responsibility for providing this aspect of patient care. In the present study, the cultural tradition of respecting older persons in Iran has emerged as a facilitating factor in the provision of care to elderly patients. There was a belief that nutritional care contributes to the wellbeing of elderly patients, satisfying them emotionally, and conveying respect and care for an older person. Individual patient care is important to maintain the dignity of elderly patients and meet their specific needs.14 Nurses described helping an elderly patient with their meal as a satisfying and nourishing experience, and there was a sense of regret and guilt among nurses who were not able to provide nutrition care. Respecting the elderly and caring for ill patients are also highly emphasised in Islam.25 These facilitating factors can be further identified and used in the improvement of care for elderly patients. Nurses criticized the healthcare system for not placing priority and focus on nutrition care. They expressed their dissatisfaction with the current level of nutritional care provided to elderly patients in hospitals, and highlighted the need for promoting this important arena of patient care. These findings support the results of a previous study reporting that 58% of hospitalized patients were not satisfied with the quality of food services in hospitals in Iran, and 49.2% expressed dissatisfaction with the available food options. Furthermore, 60.7% of the patients reported that their special dietary requirements were not met in hospital.26 Lack of recognition and an appropriate monitoring and evaluation system were found to be key factors contributing to the suboptimal nutritional care. Consequently, nutritional care to elderly patients was viewed as compassionate and humanistic care, rather than an integrated part of holistic care. A supportive organization is necessary to promote nutrition care in healthcare facilities. Poor managerial structure and lack of appropriate staff training are associated with patient malnutrition.28 The findings from the present study and the literature suggest that nutritional care is more likely to be compromised where missing a patient’s meal is not as legally important as missing a medical treatment.22 Although nurses described their experiences of providing nutritional care to elderly patients as intrinsically rewarding and fulfilling, patient nutrition care should be emphasised as an important part of holistic nursing, incorporated into patient care, and a minimum set of standards be adopted.23 The implementation of a formal assessment and monitoring system can ensure that appropriate strategies are in place to prevent and treat malnutrition in hospitalized elderly patients.3,22 Use of a valid screening tool, such as the Mini-Nutritional Assessment, has been shown to improve nutrition care of elderly patients in clinical settings, and the Malnutrition Universal Screening Tool can be used to guide | 377
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appropriate actions.29 Yet, importantly, patients should remain the focus of care, and their nutritional values, requirements and preferences should be taken into account. Nurses believed that the main changes in patient nutrition care should be initiated from the management in a top to bottom approach, and staff should be supported through reasonable workload and appropriate rostering, allowing the use of mixed experiences in working shifts. There was a belief that less experienced nurses were more likely to overlook patient nutrition care. Although, there is no research evidence to support this claim, using mixed skills in working shifts helps improve the overall quality of patient care.30 The findings of the present study suggest the need for improvement of nutritional care for older adult patients. Future research should focus on determining the prevalence of malnutrition in hospitalized elderly patients in Iran using appropriate study designs. Patient nutrition care should be emphasized as an integral part of holistic patient care in the education of health professionals, and be promoted through multidisciplinary collaborative work and managerial support. Barriers to nutritional care of elderly patients need to be further studied from the perspective of patients, families, clinicians and managers, and effective strategies developed. Developing and implementing policies that place priorities on nutritional care and supportive environments are necessary to promote patients’ nutritional status.
Disclosure statement No potential conflicts of interest were disclosed.
References 1 The Statistics Portal. Statistics and facts about U.S. hospitals. 2009 [Cited 5 Dec 2013.] Available from URL: http:// www.statista.com/topics/1074/hospitals/ 2 AIHW. Australian Hospital Statistics 2011–2012. Canberra: AIHW, 2013. 3 Loreck E, Chimakurthi R, Steinle NI. Nutritional assessment of the geriatric patient: a comprehensive approach toward evaluating and managing. Clin Geriatr 2012; 20: 20–26. 4 Compan B, di Castri A, Plaze JM, Arnaud-Battandier F. Epidemiological study of malnutrition in elderly patients in acute, sub-acute and long-term care using. J Nutr Health Aging 1999; 3: 146–151. 5 Wentzel Persenius M, Wilde-Larsson B, Hall-Lord ML. To have and to hold nutritional control: balancing between individual and routine care. A grounded theory study. Intensive Crit Care Nurs 2009; 25: 155–162. 6 Sloane PD, Ivey J, Helton M, Barrick AL, Cerna A. Nutritional issues in long-term care. J Am Med Dir Assoc 2008; 9: 476–485. 7 Izawa S, Kuzuya M, Okada K et al. The nutritional status of frail elderly with care needs according to the mininutritional assessment. Clin Nutr 2006; 25: 962–967.
