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International Journal of Nursing Practice 2015; 21: 635–644

RESEARCH PAPER

Prevalence of ‘being at risk of malnutrition’ and associated factors in adult patients receiving nursing care at home in Belgium Bart Geurden RN MSc Lecturer, Department of Nursing and Midwifery, Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium; Department of Health Care, Karel de Grote University College, Antwerp, Belgium

Erik Franck MPsych PhD Professor, Department of Nursing and Midwifery, Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium; Department of Health Care, Karel de Grote University College, Antwerp, Belgium

Maja Lopez Hartmann RN MSc Lecturer, Department of Primary and Interdisciplinary Care, Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium; Department of Health Care, Karel de Grote University College, Antwerp, Belgium

Joost Weyler MD PhD Professor, Department of Epidemiology and Social Medicine, Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium

Dirk Ysebaert MD PhD Professor, Department of Abdominal Surgery & Transplantation, Antwerp University Hospital, University of Antwerp, Edegem, Belgium

Accepted for publication February 2014 Geurden B, Franck E, Lopez Hartmann M, Weyler J, Ysebaert D. International Journal of Nursing Practice 2015; 21: 635–644 Prevalence of ‘being at risk of malnutrition’ and associated factors in adult patients receiving nursing care at home in Belgium Malnutrition is a known problem in hospitals and nursing homes. This study aims to evaluate the prevalence of being at risk of malnutrition in community living adults receiving homecare nursing and to determine factors independently associated with this risk of malnutrition. Furthermore, it also aimed to describe aspects of current nutritional nursing care. Patients (n = 100) are screened with the Malnutrition Universal Screening Tool to evaluate their risk of malnutrition. A patient survey was used to analyse associated factors. In this population, 29% are at risk for malnutrition. Following a multivariate logistic regression analysis, ‘loss of appetite’ proved the most important factor. A survey for nurses (n = 61) revealed low awareness, poor knowledge, poor communication between stakeholders and a moderate approach of malnutrition. These findings should encourage homecare nurses to use a recommended screening tool for malnutrition and

Correspondence: Bart Geurden, Department of Nursing and Midwifery, Faculty of Medicine and Health Sciences, University of Antwerpen, Universiteitsplein 1, 2610 Wilrijk, Antwerp, Belgium. Email: [email protected] doi:10.1111/ijn.12341

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to actively observe and report loss of appetite to initiate the prescription of individual tailored interventions. Belgian homecare nurses’ management does not yet fully comply with international recommendations. Additional training in nutritional nursing care and screening methods for malnutrition is needed. Systematic screening should be further developed and evaluated in this at-risk population. Key words: anorexia, homecare services, home health aides, malnutrition, nurses.

INTRODUCTION Malnutrition continues to be a common finding in different health-care settings1–3 and is related to higher rates of morbidity and mortality.4 In the Belgian health-care system, the epidemiology of malnutrition and associated factors has been well described for certain populations. Using the Mini Nutritional Assessment (MNA), it was found that 43% of older adult patients in Belgian hospitals were at risk for malnutrition and 33% were malnourished,5 whereas the prevalence in Belgian nursing home residents was 39% and 19%, respectively.2 To increase knowledge about malnutrition in particular populations of the Belgian health-care system, we investigated the prevalence of being at risk of malnutrition in adult patients receiving professional nursing care at home. Multiple definitions are used to define malnutrition. However, a universally accepted definition for malnutrition does not yet exist.6,7 The following definition by Stratton et al.8 (p. 3) is increasingly cited: ‘Malnutrition is a state of nutrition in which a deficiency or excess (or imbalance) of energy, protein, and other nutrients causes measurable adverse effects on tissue/body form (body shape, size and composition) and function, and clinical outcome’. Although the term malnutrition can refer to both under- and overnutrition, it is used here to refer to undernutrition. Several factors are thought to be associated with malnutrition. These factors include immobility, dementia, depression, difficulties in eating and swallowing, and the presence of a wound/pressure ulcer.9–13 Furthermore, vulnerability for malnutrition increases with age and weakening of functional capabilities.11 Evidence is accumulating, however, to support the idea that insufficient food intake is the main reason for the development and progression of disease-related malnutrition in adults.5,6,13 In disease-related malnutrition, the loss of both lean body mass and fat mass is related to inflammatory activity14 which consequently might lead to various adverse clinical outcomes such as delayed wound healing,15,16 fatigue and weakness,17 risk of infection and other © 2014 Wiley Publishing Asia Pty Ltd

