The feasibility and acceptability of a dementia care training program for registered dietitian nutritionists

There is a need for more Registered Dietitian Nutritionists (RDNs) trained to provide nutritional care to older adults with dementia who experience mealtime difficulties. The purpose of this single-arm, pre/post pilot study was to adapt a generalized dementia care curriculum to the learning needs of RDNs who work with individuals with dementia and to determine the feasibility and acceptability of the adapted program. Using an existing evidence-based dementia care curriculum, the research team identified learning objectives and content pertinent to the scope of RDNs. The adapted program was piloted with RDNs who work with older adults with dementia. Twenty-five RDNs registered for the training while 80% (20) attended the training and completed the post-training survey. All participants agreed that the module met the learning needs of RDNs who work with older adults with dementia, the two-hour workshop was a good use of their time, and the experience and skills gained would be useful in their work as an RDN. Implementation costs totaled $1,310. Based on the post-training feedback, the adapted program was deemed feasible and acceptable by RDN participants, who also expressed interest in using the module to train other caregivers on providing mealtime assistance to older adults with dementia.

Death by Choking or Dysphagia: A Review of Coronial Findings (Australia and Canada): A Picture of Preventable Death, Non-adherence to Written Recommendations, and Lack of Appropriate Supervision

Choking and aspiration pneumonia are a leading cause of preventable death for people in residential care in Australia. In Victoria, in 2018-2019, 59% of deaths of persons in residential care that were referred to the coroner were from aspiration pneumonia. In 2016-2017, in New South Wales, the leading cause of death in people with disability living in residential care was pneumonitis caused by solids and fluids in the lungs. Such deaths are closely linked with swallowing problems (dysphagia) and people with cognitive impairments and multiple health issues, including mental health issues, are most at risk. This commentary focuses on coronial inquests where coroners' findings have identified dysphagia or aspiration pneumonia as a cause of death or a contributor to a person's death. It also includes a summary of the recommendations by coroners which highlight processes that should be implemented to improve the safety of people with dysphagia.

Enrolled nurses' perceptions of providing nutritional care to hospitalised older people in Singapore's acute care setting: A qualitative descriptive study

BACKGROUND

Malnutrition is a growing challenge in health care as its prevalence among hospitalised older people is expected to intensify alongside the rapidly ageing world's population. Singapore's nursing framework adopts enrolled nurses as the main providers to nutritional care, where nutritional care is a process of screening, assessment, intervention, continuous monitoring and documentation. This is the first Asian study conducted on enrolled nurses' perceptions of nutritional care.

OBJECTIVE

To explore enrolled nurses' perceptions of providing nutritional care to hospitalised older people in Singapore's acute care setting.

METHODS

This is a qualitative descriptive study. Individual face-to-face semi-structured interviews using an interview guide were conducted with 15 enrolled nurses from September 2017 to January 2018. The collected data were analysed using content analysis.

RESULTS

Four main categories were identified as follows: (1) The role of enrolled nurses in the provision of nutritional care, (2) Perceived enablers in nutritional care, (3) Perceived challenges in nutritional care and (4) Proposed strategies to improve nutritional care.

CONCLUSION

This study provided insights to the perceived roles of enrolled nurses in nutritional care. It also outlined the enablers and challenges faced by the enrolled nurses and their suggestions to improve nutritional care provision. One critical finding was the need to better engage families and domestic helpers in nutritional care of older people.

IMPLICATIONS FOR PRACTICE

To optimise nutritional care delivery, healthcare institutions should explore ways to engage and involve families and domestic helpers during older patients' mealtimes. Nurses could also educate older people, their families and domestic helpers on the importance of nutritional care during hospitalisation.

Factors influencing the pace of food intake for nursing home residents with dementia: Resident characteristics, staff mealtime assistance and environmental stimulation

AIM

To examine the association of resident characteristics, staff mealtime assistance and environmental stimulation with the pace of food intake.