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8 Millen BE, Ohls JC, Ponza M, McCool AC. The Elderly Nutrition Program: an effective national framework for preventive nutrition interventions. J Am Diet Assoc 2002; 102: 234–240. 9 Hospital Caterers Association. Better hospital food. n.d. [Cited 29 Dec 2013.] Available from URL: http://www .hospitalcaterers.org/better-hospital-food/. 10 Zeitz K, Kitson A, Gibb H et al. Working together to improve the care of older people: a new framework for collaboration. J Adv Nurs 2011; 67: 43–55. 11 Maud R, Webster J. Improving nutrition for older people in hospital by assessing current practice. Nurs Times 2009; 105: 18–19. 12 Elia M, Zellipour L, Stratton RJ. To screen or not to screen for adult malnutrition? Clin Nutr 2005; 24: 867–884. 13 Kushner RF. Barriers to providing nutrition counseling by physicians: a survey of primary care practitioners. Prev Med 1995; 24: 546–552. 14 Anderberg P, Lepp M, Berglund A-L, Segesten K. Preserving dignity in caring for older adults: a concept analysis. J Adv Nurs 2007; 59: 635–643. 15 Hamadanizadeh F, Mottahedian Tabrizi E, Sarhangi F, Zigheimat F. A study of attitude among nurses to nursing care of old patients. Trauma 2008; 13: 1–2. 16 Macdonald MT. Nurse- patient encounters: constructing harmony and difficulty. Adv Emerg Nurs J 2007; 29: 73–81. 17 Yu VY. Extrauterine growth restriction in preterm infants: importance of optimizing nutrition in neonatal intensive care units. Croat Med J 2005; 46: 737–743. 18 Hosseinpour-Niazi S, Naderi Z, Delshad M, Mirmiran P. Prevalence of malnutrition in hospitalized patients in Taleghani Hospital in Tehran. J Gorgan Univ Med Sci 2011; 13: 97–106. 19 Thorne S, Kirkham SR, MacDonald-Emes J. Focus on qualitative methods. Interpretive description: a noncategorical qualitative alternative for developing nursing knowledge. Res Nurs Health 1997; 20: 169–177. 20 Thorne S, Kirkham SR, O’Flynn-Magee K. The analytic challenge in interpretive description. Int J Qual Methods 2004; 1: Art. 1. 21 Pradignac A, Petitdemange AM, Séry V, Hubsch A, Ben Ayed C, Schlienger J-L. A nutritional education program for the nursing staff may improve hospitalized patients’ nutritional assessment and management. Eur e-J Clin Nutr Metab 2011; 6: e53–e58. 22 The BAPEN Quality Group. Malnutrition matters: Meeting quality standards in nutritional care. 2010 [Cited 8 Jun 2013.] Available from URL: http://www.bapen.org.uk/ pdfs/toolkit-for-commissioners.pdf. 23 Godfrey H, Cloete J, Dymond E, Long A. An exploration of the hydration care of older people: a qualitative study. Int J Nurs Stud 2012; 49: 1200–1211. 24 Halm MA, Titler MG. Appropriateness of critical care visitation: perceptions of patients, families, nurses, and physicians. J Nurs Care Qual 1990; 5: 25–37. 25 Queensland Health and Islamic Council of Queensland. Health Care Providers’ Handbook on Muslim Patients, 2nd edn. Brisbane: Queensland Health: Division of the Chief Health Officer, 2010. 26 Nasiri H, Sanagoo A, Joubari L. Patients Satisfaction of Nutritional Status in health centers in Gorgan University of Medical Sciences. J Dev Res Nurs Midwifery 2008; 2: 22–28. 27 The Royal College of Nursing. Enhancing nutritional care booklet. 2010 [Cited 12 Aug 2013.] Available from URL: http://www.rcn.org.uk/development/practice/nutrition/ enhancing_nutritional_care. © 2015 Japan Geriatrics Society
Nutritional care of elderly patients 28 Copeman J. Promoting nutrition in older people in nursing and residential homes. Br J Community Nurs 2000; 5: 277– 278. 29 Vellas B, Guigoz Y, Garry PJ et al. The mini nutritional assessment (MNA) and its use in grading the nutritional state of elderly patients. Nutrition 1999; 15: 116–122.
