What Nursing Interventions Can Be Used to Improve Feeding and Eating for the Client

Primary Reviewer

Gail Whitelock BSc, CFJBI, APD^{one ii}

¹MSc Clinical Sciences Candidate, The Joanna Briggs Institute, Faculty of Health Sciences, The University of Adelaide, Adelaide SA 5005, Commonwealth of australia.

²Senior Dietitian, Department of Clinical Dietetics, Royal Adelaide Hospital, Adelaide, SA 5000, Commonwealth of australia

[e-mail protected]

Secondary Reviewer:

Mary-Anne Ramis BN^{i 3}

³Research Nurse, Nursing Research Center, Mater Wellness Service, South Brisbane, QLD 4101, Australia

[email protected]

Review Objective/Question

The objective of this review is to identify, assess and synthesise the bachelor prove on the effectiveness of mealtime interventions that amend nutritional intake in adult patients in the acute care setting. Interventions reviewed will non include nutritional interventions that are related to the bodily food or fluids offered or ordered, for or by the patient, just rather will include interventions that evaluate or change the environment and/or circumstances of the patient's mealtimes. Mealtimes volition exist taken to hateful both designated mealtimes and/or other times when patients may swallow or drink.

The review question is: What are the effects of identified mealtime interventions in improving the nutritional intake of adult patients in the acute intendance setting?

Background

Malnutrition has been well documented over the last few decades as being a common problem in astute care hospitals which is often unrecognised and untreated. ^ane-3 In the astute care setting malnutrition is known to consequence betwixt 20-50% of patients depending on the primary disease state and criteria used to determine nutritional status. ^1,2,iv Malnutrition is associated with a number of adverse complications including increased morbidity and mortality, delayed wound healing, increased infection rates, functional decline and increased length of stay in hospital.^i,4,five

Malnutrition can be taken to mean both under- and over-diet. Even so, despite this definition, it is under-nutrition which has been adopted past many healthcare professionals to exist the common meaning of malnutrition. Nether-nutrition has been divers by Allison as "a state of free energy, protein or other specific nutrient deficiency which produces a measurable change in body function and is associated with worse outcome from illness as well as being specifically reversed by nutritional support".^half-dozen For the purposes of this systematic review the term malnutrition will refer to the state of protein energy under-nutrition.

There have been numerous studies addressing the field of study of malnutrition in the acute intendance setting by healthcare professionals from a variety of disciplines. Many focus on aspects of identifying malnutrition and its treatment through nutritional provision like modified menus, oral nutritional supplements or enteral feeding.^7,8 However, despite the development in recent years of validated nutritional screening tools to assist in identifying patients at risk of malnutrition and the technological advances in patient nutritional provision through enteral feeding products, oral nutritional supplements and food service production malnutrition remains an issue in astute care hospitals which is costing healthcare providers and patients alike.^4,9.

Even when diagnosed as existence malnourished or identified as being at gamble of malnutrition and provided with an individualised tailored repast program, patients may however accept an inadequate nutritional intake due to suboptimal ecology factors, organisational and physical barriers.^x The post-obit scenarios may contribute to an inadequate nutritional intake:

missing meals due to medical and surgical procedures beingness performed at mealtimes
extended and/or inappropriate periods of fasting
food and fluids non being available when required
nutrient and fluids placed out of accomplish
lack of assistance with opening food and fluid packaging
lack of assistance with feeding and ready for meals
disturbances during mealtimes including noise, smells and staff interruptions
lack of the necessary encouragement to eat

In a bid to improve manage malnutrition in hospitals organisations like Age Great britain, the British Association of Parenteral and Enteral Diet (BAPEN) and the Council for Europe have been promoting strategies such as 'protected mealtimes' and the 'red tray arrangement' as supportive nutritional interventions to promote optimal eating and feeding practices in hospitals.^xi,12 Given this involvement in supportive nutritional practices which chronicle more than to the environment and circumstances of eating, this review proposes to examine those interventions which promote optimal eating and feeding for adult patients in the acute care setting which are not solely nutritional screening or interventions based on the provision of additional energy and protein.

