View
214
Download
0
Category
Preview:
Citation preview
ORIGINAL RESEARCH
Improving food services for elderly, long-staypatients in Australian hospitals: Adding foodfortification, assistance with packaging andfeeding assistancendi_1587 137..144
Karen WALTON, Peter WILLIAMS and Linda TAPSELLSmart Foods Centre, School of Health Sciences, University of Wollongong, Wollongong, New South Wales, Australia
AbstractAim: The study aims to highlight barriers and feasible opportunities to enhance nutrition support of elderly,long-stay patients in Australian hospitals.Methods: A total of 218 dietitians, nurse unit managers and food service managers from medical and rehabilitationwards of 184 hospitals completed a web-based survey about current practices, perceived barriers and priorityopportunities to enhance nutrition support in their context.Results: Cook-fresh food was the most commonly reported food-service system (50%). Eighty-eight percent stillused paper menus and one- or two-week cycles were the most common menu cycle lengths. Lack of choice due tospecial diet, boredom arising from the length of stay, a lack of feeding assistance, limited variety and inadequateflexibility of food service were the key barriers identified. Food fortification, assistance with packaging, additionalfeeding assistance by nurses, non-nursing feeding assistance and further nutrition assessment were key prioritiesfor improvement.Conclusion: A ‘toolbox’ of strategies is needed as no one intervention will improve nutrition support of all patients.Further practice-based outcomes and cost-benefit studies are needed to enhance support and advocacy for feasiblefood service interventions in the future.
Key words: feeding assistance, food fortification, food service, hospital, menu, packaging.
Introduction
The prevalence of malnutrition in Australian hospitals hasbeen reported to be up to 49%.1–7 There are many possiblecauses and long-stay and elderly patients are particularlyvulnerable.7–11
Malnutrition in the hospitalised elderly is preventableand treatable.12–14 Providing nourishing snack options,food fortification15–17 and nutritional supplements can help
improve dietary intakes.18–22 While factors that influenceintakes and some interventions have been investigated inother countries, an Australian survey of key stakeholdersabout barriers and feasible interventions is lacking.
This study builds on an earlier focus group study withpatients, nurses, food service managers, food service assis-tants, dietitians and nutrition assistants in NSW hospitals,which asked their views about all aspects of food servicefor long-stay patients.23 This revealed five key themes ofconcern: the food service system; menu variety; preparationto eat/feeding assistance; packaging; and serve size. Thosefindings were used to plan a comprehensive national surveyof key stakeholder views, the results of which are presentedin this paper.
The aims of this study were to:Explore current practices of food service provision inAustralian hospitals.Determine the key barriers to adequate dietary intakes.Prioritise the most practical interventions for ongoingimprovements to food service provision.
K. Walton, PhD, APD, Senior Lecturer, Bachelor of Nutrition andDietetics CoordinatorP. Williams, PhD, FDAA, Advanced Dietetics Practice CoordinatorL. Tapsell, PhD, FDAA, Director of Smart Foods Centre and Nutritionand Health Strategic Research InitiativeCorrespondence: K. Walton, Smart Foods Centre, School of HealthSciences, University of Wollongong, Wollongong, NSW 2522,Australia. Email: kwalton@uow.edu.au
Accepted September 2011
Nutrition & Dietetics 2012; 69: 137–144 DOI: 10.1111/j.1747-0080.2012.01587.x
© 2012 The AuthorsNutrition & Dietetics © 2012 Dietitians Association of Australia
137
Methods
The 2005 Australian Hospitals Directory listed 748 publicand 549 private hospitals, of which 670 were initiallydeemed eligible to participate in the survey. As longer-stay,elderly patients were the focus of this research, we excludedday only; maternity, paediatrics, psychiatric, palliative care,dental, eye and endoscopy hospitals; those with fewer than20 beds; and those with no medical ward.
A letter of invitation was mailed to the food servicemanager (FSM) and chief dietitian at each hospital duringAugust 2005. Information for nurse unit managers (NUMs)was sent to the director of nursing, along with a letter out-lining the study and asking that the information be for-warded to the most appropriate NUM. The NUM is definedas a senior registered nurse who manages a hospital ward.