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30 Morrison AL, Beckmann U, Durie M, Carless R, Gillies DM. The effects of nursing staff inexperience (NSI) on the occurrence of adverse patient experiences in ICUs. Aust Crit Care 2001; 14: 116–121.
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Geriatr Gerontol Int 2016; 16: 374–379
ORIGINAL ARTICLE: EPIDEMIOLOGY, CLINICAL PRACTICE AND HEALTH
Nutritional care of elderly patients in acute care settings: A qualitative study Leila Gholizadeh,1 Khadijeh Yazdi,2 Nahid Dehghan Nayeri3 and Eesa Mohammadi4 1 Faculty of Health, University of Technology, Sydney, Sydney New South Wales, Australia; 2Nursing Research Center, Golestan University of Medical Sciences, Gorgan, 3Faculty of Nursing & Midwifery, Tehran University of Medical Science, and 4Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran
Aim: Poor nutritional status is common in older adult patients. The present study aimed to explore barriers and facilitators to nutritional care of elderly patients in acute care settings. Methods: Data were collected through individual face-to-face interviews with 12 registered nurses, and analyzed using interpretive description methodology. Results: Two core themes emerged from the analysis of data: (i) neglected care, with three subthemes of “support but also independence,” “unsupportive environment” and “responsibility of the family;” and (ii) a humanitarian ethic, with two subthemes of “respect and dignity” and “humanitarian care.” Conclusions: As an integral part of holistic care, elderly patient nutrition should be emphasised in health professional education, and promoted through managerial support, multidisciplinary collaborations, and implementation of appropriate monitoring and evaluation systems. Geriatr Gerontol Int 2015; 16: 374–379. Keywords: acute care setting, elderly, nursing, nutrition, qualitative study.
Introduction As the elderly population is growing globally, adjustments in provision of healthcare services are necessary to meet the special needs of older consumers. Older adults are the significant users of healthcare services. In the USA, people aged 65 years and over account for the highest percentage of hospitalizations.1 Similarly, in Australia, the number of hospital separations increased by 18% and 9% for people aged 55–64 years and ≥85 years, respectively, between years 2007–2012.2 Elderly patients have complicated care needs, and poor nutritional status is a common problem, with 90% of hospitalized older patients being malnourished or at risk of malnutrition.2 The causes of malnutrition are multifactorial, including physiological, psychological, cognitive and social factors related to aging.3 Acute illness episodes, disease symptoms and medications can
Accepted for publication 3 February 2015. Correspondence: Dr Leila Gholizadeh PhD MSc BSc, Faculty of Health, University of Technology, Sydney, Broadway, Sydney, NSW 2007 (PO Box 123), Australia. Email: [email protected]
374 |
doi: 10.1111/ggi.12532
also adversely affect the nutritional status of elderly patients. The condition is further worsened by hospitalization due to factors such as inadequate food supply, lack of food choice availability and disregarding the patient’s cultural or religious requirements or preferences. Some additional contributing factors include: interruptions to mealtimes by care providers, fasting for tests or procedures, inadequate staffing to assist with patient feeding and poor dining conditions.3,4 Maintaining and promoting patient nutrition is an important aspect of holistic nursing care, affecting patient recovery and outcomes.5 Poor nutritional status is associated with increased hospital stay, healthcare costs, and morbidity and mortality.4 Current standards recommend that the nutritional needs of patients should be met through provision of a healthy and balanced diet, and sufficient food and fluid intake be encouraged.6 This is particularly important in elderly patients because of the high impact of malnutrition on older patients’ general health status and ability to recover from illness.7 A poor nutritional status accelerates muscle tone loss, increasing the risk of instability and falls, and restricting the elderly patient’s ability to mobilize effectively. Weight loss is associated with increased risk of bone loss, hip fractures and pressure © 2015 Japan Geriatrics Society
Nutritional care of elderly patients