complications,18 increased mortality, length of stay in hospital,19 a decreased quality of life,20–22 rate of general practitioner (GP) visits, prescription rates, hospital (re)admissions, and need for care-home admission or home health care.23 At any given point in time, the vast majority (93%) of people at risk of malnutrition (in the UK) are living in the community, 5% are in care homes and 2% are in a hospital.24 Recently published prevalence rates for home health care vary between 12% and 53% depending on screening methods and casemix.25–28 However, data on the prevalence of malnutrition in community-dwelling adults receiving nursing care at home in Belgium are unknown. In Belgium, nursing care at home is provided by nurses employed by private not-for-profit organizations and by self-employed nurses.29 There are two qualification levels of nurses: bachelor level and diploma level. All are referred to as ‘registered nurses’ (RN). Nurses of both qualification levels are authorized to perform all clinical nursing interventions.29 In recent years, the organizational context and the complexity of care provided in Belgian home nursing has changed due to shorter lengths of hospital stays, increased importance of day hospital admissions, higher demands for collaboration between nurses, higher need for integration of nursing care in primary care, integrated services for homecare and increased interest of home nurses to participate in shared care provisions with hospitals.29 RNs providing nursing care at home can play an essential role in both prevention and screening or treatment of malnutrition because of their everyday contact with patients living at home. However, in Belgium, little is known about current nursing practices in home health care concerning systematic screening and prevention or treatment of malnutrition.

Aims In the present study, we aimed to investigate the prevalence rates of malnutrition risk and associated factors among free living adult patients living in Belgium that are receiving professional nursing care at home. Second, this

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study aims to describe aspects of the current nursing practice concerning systematic screening and prevention or treatment of malnutrition in homecare.

METHODS Study design We used a cross sectional study design of randomly selected community-dwelling adults receiving professional nursing care at home in a very dense urban area of Antwerp, Belgium. This study was approved by the Ethics Review Committee on Human Research of the Antwerp University Hospital.

Sample and participants Patient sample During a 3 month period, we visited a large homecare service and accompanied 17 of their RNs while they were providing patient care. Inclusion criteria were age (≥ 18 years) and receiving nursing care at home on a very regular basis (≥ 3 times a week), regardless of diagnosis. These home visits resulted in a study sample of 100 consecutive individual patients. All these patients had at least one chronic disease; 13% were acutely ill with a significant impact on appetite and food intake and 39% were hospitalized in the last 3 months. Nursing care consisted mainly of assistance with activities of daily living, administering prescribed medications, diabetic care, and wound care or a combination of these interventions. Due to practical and ethical reasons, we were only allowed to visit patients at home in the presence of the patients’ regular nurse. In order to not disturb the continuity of care, we only had a short amount of time to measure anthropometrics and complete a short survey.

Nurses sample The second study population consisted of 61 RNs, all employed in the same homecare service, including the 17 RNs responsible for the patients involved in this study. University college is the highest level of education in 90% of the nurse participants.

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attached to the weigh chair (SECA model 221, maximum 230 cm and d = 0.5 cm). Measurements were used to calculate patients’ body mass index (BMI) and percentage unintended loss of body weight. These results were used to complete the Malnutrition Universal Screening Tool (MUST) (see http://www.bapen.org.uk). According to the British Association of Parenteral and Enteral Nutrition (BAPEN) (see http://www.bapen.org.uk/screening-formalnutrition/must/must-report), MUST has face validity, content validity, concurrent validity with a range of other screening tools30 and predictive validity. In the community-dwelling population, MUST predicts rates of hospital admissions and GP visits, and shows that appropriate nutritional intervention improves outcomes. MUST has been made user friendly through extensive field testing by a wide range of professionals in different health-care settings. The tool is internally consistent and reliable, and has very good to excellent reproducibility when different observers assess the same patients (kappa values between 0.8 and 1.0).30 MUST assigns risk for malnutrition based on baseline BMI (< 18.5 kg/m = 2; 18.5–20 = 1; > 20 = 0), unplanned weight loss in 3–6 months (< 5% = 0; 5–10% = 1; > 10% = 2), and acutely ill with no nutritional intake or likelihood of no intake for more than 5 days (= 2). A total score of 2 or more indicates high risk of malnutrition with treatment recommended. A score of 1 is interpreted as medium risk with recommended follow-up. A score of 0 indicates low risk with continual care as usual. MUST is a validated screening tool recommended for use in homecare by the American Society for Parenteral and Enteral Nutrition,31 the European Society for Clinical Nutrition and Metabolism (ESPEN),32 the BAPEN and its Standing Committee, the Malnutrition Action Group. In 2013, the National Institute for Health and Care Excellence (NICE) recommended MUST for staff working in hospitals, primary care and care homes to aid implementation on the new NICE Quality Standard for Nutritional Support of Adults (see http:// guidance.nice.org.uk/QS24).

