An exploratory case study of cancer nurses’ understanding and use of nutritional screening in patients diagnosed with cancer
Authors: Hodge A. 
Published: July 2008

Background:  Cancer is often associated with malnutrition and therefore nutritional support should be considered a major component of treatment and used in adjunct with anti‐neoplastic therapies (Read et al., 2006). Successful nutritional support depends on thorough nutritional assessment (Mercadante, 1996). The literature suggests that systematic screening through the use of a tool enables practitioners to provide relevant nutritional support but this does not occur in practice due to a lack of formal education and gaps in knowledge (Savage & Scott, 2005). This gap in the evidence appears to relate to the nurses’ own perceptions of the importance of nutritional assessment and its’ application in practice. The aim of this study was to explore nurses’ understanding and use of nutritional assessment in patients diagnosed with cancer.

Methods:  Case study methodology was used to understand the culture of the ward. Sampling was defined by the methodology as the case was chosen to facilitate exploration of the phenomenon. Non‐random sampling was employed as it allowed for the richest possible source of information (O’Leary, 2004). A letter of invitation and information sheet was sent to all eligible nurses. Data from two nursing staff focus groups (n = 7, n = 11), a survey of patient documentation (n = 27) and field observations were used to elicit influences of nursing practice on nutritional risk screening. A tentative focus group question guide was used to ensure that the process had as few interruptions as possible and a moderator facilitated this. The focus groups were audio tape‐recorded and were transcribed verbatim. The data was analyzed using triangulation, looking for phrases and themes that related to the propositions. A mind map was used to explore connections between the themes and propositions along with my own perceptions ensuring transparency of analysis. The case was reported using a reflexive narrative enabling the causal links between the data and propositions to be explored. Study propositions were: did nurses play a critical role in identifying patients at nutritional risk? What were the nurses’ understanding and use of nutritional assessment? Was the nurse's commitment to nutrition inconsistent with their actions and documentation?

Results:  Nurses’ felt they played a critical role in nutritional risk assessment; ‘it's everyone's responsibility but mainly the nurses and makes a difference in the success of treatment”, this was not reflected in the survey. Their understanding of nutritional risk assessment was apparent ‘you need to get their weight history and what they can eat’but they blamed lack of time and increasing pressures of medicalised tasks, for example drug administration to justify the assessment being observational and ad hoc. The survey of patients’ documentation supported this, 81% of patients had incomplete documentation of their nutritional risk.

Discussion:  Pressures of workload and conflicting primary tasks influence nurses’ behaviour around nutritional support. The survey of documentation showed that NICE (2006) guidelines have had little impact in practice. Nurses’ are involved in multiple tasks and due to pressures on time and resources have become reactive and not proactive; nutritional assessment is a proactive activity.

Conclusions:  Lack of recognition the impact ward and organizational culture had on individual behaviour may have been the pivotal factor that led to the inconsistency in understanding and use of nutritional risk assessment. The relationship between nurses’ attitude to nutritional assessment, knowledge of nutrition and practice was complex. The priority of nutrition needs to increase in both the organisation and ward culture in order for nutritional support to be successfully implemented.

References  Mercadante, S. (1996) Nutrition in cancer patients. Support. Care Cancer 4, 10–20.

National Institute for Clinical Excellence. (2006) Nutrition support in adults: oral nutrition support, enteral tube feeding and parenteral nutrition. London: Department of Health.

O’Leary Z. (2004) The Essential Guide to doing Research. London: Sage.

Read, J.A. et al. (2006) An evaluation of the prevalence of malnutrition in cancer patients’ attending the oncology outpatient oncology clinic. Asia‐Pacific J. Clin.Oncol.2, 80–86.

Savage, J. & Scott, C. (2005) Patients’ nutritional care in hospital: an ethnographic study of nurses’ role and patients’ experience. London: RCN.