ulcers in this population group.4,8 A body mass index less than 22 kg/m2 at discharge is the predictor of developing a new disability in basic daily living activities in older patients.1 The important role of nutrition in health promotion and maintenance is increasingly being appreciated in healthcare systems, and strategies are implemented to improve the nutritional status of patients,9 but there exists a significant gap between the recommended nutritional care and actual practice in many healthcare facilities.5 Malnutrition in patients is not often identified, documented and treated by health professionals,3,10,11 with over half of the cases of malnutrition in elderly patients remaining undiagnosed in acute care settings.3,12 In a study, although nearly three-quarters of physicians felt that dietary counselling was important and was their responsibility, just two-thirds of physicians provided dietary counselling to 40% or less of patients, and spent 5 min or less on the counselling.13 In acute care settings, nurses are in unique positions to intervene at multiple levels to promote patient nutrition care. Because of their holistic care role, nurses have closer contact with patients and are considered as frontline caregivers.14–16 Thus, nurses have a wealth of experience, and can provide valuable first-hand information on the current practices in patient care, help identify facilitators and barriers, and cultivate strategies to optimize patient nutrition care. Furthermore, understanding the attitudes of nurses towards elderly patients and their nutritional care is important, and can affect the care provision. These attitudes are influenced by personal beliefs, knowledge and previous experiences, as well as social and cultural values.17 Similar to many healthcare systems, patient nutrition care has not been a focus of research and practice in Iran. One particular study reported that malnutrition was present in 52% of patients admitted to a general hospital in Tehran.18 Understanding the factors that contribute to nutrition care can help develop strategies to improve the care provision. The present study sought to explore the current practices, facilitators and barriers to the provision of nutritional care to elderly patients in acute care settings in Iran.
Methods The present qualitative study was part of a larger project that aimed to explore elderly care in Iran. The ethics committee of the participating university and hospital approved the study protocol. Participants received information about the study and provided informed consent. Using purposive sampling, 12 registered nurses with minimum of 6 months experience in elderly patient care were recruited from a tertiary general hos© 2015 Japan Geriatrics Society
pital in Tehran, Iran. Elderly was defined as age 65 years and older. Except for a nurse, all those invited agreed to participate in the study. Data were collected through individual interviews, which were carried out by one of the authors, scheduled at the participants’ convenience, carried out at the hospital and they took an average 40 min to complete. An interview guide was used to provide a rough structure to the interviews while allowing unanticipated themes to emerge. Participants were debriefed at the end of each interview to ensure accuracy and completeness of the provided data. Data saturation was achieved after 10 interviews; however, two further interviews were carried out to ensure that theoretical saturation had been reached. The interviews were recorded and transcribed verbatim, and data analysis commenced immediately after the first interview. Data were open-coded by one of the authors who also carried out the interviews, and categories were derived from the coded data. Codes and categories were reviewed and validated by other two authors, and analysis was guided by the interpretive description method.19,20 This method enabled the researchers to describe, interpret and develop a deeper understanding of factors that contribute to nutritional care of elderly patients in a hospital environment.19,20
Results Two themes representing the provision of nutrition care to elderly patients were identified from the interview data: (i) neglected care, with three subthemes of “support but also independence,” “unsupportive environment” and “responsibility of the family;” and (ii) a humanitarian ethic, with two subthemes of “respect and dignity” and “humanitarian care.”
Neglected care Support but also independence Nurses’ discussions on the nutritional care for elderly patients revolved around patient assessment and monitoring, physical support, encouragement, nutrition education, and dignity in care. A rich and nutritious diet was perceived to be vital to maintain the optimal health of an elderly patient and promote patient recovery. Nurses commented on their experiences of providing nutritional care to older patients, asserting that nutritional care begins with an assessment of the patient’s ability to eat independently, and assistance, education and encouragement are provided as required. They believed that elderly patients should be empowered through providing support and reinforcement to take more responsibilities for their health. They should be | 375
L Gholizadeh et al.
encouraged to self-feed themselves, and assistance provided if required. I help them with holding the glass when drinking water, so not to splash it on their clothes. At meal times, I give them a tissue and lift the head of the bed.You have to constantly remind them “Hold the spoon like this . . .” to encourage them to eat their food.