Measures

Surveys

All patients reported their normal body weight before their actual body weight and height were taken. All measurements were executed by one researcher using a calibrated weigh chair (SECA Model 954 1309103, maximum 200 kg and d = 0.1 kg; Medical Measuring Systems and Scales, Birmingham, UK) and a stadiometer,

Two short surveys were used in this study: one for patients and one for nurses. The patient survey (see Table 1) included patient characteristics and yes/no questions about the presence of major risk factors for malnutrition. Selection of potential undernutrition-related questions is based on consensus literature. Questions about eating problems, © 2014 Wiley Publishing Asia Pty Ltd

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Table 1 Patient characteristics and risk for malnutrition according to the Malnutrition Universal Screening Tool (MUST) MUST

Body weight (kg) Height (cm) Body mass index % Loss of body weight Acute ill, no oral intake 5 days (N (%)) Survey Age [Mean, (SD)] Female Hospitalized in the last 3 months Last visit GP (days ago) (Mean, (SD)) Eating problem (Ep) Swallowing problem Loss of appetite (Loa) Concerned about Ep or Loa GP informed about Ep or Loa Nutritional intervention prescribed Independent shopping Independent cooking One warm meal every day Informal care present Professional home care† present

Patients (N = 100) MUST-score 0 n = 71 Mean (SD)

MUST-score ≥ 1 n = 29 Mean (SD)

P

72.9 (14.2) 166 (7.6) 26.4 (4.2) 0.51 (1.12) 0 (0) N (%) 74.8 (17.6) 53 (74.6) 24 (33.8) 19.9 (19.3) 0 (0) 0 (0) 6 (8.4) 2 (2.8) 1 (1.4) 0 (0) 32 (45.0) 41 (57.7) 51 (71.8) 58 (81.6) 47 (66.1)

59.7 (11.2) 166 (7.6) 21.9 (3.3) 8.06 (6.9) 13 (44.8) N (%) 76.1 (16.0) 25 (86.2) 15 (51.7) 9.5 (14.1) 19 (65.5) 0 (0) 28 (96.5) 16 (55.1) 14 (48.2) 0 (0) 10 (34.4) 13 (44.8) 21 (72.4) 24 (82.7) 19 (65.5)

< 0.001 1.000 < 0.001 < 0.001 < 0.001 0.73 0.289 0.116 0.01 < 0.001 – < 0.001 < 0.001 < 0.001 – 0.378 0.274 1.000 1.000 1.000

†

Professional home caregivers other than registered nurses. GP, general practitioner; SD, standard deviation.

swallowing problems and loss of appetite are based on the research of Westergren et al.13 Those about recent hospitalization and last visit to GP are based on Yang et al.,23 and the use of oral nutritional support is based on Elia and Russell24 and Okumura.25 All other questions are inspired by the work of Albert33 and Arvanitakis et al.34 The second survey (see Table 2) was completed by all RNs (n = 61) at the start of the research and before the anthropometric measurements of the patients were taken. This paper-based survey included nurses’ characteristics and 10 statements to which nurses could agree or not agree. These statements included items like the risk and the importance of malnutrition in patients receiving nursing care at home; patients’ and their family caregivers’ concern about eating problems and loss of appetite; nurses’ knowledge about screening of malnutrition; and nurses’ communication with the general practitioner © 2014 Wiley Publishing Asia Pty Ltd

about patients’ nutritional problems. To assess current awareness about the prevalence of malnutrition in patients living at home, we asked the nurses who are currently responsible for the 100 patients in this study (n = 17) to estimate, in percent, the prevalence of risk of malnutrition in their patients.