It is also envisaged that this review will assist in formulating some guidance with regard to supportive environmental and nutritional practices in acute care.

An initial limited search has been undertaken to define the suitability of the proposed topic and to determine if this or a similar review had already been conducted. The following related articles were found:

Joanna Briggs Institute (JBI) Systematic Review by Vanderkroft et al in 2007 entitled 'Minimising under nutrition in the older person'.¹³ This review was undertaken in the acute intendance setting and gear up out to identify best practices to minimise under-nutrition in patients aged 65 years and older. The review included 29 identified studies from 1980 to 2005. The interventions in the included studies related to additional nutritional provision from modified menus, oral nutrition supplementation or enteral feeds. Although conducted in the aforementioned setting every bit the intended review, Vanderkroft's review was specific to elderly patients and focused on nutritional provision interventions.
Joanna Briggs Institute Systematic Review Protocol 'The effectiveness of interventions to reduce nether-diet and promote eating in older adults with dementia: a systematic review' past Jackson was registered in 2009.^fourteen The protocol indicates that the author will exist because both direct nutritional provision and related nursing, food service, dietetic and feeding practices. Although these related practices are as well the intended focus of this review the population groups are different in that this protocol indicates that the author intends only to focus on patients with dementia and not other affliction states and that a variety of care settings will be reviewed.
The Cochrane review by Milne et al in 2009 entitled 'Protein and energy supplementation in elderly people at risk from malnutrition'.⁸ This review examined 62 randomised and quasi-randomised controlled trials conducted with elderly patients who were provided with additional energy and poly peptide primarily from oral nutritional supplements. Every bit this review did not examine supportive nutritional practices and its focus was on elderly patients it is deemed sufficiently different to the intended review.
Review in the Journal of Clinical Nursing by Jefferies et al in 2011 entitled 'Nurturing and nourishing: the nurses' role in nutritional intendance.'¹⁵ The aim of this qualitative systematic review was to draw what nurses could do to reduce the incidence of malnutrition in patients in acute care and long term hospitals. The review examined what nurses could do to facilitate access to food, support the mealtime environs and prevent prolonged and repeated periods of nil-by-mouth. The review identified 73 papers from 1998 to 2008 and used JBI appraisal instruments to evaluate the literature. The outcome of this review was used to produce viii nursing standards to form the basis of a infirmary policy. This review examined patients in both acute and long term care and was only concerned with exploring the nurses' office and not that of other staff members.

Inclusion Criteria

Types of Participants

The review volition consider publications that include male and female adults anile xviii years old and over, from any indigenous background, who are inpatients in astute care hospitals with any diagnosis. The review will consider patients who obtain their nutrition by oral route and exclude patients who are enterally or parentrally fed.

The review volition exclude patients in intensive care or high dependency facilities, palliative care and end of life patients. Other healthcare settings such as rehabilitation, transitional care and residential aged care facilities will non be considered.

Types of Intervention

Interventions may include just will not exist limited to:

Organisational practices

Food Service practices

Nursing practices

Medical practices

Dietetic practices

Dietetic/Nutrition/Nutrition Assistant practices

Volunteer practices

Family/carer practices

The following mealtime interventions have been identified as having the potential to influence nutritional intake and therefore will be examined in the kickoff instance:

Focused or ready for meals practices where a pre-mealtime routine of getting patients ready for mealtimes occurs. This practise may include washing easily, toileting, ensuring space bachelor for meal tray and correct position for eating.
Meal delivery systems or targeted feeding help practices e.yard. 'ruby tray system' where patients previously identified equally requiring feeding aid accept their repast delivered on a red tray which acts equally a visual cue to all staff that the patient requires feeding aid.
Feeding assistance practices where patients are provided with feeding help past nursing staff, nursing/dietetic/nutrition assistants or volunteers.
'Protected meal times' where patients are allowed to eat undisturbed at mealtimes and exercise not undergo medical procedures during this fourth dimension.
Ward dining rooms where patients eat in a designated room or expanse specifically designed for mealtimes and free from other ward distractions.
Ward kitchens/pantries which let patients 24 hr access to food and fluids.
Nutrition support teams who consider more than just the foods or fluids prescribed for the patient but also the commitment of the higher up practices.