Unsupportive environment There was a perception that overall nutrition care failed to receive priority attention in clinical practice. Nurses criticized food service for inflexible meal times, limited food options, serving patients with monotonous and hard to chew and digest food, and not taking into account the elderly patients’ needs and preferences in preparing and serving meal. The same food every day: rice, stew and a bit of soup. They should get quality food. Elderly patients do not like butter, cheese or jam for breakfast, the same day after day. They should have some porridge with a glass of fresh milk for breakfast . . . but these are not served here.The patient cries “I cannot eat this food, I cannot swallow it” . . . They like soup and other soft foods. The issues related to food quality and quantity along with lack of an appropriate monitoring and evaluation system were perceived by nurses as having adverse effects on nutritional care of elderly patients. We have older patients who are lonely (without a family caregiver), nobody comes to visit them; nobody cleans them or helps with food. A novice nurse gives their medication. Well, the patient’s medications are given and documentation is complete. Everything looks OK legally . . . nobody monitors what the patient eats. Nurses collectively believed that patient nutrition care requires the collaboration of different sectors of the hospital, including the management, kitchen and nursing. They believed that changes for promoting patient nutrition care should start from a managerial level. Allocating an adequate food budget, staff nutrition education programs, and having in place an appropriate assessment and monitoring system could help improve the quality of nutritional care to patients. Sometimes I (nurse manager) say “Hey, let’s go and help out the patient with his food.” As soon as I intervene, the nurse starts assisting the patient. There was also a belief that the use of combined experiences and skills in each working shift can help improve patient nutrition care. It is more common to see patients’ meals are left on the tables untouched when novice nurses are rostered together. Usually, less experienced nurses are less keen to feed patients. Experienced nurses 376 |
are more likely to be involved in patient nutritional care; at least they know how to get someone to help out the patient. The presence of an experienced nurse in each working shift is very important, but this needs the manager’s cooperation of course.
Responsibility of the family Because of factors including high nursing workload, involvement of the family in care giving to elderly patients seemed imperative. Families were often involved in providing nutritional care to elderly patients, such as assisting the patient at meal times, and they were encouraged by nurses to bring in the patient’s favorite foods and between-meal snacks. Nevertheless, patient nutrition care was compromised at times if the family caregiver was not present. In the handover, sometimes I ask why the patient’s food is left on the table; they (nurses) say “Her family caregiver is not here to help.”
Humanitarian ethic Respect and dignity Nurses believed that not only was nutrition important for maintaining physical health, it could also affect elderly patients’ overall well-being. There was a belief that nutrition care entails respect and dignity for an elderly person. Food and mealtimes were perceived to be important for the elderly, and quality food could help improve the general health and well-being of older patients. Taking into consideration the patient’s food preferences and their eating habits, and providing patients with timely assistance were perceived to be the important aspects of respecting the dignity of elderly patients. We should be careful not to spill the food on their clothes when feeding them. They (elderly patients) are very irritable and get offended quickly. Although the importance of high-quality food intake for older patients was acknowledged by the nurses, this aspect of patient care was more likely to be overlooked in a busy shift. A sense of remorse and guilt, however, was described by some nurses who were not able to adequately meet the care needs of older adult patients. We are Muslim, right! But I am sorry I have to say that we often don’t even have enough time to properly check the patients’ vital signs. It is a shame to be a nurse and see patients’ foods left untouched on the tables.
Humanitarian care Lack of time was the most frequently mentioned barrier to the provision of nutritional nursing care in the © 2015 Japan Geriatrics Society
Nutritional care of elderly patients
hospital setting. Furthermore, managers and accordingly nurses placed a high priority on nursing procedures, such as dressing, administering patient medications and attending to doctors’ orders, while they failed to pay attention to patient nutrition care. In view of this, nurses who were engaged in the provision of nutritional care for elderly patients seemed to be rather motivated by sympathy than viewing this aspect of care as a necessary part of professional nursing practice. They (older patients) are helpless and rely on us. I feel sorry for them; so despite my heavy workload, I try to help them at meal times.When caring for older adults, you have to consider humanity. You know, there is not enough recognition for the work you do. Some nurses say there is no salary difference between a dodgy nurse and a nurse who puts her heart and soul into the work.