Data analysis MUST-screening results are dichotomized in patients not at risk for malnutrition (total MUST-score 0) and patients with medium and high risk for malnutrition (total MUSTscore ≥ 1). Data are reported as mean ± standard deviation, median, range, and as absolute values or percentages. Differences between both groups are evaluated, and analysis included unpaired t-tests and chi-squared-tests. Finally, to independently investigate associated factors, we conducted multiple logistic regression analyses with

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Table 2 Characteristics of the homecare nurses cohort Nurses’ characteristics

N = 61 N (%)

Women Age [Mean, (SD)] Job experience in homecare (in months) [Mean, (SD)] Employed full time University college as highest level of education

56 (91.8) 36.5 (9.4) 130.7 (97.8) 28 (45.9) 55 (90.2)

Statements

Yes N (%)

Malnutrition is not common in homecare patients. The risk for malnutrition in homecare patients is low. Nutritional care is a priority in homecare nursing. Weighing patients is routine in homecare nursing. I can calculate the body mass index. I can apply the Malnutrition Universal Screening Tool. I can apply the Mini Nutritional Assessment. Informal caregivers are concerned about eating problems in their patient. Patients themselves are concerned about their eating problem. I always inform the GP if my patient has an eating problem.

33 (54.1) 39 (63.9) 26 (42.6) 23 (37.7) 28 (45.9) 0 (0) 0 (0) 45 (73.8) 32 (52.5) 27 (44.3)

M, mean; SD, standard deviation.

malnutrition as the dependent variable. A P-value of < 0.05 was considered to be significant. Data were analysed using the Statistical Package for the Social Sciences (SPSS version 18; Chicago, IL, USA).

RESULTS Patients

According to MUST, 13% of all patients scored ≥ 1 and another 16% scored ≥ 2, indicating that 29% were at moderate to high risk for malnutrition (see Table 1). The majority of all patients in this study were women (78%) and 81% of all patients were aged 65 years and older (mean 75.2, SD 17, median 80, range 20–98). There were no significant differences for age (P = 0.73) or sex (P = 0.289) between patients at risk of malnutrition and those who were not at risk for malnutrition (see Table 1).

A MUST-score ≥ 1 was measured in 28.4% (n = 23) of all patients aged 65 years or older (n = 81) and in 31.6% (n = 6) of patients < 65 years of age (n = 19). Patients at risk of malnutrition were also significantly more acutely ill with an important impact on their food intake (P < 0.001), and their last visit (in days ago) to their GP was more recent (mean 9.5, SD 14.1) than in patients not at risk (mean 19.9, SD 19.3). Patients at risk were not significantly more hospitalized in the weeks prior to the inquiry (P = 0.116). The patient survey revealed significant differences between both groups (see Table 1). Patients at risk had significantly (P < 0.001) more eating problems such as difficulties with chewing or swallowing and loss of appetite. Almost one in two patients at risk of malnutrition was not concerned about eating problems or loss of appetite (45%), and had not informed their GP about eating problems or loss of appetite (52%). According to the recommendations in MUST, 16% of all patients in this study needed nutritional treatment. However, none of the patients at risk were actually using prescribed oral nutritional supplements (ONS). The survey also questioned the patients’ physical independence in buying and preparing their own meals. There were no significant differences for these activities between patients at risk of malnutrition and those not at risk for malnutrition. The most remarkable finding was that one in four patients in both groups was not eating at least one hot meal a day despite the similar presence of informal caregivers in more than 80% of the cases and professional homecare providers other than registered nurses in more than 60% of the cases (see Table 1). To independently investigate associated factors, we used a multiple logistic regression with malnutrition (yes/ no) as the dependent variable and patient characteristics as predictors. In this analysis, only the characteristic ‘loss of appetite’ was related to malnutrition (P < 0.001).

Nurses The majority of all nurses (n = 61) in this study were women (91.8%), with a mean age of 36.5 years and a mean job experience in homecare nursing of more than 10 years. Almost half of the nurses (46%) were employed full time. The highest level of education was bachelor level (90%) or diploma level (10%) (see Table 2). Based on their observations, the nurses responsible for the patients in this study (n = 17) estimated that 13.2% (SD 12.8) of their patients (n = 100) were malnourished. © 2014 Wiley Publishing Asia Pty Ltd

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Of all nurses (n = 61), 54% were convinced that malnutrition was not a common problem in patients living at home and 64% indicated that the risk of malnutrition in homecare patients is low. More than half of all the nurses (57%) indicated that nutritional care is not a priority in homecare nursing. In addition, 62% were not routinely weighing their patients and one in two (54%) were not capable of calculating BMI (see Table 2). Recommended screening tools for malnutrition like the MUST or the MNA were not known. Finally, according to the nurses, almost three in four (73.8%) informal caregivers and one in two (52.5%) patients were concerned about eating problems. Only 44.3% of the nurses always informed the GP about eating problems in their patients (see Table 2).