DESIGN

A secondary analysis of 36 baseline eating videos involving 19 nursing assistants and 15 residents with dementia in eight nursing homes from a communication intervention study.

METHODS

The outcome variable was the pace of food intake (the number of bites and drinks per minute). The exploratory variables were resident characteristics (age, gender, dementia stage and eating performance), staff mealtime assistance (frequency of verbal, visual, partial and full physical assistance) and environmental stimulation. Multi-level models were used to examine the association.

RESULTS

A faster pace of food intake is associated with being male, better eating performance, staff provision of visual and physical assistance and better quality of environmental stimulation that involved interaction. The pace of food intake was not associated with resident age, staff verbal assistance or partial physical assistance.

Exploring staff perceptions and experiences of volunteers and visitors on the hospital ward at mealtimes using an ethnographic approach

AIMS AND OBJECTIVES

To explore multiple perspectives and experiences of volunteer and visitor involvement and interactions at hospital mealtimes. In addition, to understand how the volunteer and visitor role at mealtimes is perceived within the hospital system.

BACKGROUND

Mealtime assistance can improve patients' food intake and mealtime experience. Barriers to providing mealtime assistance include time pressures, staff availability and inadequate communication. Volunteers and visitors can encourage and assist patients at mealtimes. There is a lack of evidence on the relationship between hospital staff, volunteers and visitors.

DESIGN

A qualitative, ethnographic approach.

METHODS

Sixty-seven hours of fieldwork were conducted on two subacute wards within an Australian healthcare network in 2015. Mealtime practices and interactions of hospital staff, volunteers and visitors were observed. Sixty-one staff, volunteers and visitors were interviewed in 75 ethnographic and semi-structured interviews. Data were inductively and thematically analysed.

RESULTS

Three key themes emerged as follows: "help"-volunteers and visitors were considered helpful when they assisted patients at mealtimes, supported well-being and aided staff-patient communication; "hindrance"-staff perceived visitors as negative presences when they inhibited patient progress and impacted staff work practices; and "reality of practice"-visiting hours, visitor engagement in patient therapy and communication between staff, volunteers and visitors were important practical considerations of mealtime involvement.

CONCLUSIONS

The findings show how and why volunteers and visitors can be helpful and unhelpful at hospital mealtimes on subacute wards. More research on the role and contribution of volunteers and visitors on hospital wards will inform future practice in healthcare settings.

RELEVANCE TO CLINICAL PRACTICE

This healthcare organisation should continue to encourage volunteer and visitor involvement at hospital mealtimes. More effort is needed to educate visitors about patients' therapeutic goals and the importance of nutrition. The working relationship between hospital staff, volunteers and visitors should be strengthened to improve nutritional care.

Can trained volunteers improve the mealtime care of older hospital patients? An implementation study in one English hospital

OBJECTIVE

Multinational studies report undernutrition among 39% older inpatients; importantly, malnutrition risk may further increase while in hospital. Contributory factors include insufficient mealtime assistance from time-pressured hospital staff. A pilot study showed trained volunteers could safely improve mealtime care. This study evaluates the wider implementation of a mealtime assistance programme.

DESIGN

Mixed methods prospective quasi-experimental study.

SETTING

Nine wards across Medicine for Older People (MOP), Acute Medical Unit, Orthopaedics and Adult Medicine departments in one English hospital.

PARTICIPANTS

Patients, volunteers, ward staff.

INTERVENTION

Volunteers trained to help patients aged ≥70 years at weekday lunchtime and evening meals.

MAIN OUTCOME MEASURES

The number of volunteers recruited, trained and their activity was recorded. Barriers and enablers to the intervention were explored through interviews and focus groups with patients, ward staff and volunteers. The total cost of the programme was evaluated.