Discussion Important initiatives are being undertaken at the government level to improve geriatric care in Iran through stimulation of specialty studies. Hence, exploring the current practices in elderly care including patient nutrition is a timely research topic and could inform the development of educational curriculums for geriatric specialties. Training of health professionals in nutrition care is imperative, and helps promote the nutritional assessment and management in elderly patients in acute care settings.21,22 In the current study, nurses expressed positive attitudes towards improving nutritional care for hospitalized patients. Their involvement in nutritional care of elderly patients included providing the patients with physical support, education and encouragement. However, there were cited barriers that interfered with the nurses’ desire to provide optimum nutrition care to patients, including lack of time, shortcomings of the hospital’s food production or delivery processes, and lack of recognition and an appropriate monitoring and evaluation system. Yet, nurses made efforts to compensate for the care deficit by improving the self-care abilities of patients to be able to eat their meal independently and involving family caregivers in elderly patient care. They encouraged families to bring in quality and favorable homemade food, and assist the patient at mealtimes. Although engaging the family in the care of hospitalized patients, particularly activities of daily living, has been documented in the literature,23 and it might help improve the nutritional care of elderly patients, the desire of the family to become involved in patient care should be discussed, and appropriate guidance and supervision provided.24 More importantly, the family’s involvement in patient nutrient care should not replace © 2015 Japan Geriatrics Society
the nurses’ responsibility for providing this aspect of patient care. In the present study, the cultural tradition of respecting older persons in Iran has emerged as a facilitating factor in the provision of care to elderly patients. There was a belief that nutritional care contributes to the wellbeing of elderly patients, satisfying them emotionally, and conveying respect and care for an older person. Individual patient care is important to maintain the dignity of elderly patients and meet their specific needs.14 Nurses described helping an elderly patient with their meal as a satisfying and nourishing experience, and there was a sense of regret and guilt among nurses who were not able to provide nutrition care. Respecting the elderly and caring for ill patients are also highly emphasised in Islam.25 These facilitating factors can be further identified and used in the improvement of care for elderly patients. Nurses criticized the healthcare system for not placing priority and focus on nutrition care. They expressed their dissatisfaction with the current level of nutritional care provided to elderly patients in hospitals, and highlighted the need for promoting this important arena of patient care. These findings support the results of a previous study reporting that 58% of hospitalized patients were not satisfied with the quality of food services in hospitals in Iran, and 49.2% expressed dissatisfaction with the available food options. Furthermore, 60.7% of the patients reported that their special dietary requirements were not met in hospital.26 Lack of recognition and an appropriate monitoring and evaluation system were found to be key factors contributing to the suboptimal nutritional care. Consequently, nutritional care to elderly patients was viewed as compassionate and humanistic care, rather than an integrated part of holistic care. A supportive organization is necessary to promote nutrition care in healthcare facilities. Poor managerial structure and lack of appropriate staff training are associated with patient malnutrition.28 The findings from the present study and the literature suggest that nutritional care is more likely to be compromised where missing a patient’s meal is not as legally important as missing a medical treatment.22 Although nurses described their experiences of providing nutritional care to elderly patients as intrinsically rewarding and fulfilling, patient nutrition care should be emphasised as an important part of holistic nursing, incorporated into patient care, and a minimum set of standards be adopted.23 The implementation of a formal assessment and monitoring system can ensure that appropriate strategies are in place to prevent and treat malnutrition in hospitalized elderly patients.3,22 Use of a valid screening tool, such as the Mini-Nutritional Assessment, has been shown to improve nutrition care of elderly patients in clinical settings, and the Malnutrition Universal Screening Tool can be used to guide | 377
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appropriate actions.29 Yet, importantly, patients should remain the focus of care, and their nutritional values, requirements and preferences should be taken into account. Nurses believed that the main changes in patient nutrition care should be initiated from the management in a top to bottom approach, and staff should be supported through reasonable workload and appropriate rostering, allowing the use of mixed experiences in working shifts. There was a belief that less experienced nurses were more likely to overlook patient nutrition care. Although, there is no research evidence to support this claim, using mixed skills in working shifts helps improve the overall quality of patient care.30 The findings of the present study suggest the need for improvement of nutritional care for older adult patients. Future research should focus on determining the prevalence of malnutrition in hospitalized elderly patients in Iran using appropriate study designs. Patient nutrition care should be emphasized as an integral part of holistic patient care in the education of health professionals, and be promoted through multidisciplinary collaborative work and managerial support. Barriers to nutritional care of elderly patients need to be further studied from the perspective of patients, families, clinicians and managers, and effective strategies developed. Developing and implementing policies that place priorities on nutritional care and supportive environments are necessary to promote patients’ nutritional status.
Disclosure statement No potential conflicts of interest were disclosed.
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