Nutritional screening in home-based nursing care can be improved

Bente Gunn Melheim Høgskulelektor Institutt for sjukepleieutdanning, Høgskulen på Vestlandet, Førde Anne Marie Sandvoll Førsteamanuensis Avdeling for helsefag, Høgskulen på Vestlandet, Førde Authors Results: Many elderly patients present a complex clinical picture that complicates the assessment of nutritional status. Short visits to patients make it di cult to prioritise screening for nutritional status. Moreover, the large selection of screening tools available makes it challenging to choose the best suited. The short form of the Mini Nutritional Assessment (MNA-SF) is evaluated as being best. The MNA is based on weight and height measurement (BMI). Standing on a set of scales may be a challenge for some elderly patients. Moreover, a changing body posture or being bedridden may make height measurements uncertain. In the MNA-SF, measurement of calf circumference can replace BMI. Managers are well positioned to put screening on the agenda as part of interdisciplinary nutritional efforts. Nurses want to have more nutritional expertise and a clearer allocation of responsibility. A variety of studies call for more knowledge about screening tools and a better standard of documentation of nutritional data in electronic patient records (EPR). Therefore, expertise is of key importance in strengthening and quality assuring nutritional efforts. Conclusion: Screening for nutritional status can make it easier to detect nutritional problems before undernutrition arises. A good solution is to screen for nutritional status using the Mini Nutritional Assessment short form (MNA-SF). The nutrition manual provides useful tips. Half of the elderly patients receiving home-based nursing care are undernourished or are in danger of becoming so, usually because of illness (1–6). National professional guidelines and the nutrition manual give advice on how the health and care services can prevent and treat undernutrition. By screening for nutritional status when the need for home-based nursing care arises, and subsequently at regular intervals, the nurse can detect nutritional problems at an earlier stage (7, 8). In the absence of good routines, unintended weight loss can be difficult to detect, with undernutrition as the result (1, 3). Symptoms of undernutrition may be confused with the symptoms of cognitive impairment or dementia, or may mask other illnesses that necessitate treatment (9). Using targeted nutritional interventions as part of good screening routines will make it easier to prevent patients from becoming undernourished and underweight. Screening forms the basis of future assessment and implementation of nutritional interventions to prevent the occurrence of undernutrition (7, 8). The nurse has clear responsibility for screening for nutritional status (7). Despite explicit national guidelines, the Norwegian Board of Health Supervision reports inadequate follow-up of nutrition in several municipalities (10). Therefore, we wonder why there is such a variation in practice. In this article, we discuss the challenges associated with screening for nutritional status in home-based nursing care. The objective is to shed light on good solutions that simplify and systemise the assessment of nutritional status. There is no lack of evidence about the extent of undernutrition among elderly people in the healthcare services and about the considerable lack of knowledge, resources and staff with nutritional expertise (5, 11, 12). Many municipalities have routines for systematic screening for nutritional status (10). For example, nutritional follow-up of cognitively impaired elderly people living at home has proved to be fruitful (13). In other municipalities, no such standardised practice exists. The Norwegian Board of Health Supervision also finds municipalities with written routines that call for the use of screening tools, but where no such practice has been established (10). What explanation can there be for nurses failing to screen for nutritional status? Home visits are shorter and less frequent than in an institution. Sometimes there is no opportunity to ask about or observe food intake, to measure weight or screen for nutritional status in the time allocated. In cases where screening is difficult and the patient is unable to answer, the patient may become undernourished and underweight before the nurse has a chance to react. Inadequate screening «What explanation can there be for nurses failing to screen for nutritional status? » Earlier screening can prevent such developments if there are targeted nutritional interventions. In one study, nurses talk about the lack of weight measurement scales. They describe patients who do not want to be weighed or to talk about their own diet. The familiarity of the nurses in the study with the content of the national professional guidelines varies. Many of them are not familiar with terms such as nutritional status, nutritional plans and undernutrition. Instead, the