Interventions which solely chronicle to the actual food or fluid offered or ordered, for or by the patient, volition not be considered. Strategies to promote the identification of malnutrition due east.g. nutritional screening volition not exist included in this review.

Types of Upshot

The master outcomes of interest are measures of improved dietary intake and/or nutritional status. These may include actual or subjective measures of plate waste matter, documented food intakes, patient weight, Body Mass Index (BMI) and malnutrition status as determined by nutritional screening or assessment tools. Secondary outcome measures of length of stay in hospital and all-crusade mortality will besides exist considered.

Types of Studies

This review will consider any experimental studies including Randomised Control Trials (RCTs) and quasi-RCTs. In the absenteeism of these studies or in the outcome of bereft data beingness available the review volition extend to other report designs primarily prospective observational studies.

Search Strategy

The search strategy aims to find published and unpublished studies reported in English language. A iii step search strategy will be utilised in this review. An initial limited search of MEDLINE and CINAHL will exist undertaken followed by analysis of the text words contained in the title and abstract, and of the index terms used to depict the article.

A 2nd search using all identified keyword and index terms volition then be undertaken beyond all included databases. Thirdly, the reference listing of all identified reports and manufactures will be searched for additional studies.

The following databases will be searched:

MEDLINE

CINAHL

EMBASE

Informit - Wellness

Cochrane Clinical Trials Register

Scopus

Australian Digital Theses Program

Alphabetize to Theses

Proquest Dissertations & Theses

The following keywords have been identified for use in the initial search:

Mealtimes

Food service

Dining rooms

Eating

Feeding methods

Eating behaviour

Feeding assistance

Assisted feeding

Feeding volunteers

Red tray

Protected mealtimes

Focused mealtime

Food

Nutritional intake

Food intake

Dietary intake

Diet records

Plate waste product

Torso Mass Alphabetize

Weight loss

Length of stay

Nutritional status

Malnutrition

Nether-diet

Adults

Inpatients

Patients

Acute intendance

Hospitals

Hospitalisation

Exclusion terms volition include enteral feeding, tube feeding, PEG feeding and parenteral feeding.

In add-on, this review will also search the following organisations publications, reports and spider web sites:

Australian State and Federal Government Departments of Health

National Health Service, UK

Age United kingdom

Dietitians Clan of Australia

British Dietetic Clan

American Dietetic Association

Dietitian of Canada /Les diététistes du Canada

Australasian Order for Parenteral and Enteral Nutrition

British Clan for Parenteral and Enteral Nutrition

European Lodge for Parenteral and Enteral Nutrition

Australian Nursing Federation

Royal College of Nursing United kingdom

American Nurses Association

Canadian Nurses Association

Selected journals that feature a number of papers from the beginning, 2d and third searches will be hand searched to locate any boosted papers which may see the search criteria.

Assessment of Methodological Quality

Papers selected for retrieval volition be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standard disquisitional appraisal instruments from the Joanna Briggs Plant Meta Analysis Statistics Assessment and Review Instrument (JBI-MAStARI), (Appendix I). Any disagreements that arise betwixt the reviewers will be resolved through discussion, or with a third reviewer experienced in the topic and the systematic review procedure.

Data Drove

Every bit this review will focus on quantitative measures, the data will exist extracted using the JBI data extraction tool MAStARI, (Appendix Ii). The primary and secondary reviewers volition extract the information independently.