DISCUSSION This cross-sectional study reports a prevalence of 29% risk of malnutrition in community-dwelling adult patients receiving nursing care at home in Belgium. Of all the included associated factors of malnutrition, only the characteristic ‘loss of appetite’ was independent and statistically significantly related to malnutrition (P < 0.001). Furthermore, we found low awareness, a moderate approach to malnutrition and a discrepancy between nurses’ estimation of the extent of malnutrition in their patients when compared with the MUST screening. Comparing this rather high prevalence with other studies in the field is a real challenge. Depending on the operationalization of malnutrition, most studies used different screening tools and elements, as well as populations and settings compared with this study. Yet a general comparison shows that our prevalence range is in the middle of that indicated by Meijers et al.28 (21.7%) in adult patients receiving nursing care at home in The Netherlands and by Schilp et al.35 (35%) in Dutch community-dwelling older individuals. Schilp et al. assessed the nutritional status by the Short Nutritional Assessment Questionnaire 65+, which combines four criteria: involuntary weight loss in the last 6 months, mid-upper arm circumference, poor appetite last week, difficulties walking stairs; this set of criteria shows good face validity and moderate predictive validity.36 Meijers et al.28 assessed the nutritional status in patients receiving nursing care at home using a combination of three criteria: BMI, undesired weight loss and nutritional intake. MUST combines the same three components because they can independently influence clinical outcomes.8 Furthermore, MUST could be used to © 2014 Wiley Publishing Asia Pty Ltd

approximate implementation of the nutritional screening that is recommended or required by key initiatives in the UK, such as the National Framework for Older People, Essence of Care, Care Homes for Older People (Care Standards Act), and Food, Fluid and Nutritional Care in Hospitals (Scotland) (see http://www.bapen.org.uk/ pdfs/must/must_10points.pdf). In this study, the majority (81%) of patients were 65 years of age or older; 78% of patients were women. Only 4 out of the 22 male patients in this study are at risk of malnutrition. Therefore, we decided to refrain from statistical analysis on the differences between male and female patients regarding risk of malnutrition. Due to logistic reasons, we were not able to use additional validated scales to assess and describe a more detailed casemix. Our limited survey revealed that all patients at risk of malnutrition visited their GP more recently (P = 0.01); this suggests that their health status might be more problematic than that of normal fed patients. None of the included patients suffered from swallowing problems. However, one in five patients (19%) had at least one eating problem such as difficulties chewing, painful mouth or failing motor skills causing lower food intake. Westergren et al.37 found that in addition to advanced age and diagnostic group, low food intake is the only other component associated with malnutrition. In line with this finding, all patients in our study with an eating problem were at moderate to high risk of malnutrition even though eating problems are not an element in the MUST assessment. Yet only one in three patients with eating problems and one in two patients with loss of appetite (data not shown) are concerned about these conditions, indicating that a lack of knowledge in these patients about the potential implications might exist. Consequently, there is room for educational nursing interventions. In contrast with other studies,38–40 our findings indicate that patients at risk of malnutrition are not significantly more recently hospitalized than patients without risk of malnutrition. This might be due to the rather small sample sizes of the present study. Also, the design of this study did not allow for a causal exploration of this finding in depth. However, it is reasonable to consider that hospitalization and the reasons for hospitalization, such as the presence of a specific illness, might also accelerate the process of malnutrition. This association needs further attention in both practice and future research.