nurses talk about what the patient has eaten, and how to facilitate intake of food and meals. They have thoughts about deficiencies and about what is needed but they are unable to change their practice. The nurses expect managers to choose a screening tool and put nutritional screening on the agenda (14). In this respect, managers have a key responsibility for improving screening routines. When a nurse discovers that a patient is in danger of becoming undernourished, the doctor must follow up by making a diagnosis and assessing nutritional interventions. The doctor is responsible for medical treatment and the nurse is responsible for screening for and assessing nutritional status. The nurse must prepare a nutrition plan and evaluate the intervention in conjunction with the doctor (7, 8). The nurses in the study seek clarification of the doctor’s role in nutritional efforts (14). Unable to change practice Seek clari cation of the doctor’s role «The doctor is responsible for medical treatment and the nurse is responsible for screening for and assessing nutritional status. » This may indicate that many patients present a complex clinical picture that makes assessment of nutritional status more difficult. When the clinical picture is complex, nutritional problems can be interpreted as something other than undernutrition (9). It may not be easy to detect gradual weight loss until the patient’s clothes become too loose. A simple solution is to measure the weight of the patient regularly. It is essential that the nurse observes the patient’s general condition on each home visit and assesses relevant interventions. Since the clinical picture may be complex, nurses need a professional community where they can discuss their assessments. Is there sufficient leeway for such discussions? Nurses are responsible for consulting others with the relevant professional background in order to discuss their professional assessments (8). Thus, the key to collaboration lies with the nurse. For some of the nurses in the study, it was unclear who had responsibility for what (14). As a result, it was difficult to take the initiative in interdisciplinary collaborations. There are many different actors working in the field of nutrition in the healthcare services. The establishment of interdisciplinary resource groups consisting of, for example, a cook, care worker, nurse and doctor can strengthen collaboration (8). In order to ensure quality and continuity in nutritional efforts, it is crucial that everyone in the healthcare services knows who is responsible for what. When there is no allocation of responsibility, it is difficult to put in place good routines and a professionally sound collaboration. This concerns more than doctors’ failure to diagnose undernutrition (15), or nurses omitting to assess nutritional status. The nurse holds the key to collaboration According to the Norwegian Board of Health Supervision, written documentation on the distribution of responsibility for nutritional efforts is lacking in several municipalities (10). National professional guidelines set out requirements for closer collaboration and a clearer distribution of responsibility (7, 8). Managers are in a key position to put screening on the agenda as part of interdisciplinary nutritional efforts. The Board finds that there is a variation in the extent to which municipalities screen for nutritional status (10). Lack of knowledge may be an explanation when nutritional problems are not detected at a sufficiently early stage (2, 11, 14). Can lack of knowledge about screening tools also be a reason? The many screening tools differ as regards nutrition-related factors and the recommended target group. Does this make it difficult to choose the most suitable tool? The Ernæringsjournal (nutrition record chart) and the Mini Nutritional Assessment (MNA) are most often used in home-based nursing care and in projects under the auspices of the Centre for Development of Institutional and Home Care Services (16). National professional guidelines recommend the MNA and the Malnutrition Universal Screening Tool (MUST) in the primary health service, supported by well-designed, non-randomised studies. Other screening tools such as the nutrition record chart, screening for nutritional risk (NRS 2002) and the Subjective Global Assessment of Nutritional Status (SGA) are good alternatives, but the recommendations are not backed up by research studies (7). Many screening tools Effective screening tools Since the recommendations of the Norwegian Directorate of Health regarding the two screening tools carry different professional weight, it is interesting to examine the grounds for the recommendations more closely. It is crucial that the nutritional variables in the screening tool take diet, body measurement and bodily functions into account (17). Both of the tools do so. Moreover, they are both evaluated as being valid and reliable tools for nutritional screening but on different grounds (7). The nutriti