Data Synthesis

Data from the studies will, where possible, be pooled in statistical analysis using JBI-MAStARI, with results displayed in a forest plot. All results volition be subject to double data entry. Odds ratio (for chiselled data) and weighted mean differences (for continuous data) and their 95% confidence intervals volition be calculated.

Heterogeneity volition exist assessed using the standard Chi-square with a random effects model considered for the presentation of statistics. Methodological differences encountered, for example differences in written report pattern, may be explored by sub-analysis where advisable. Where statistical pooling is non possible the findings will be presented in narrative form.

Conflicts of Interest

None

Acknowledgements

As this systematic review forms part of a submission for a MSc Clinical Sciences, a secondary reviewer will only be used for disquisitional appraisal and data entry stages of the review.

References:

1. Watterson C, Fraser A, Banks M, Isenring E, Miller M, Silvester C et al. Evidence Based Practice Guidelines for the Nutritional Management of Malnutrition in Developed Patients Across the Continuum of Care. Journal of Diet & Dietetics. 2009: 66; 3.

Cited Here

two. McWhirter JP, Pennington CR. Incidence and recognition of malnutrition in infirmary. British Medical Journal. 1994; 2008: 945-948.

3. Butterworth CE. The Skeleton in the Infirmary Closet. Nutrition Today. 1974; 9: ii: four-viii.

Cited Hither

4. Stratton RJ, Green CJ and Elia K. Disease-related malnutrition: an evidence-based approach to treatment. Wallingford: CABI Publishing, 2003.

Cited Here

v. Middleton MH, Nazarenko Thousand, Nivison-Smith I, Smerdely P. Prevalence of malnutrition and 12 month incidence of mortality in ii Sydney teaching hospitals. Internal Medicine Journal 2008; 31: 455-461.

6. Allison SP. Malnutrition, disease and outcome. Nutrition 2000;16 (7/8):590-593.

vii. Jones JM. Nutritional screening and assessment tools. New York: Nova Science Publishers Inc, 2006.

Cited Hither

8. Milne Ac, Potter J, Vivanti A & Avenell A. Protein and energy supplementation in elderly people at risk from malnutrition (Review). Cochrane Database of Systematic Reviews. 2009, Issue two. Art. No.: CD003288.

Cited Hither

9. Lennard-Jones JE et al. A Positive Approach to Nutrition every bit Treatment. Kings Fund Centre. 1992.

Cited Here

10. Naithani South, Whelan Yard, Thomas J, Gulliford MC & Morgan M. Infirmary inpatients' experiences of access to food: a qualitative interview and observational study. Health Expectations 2008; xi: 294-303

Cited Hither

11. Age Concern. Hungry to be Heard - The scandal of malnourished older people in hospital. London: Age Concern, 2006.

Cited Here

12. Council for Europe - Commission of Ministers. Resolution ResAP(2003)3 on food and nutritional intendance in hospitals, 2003.

Cited Here

13. Vanderkroft D, Collins CE, Fitzgerald M, Lewis S, Neve M and Capra S Minimising undernutrition in the older inpatient. International Journal Of Evidence-Based Healthcare 2007; v: 3 110-181.

Cited Here

14. Jackson J et al. Systematic Review Protocol - The effectiveness of interventions to reduce undernutrition and promote eating in older adults with dementia: A systematic review. JBI protocol 2009.

Cited Here

xv. Jefferies D. Johnson Chiliad & Ravens J. Nurturing and nourishing: the nurses' role in nutritional care. Journal of Clinical Nursing 2011; 20: 317-330.

Appendix I JBI critical appraisal tools MAStARI

TU3-7 — Table:
No Explanation available.

Appendix Ii JBI data extraction tools MAStARI

TU4-7 — Table:
No Explanation available.

solanoskiatio.blogspot.com

Source: https://journals.lww.com/jbisrir/fulltext/2011/09481/effectiveness_of_mealtime_interventions_in.7.aspx