RESULTS

65 volunteers (52 female) helped at 846 meals (median eight/volunteer, range 2-109). The mix of ages (17-77 years) and employment status enabled lunch and evening mealtimes to be covered. Feeding patients was the most common activity volunteers performed, comprising 56% of volunteer interactions on MOP and 34%-35% in other departments. Patients and nurses universally valued the volunteers, who were skilled at encouraging reluctant eaters. Training was seen as essential by volunteers, patients and staff. The volunteers released potential costs of clinical time equivalent to a saving of £27.04/patient/day of healthcare assistant time or £45.04 of newly qualified nurse time above their training costs during the study.

CONCLUSIONS

Patients in all departments had a high level of need for mealtime assistance. Trained volunteers were highly valued by patients and staff. The programme was cost-saving releasing valuable nursing time.

TRIAL REGISTRATION NUMBER

NCT02229019; Pre-results.

Assisted or Protected Mealtimes? Exploring the impact of hospital mealtime practices on meal intake

AIMS

To evaluate the impact of mealtime practices (meal time preparation, assistance and interruptions) on meal intake of inpatients in acute hospital wards.

BACKGROUND

It is common for patients to eat poorly while in hospital, related to patient and illness factors and possibly mealtime practices. Few studies have quantified the impact of mealtime practices on the meal intake of hospital patients.

DESIGN

Cross-sectional study.

METHODS

Structured observations were conducted at 601 meals across four wards (oncology, medical and orthopaedic and vascular surgical) during 2013. Each ward was observed by two dietitians and/or nurses for two breakfasts, lunches and dinners over 2 weeks. Data were collected on patient positioning, mealtime assistance, interruptions and meal intake (visual estimate of plate waste). Associations between mealtime practices and 'good' intake (prospectively defined as ≥75% of meal) were identified using chi-squared tests.

RESULTS

Sitting up for the meal was associated with good intake, compared with lying in bed. Timely mealtime assistance (within 10 minutes) was associated with good intake, compared with delayed or no assistance. Mealtime interruptions had no impact on intake. Forty percent of patients (n = 241) ate half or less of their meal, with 10% (n = 61) eating none of the meal provided.

CONCLUSION

Timely mealtime assistance and positioning for the meal may be important factors that facilitate intake among hospital patients, while mealtime interruptions appeared to have no impact on intake. To improve intake of older inpatients, mealtime programmes should focus on 'assisted mealtimes' rather than only Protected Mealtimes.

Should we implement mealtime assistance in the hospital setting? A systematic literature review with meta-analyses

AIMS AND OBJECTIVES

This review aimed to determine the effect of mealtime assistance provided to hospitalised patients (≥65 years) by nurses, trained staff or volunteers on nutritional and anthropometric outcomes.

BACKGROUND

Malnutrition is a critical issue in hospitals with a reported prevalence of 20-50%. Nutritional supplementation has been associated with increased weight gain, improved function and decreased mortality; however, other system approaches including mealtime assistance may also contribute to improving nutritional intake.

DESIGN

A systematic literature review.

METHODS

Six electronic databases (CINAHL Plus, Cochrane Library, ProQuest Nursing and Allied Health Source, Scopus, PsycINFO and MEDLINE) were searched from their inception to August 2014. Inclusion criteria were hospitalised patients ≥65 years, provided mealtime assistance by nurses, volunteers or trained staff. Studies were examined for quality and risk of bias. Outcome data were combined narratively and by meta-analyses.

RESULTS

From 5458 publications, five studies met the inclusion criteria. Studies were rated neutral and positive according to the Academy of Nutrition and Dietetics Quality Checklist. Adherence to study protocols was not always reported. Meta-analyses demonstrated significantly greater daily energy and protein intake where mealtime assistance was provided. Anthropometric outcomes generally did not differ significantly with mealtime assistance. Observation and sampling bias were noted in several studies.

CONCLUSIONS

There is evidence that mealtime assistance increases daily energy and protein intake in hospitalised patients (≥65 years). More robust research is needed to elucidate whether this strategy may be an effective means of addressing the high prevalence of malnutrition in hospitals.