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The most at-risk groups in the community are often those who are housebound or who have limited mobility and do not have a social support network in place to assist with tasks such as shopping and cooking.21 In our study, we found no significant difference in formal and/or family support to assist with these tasks between both groups. Yet one in four patients in both groups were not eating at least one hot meal a day. Soini et al.,40 in their study of homecare patients, found that one-third of the participants had an unbalanced diet and approximately half received assistance with shopping and food preparation from an informal caregiver. Our finding is also in line with the study of meal frequency and composition by Quandt et al.41 in which they found that only 65% of adults consumed three meals every day and less than one-third regularly snacked; patterns in the use of hot, cooked meals and cold, uncooked meals, varied by sociodemographic characteristics. Because all patients in our study had professional nursing care at home and a similar high amount of other formal caregivers and family care providers, they should in fact have benefited from a high degree of control in the quantity and quality of their food intake. In our study, loss of appetite was found to be independently associated with a MUST-score ≥ 1. For homecare nurses, this indicates that in addition to the use of a recommended screening tool for malnutrition, loss of appetite is probably the most relevant parameter to observe, report and treat to prevent the many consequences of malnutrition in patients and/or to initiate a tailored nutritional intervention. Yet in contrast with evidence-based recommendations,30,31,33 the nurses in this study were not screening for malnutrition and therefore, consequently underestimating the prevalence of malnutrition in their patients. Ockenga et al.42 found that the number of patients with malnutrition detected increases markedly when screening procedures are implemented. Less awareness of the prevalence of malnutrition in homecare patients and a low level of priority for nutritional care might be explained by nurses’ lack of knowledge about screening tools and screening process for malnutrition. Internationally, the most recommended screening tools for malnutrition in the homecare setting are the MUST43 and the MNA.44 Both extensively validated tools were, however, not yet known or used by the RNs in this study. This might also explain the nurses’ low level of reporting of eating problems or loss of appetite to the GPs. In the Belgian health-care context, RNs are authorized to perform all clinical nursing interventions including patient

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education about nutrition and balanced food intake. However, this does not include referral to a dietician or prescribing food supplements; in Belgium, only a GP is authorized to do this. Therefore, reporting loss of appetite or eating problems to the GP is an important, if not the only, trigger to start a prescribed tailored nutritional intervention. The poor communication between RNs and GPs and patients and their GP probably explains why none of the patients in this study was receiving a tailored nutritional interventions or using prescribed oral nutritional supplements. A possible barrier in this matter could be compliance44 because of costs and non-reimbursement of ONS in the Belgian home health care. Another and even more important barrier is the nationally regulated financial compensation for homecare nurses which is based on performance. This financial arrangement uses an encoded list of nursing activities and interventions, which is prepared and maintained by the government. Only nursing activities, like screening and assessment for malnutrition or nursing interventions like patient education and many others, are not compensated because they are not yet encoded. Such lack of compensation possibly impedes recommended good practice in nutritional nursing care at home. Finally, some limitations must be accounted for. First is the use of the cross-sectional study design and a small sample of patients. This design did not allow reporting on a causal relationship between malnutrition and antecedents. A longitudinal design and a large sample of patients are recommended to address this limitation. Second, due to the limited time spent with each patient, eating problems, swallowing problems and loss of appetite were reported by the patient instead of being observed by the researcher. Also, cognitive and physical decline, depressive symptoms and emotional changes were not assessed. A final limitation consists of the voluntary participation of the nurses in this study. Increased awareness of malnutrition might have been present in the participating nurses influencing their estimation of the prevalence of malnutrition. On the other hand, this study can be repeated over time to assess possible improvements in RNs’ awareness, knowledge and management of malnutrition in home health care.

CONCLUSION In sum, risk of malnutrition is a highly prevalent condition in Belgian community-dwelling adult patients receiving nursing care at home. Several factors associated with risk © 2014 Wiley Publishing Asia Pty Ltd

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of malnutrition were analysed in this study and, following a multivariate logistic regression analysis, ‘loss of appetite’ proved to be the most important factor. This finding should urge homecare nurses to actively observe and report loss of appetite to initiate the prescription of a tailored nutritional intervention. Patients themselves are not always concerned about their loss of appetite, indicating that there is a need for educational nursing interventions. Belgian homecare nurses’ management does not yet fully comply with international recommendations. Our survey for nurses revealed low awareness, poor knowledge and poor communication between stakeholders. Systematic screening should be further developed and evaluated in this at-risk population. Additional training in nutritional nursing care and screening methods for malnutrition are needed.

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ACKNOWLEDGEMENTS

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The authors would like to thank Hilde Van Loon, care manager, and all nurses of Wit-Gele Kruis, Antwerp, Belgium, who were involved in the data acquisition for this study.

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DECLARATION OF INTEREST The authors report no conflicts of interest. They alone are responsible for the content and writing of the paper.

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