RELEVANCE TO CLINICAL PRACTICE

The evidence identified suggests that mealtime assistance provided to hospitalised older patients (≥65 years) leads to a statistically significant increase in energy and protein intake. For many patients, this increase in both energy and protein intake will be clinically significant, reducing the gap between requirements and actual intake.

The feasibility and acceptability of training volunteer mealtime assistants to help older acute hospital inpatients: the Southampton Mealtime Assistance Study

AIMS AND OBJECTIVES

To determine the feasibility and acceptability of using trained volunteers as mealtime assistants for older hospital inpatients.

BACKGROUND

Poor nutrition among hospitalised older patients is common in many countries and associated with poor outcomes. Competing time pressures on nursing staff may make it difficult to prioritise mealtime assistance especially on wards where many patients need help.

DESIGN

Mixed methods evaluation of the introduction of trained volunteer mealtime assistants on an acute female medicine for older people ward in a teaching hospital in England.

METHODS

A training programme was developed for volunteers who assisted female inpatients aged 70 years and over on weekday lunchtimes. The feasibility of using volunteers was determined by the proportion recruited, trained, and their activity and retention over one year. The acceptability of the training and of the volunteers' role was obtained through interviews and focus groups with 12 volunteers, nine patients and 17 nursing staff.

RESULTS

Fifty-nine potential volunteers were identified: 38 attended a training session, of whom 29 delivered mealtime assistance, including feeding, to 3911 (76%) ward patients during the year (mean duration of assistance 5·5 months). The volunteers were positive about the practical aspects of training and ongoing support provided. They were highly valued by patients and ward staff and have continued to volunteer.

CONCLUSIONS

Volunteers can be recruited and trained to help acutely unwell older female inpatients at mealtimes, including feeding. This assistance is sustainable and is valued.

RELEVANCE TO CLINICAL PRACTICE

This paper describes a successful method for recruitment, training and retention of volunteer mealtime assistants. It includes a profile of those volunteers who provided the most assistance, details of the training programme and role of the volunteers and could be replicated by nursing staff in other healthcare units.

Southampton Mealtime Assistance Study: design and methods

BACKGROUND

Malnutrition is common in older people in hospital and is associated with adverse clinical outcomes including increased mortality, morbidity and length of stay. This has raised concerns about the nutrition and diet of hospital in-patients. A number of factors may contribute to low dietary intakes in hospital, including acute illness and cognitive impairment among in-patients. The extent to which other factors influence intake such as a lack of help at mealtimes, for patients who require assistance with eating, is uncertain. This study aims to evaluate the effectiveness of using trained volunteer mealtime assistants to help patients on an acute medical ward for older people at mealtimes.

METHODS/DESIGN

The study design is quasi-experimental with a before (year one) and after (year two) comparison of patients on the intervention ward and parallel comparison with patients on a control ward in the same department. The intervention in the second year was the provision of trained volunteer mealtime assistance to patients in the intervention ward. There were three components of data collection that were repeated in both years on both wards. The first (primary) outcome was patients' dietary intake, collected as individual patient records and as ward-level balance data over 24 hour periods. The second was clinical outcome data assessed on admission and discharge from both wards, and 6 and 12 months after discharge. Finally qualitative data on the views and experience of patients, carers, staff and volunteers was collected through interviews and focus groups in both years to allow a mixed-method evaluation of the intervention.

DISCUSSION

The study will describe the effect of provision of trained volunteer mealtime assistants on the dietary intake of older medical in-patients. The association between dietary intake and clinical outcomes including malnutrition risk, body composition, grip strength, length of hospital stay and mortality will also be determined. An important component of the study is the use of qualitative approaches to determine the views of patients, relatives, staff and volunteers on nutrition in hospital and the impact of mealtime assistance.

TRIAL REGISTRATION

Trial registered with ClinicalTrials.gov NCTO1647204.