Three versions of a web-based questionnaire were devel-oped. Each had the same 35 core questions, plus othersspecific to each professional; for example, food servicesystem (food service managers), nutrition assessment (dieti-tians) and foods brought in from outside (nurses). Initialversions of each questionnaire were pilot tested with fourdietitians, two food service managers and two NUMs, whichresulted in some changes to the order of questions andresponse options.
The key questions related to barriers to dietary intakesand priority interventions.23 Participants were asked tochoose and rank their top 10 barriers from a possible list of20, where number one was the most important barrier and10 was the least important. Participants then chose theirtop 10 intervention priorities (in no particular order) from alist of 20, and provided a feasibility rating for each (where1 = very easy, 2 = somewhat easy, 3 = possible, 4 = somewhatdifficult and 5 = very difficult).
Fifty-five of the original 670 hospitals were unable to takepart in the survey as they had either amalgamated, closedor advised that they did not routinely see long-stay,elderly patients, leaving us with 615 eligible hospitals.Survey responses were received from 92 dietitians, 58 FSMsand 68 NUMs from 184 hospitals (Table 1). Public hospitalsrepresented 68% of the invited sample and were the work-place of 77% of the participants. Responses represented 42%of hospital beds across Australia.
Stakeholder responses to each question were determinedand a combined mean feasibility rating was calculated foreach priority intervention. The number of responses for eachoption was recorded and a factor applied to account forthe importance of order. For example, the number of timesthat an option such as ‘limited variety’ was rated as ‘1’ (mostimportant) was multiplied by 10; the number of times it wasrated as ‘10’ (least important) was multiplied by one. Simpleaddition allowed a cumulative total for each barrier for eachstakeholder group to be determined, which was the resultantraw, unweighted data.
To calculate a combined summary of the 10 most impor-tant barriers and priority interventions identified by allthe three stakeholder groups, the number of responses fromeach stakeholder (92 dietitians, 58 FSMs and 68 NUMs) wasmultiplied by an appropriate weighting factor: 615/92 fordietitians, 615/58 for FSMs and 615/68 for NUMs. Theseweighted results are reported in Tables 3 and 4.
Statistical analyses were performed using the StatisticalPackage for the Social Sciences (SPSS Version 15 forWindows, 2006, SPSS Inc., Chicago, IL, USA). Chi-squareanalyses or Fisher’s exact test were used to determine anystatistically significant differences between categorical data.The P-value was set at <0.05 and all tests were two tailed.
Ethics approval was obtained from the University of Wol-longong Human Research Ethics Committee. Informationsheets were sent to each participant, and completion of thesurvey was viewed as consent given.
Results
Table 2 shows that FSMs reported cook-fresh as the mostcommon food service system. Fifty percent of respondentswere in hospitals with a cook-fresh system; 31% had cook-chill, 17% used a combination of systems and 2% used acook freeze system. Findings from a 2001 NSW food servicesurvey are included for comparison.24 Approximately 93% ofall hospitals plated meals centrally, while 7% used decentra-lised plating and there was no difference based on hospitalsize. Patient meals were mostly delivered by a food serviceassistant (88%), followed by ward assistants (5%) and nurses(2%), with no significant association between the staffmember who distributed meals and the hospital size.
Table 1 Hospital size (bed numbers) and stakeholder categories (number, %)
Bed numbers DietitianFood service
managerNurse unitmanager Total
�100 beds 36 30 28 9439% 52% 41% 38% Diet
32% FSM30% NUM
>100 beds 56 28 40 12461% 48% 59% 45% Diet
23% FSM32% NUM
Total 92 58 68 218
Diet, dietitians; FSM, food service manager; NUM, nurse unit manager.
K. Walton et al.
© 2012 The AuthorsNutrition & Dietetics © 2012 Dietitians Association of Australia
138
Paper menus were used in 88% of hospitals. A combina-tion of paper menus and palm pilots were used in 10.7% ofhospitals with >100 beds, while only 3.3% of hospitals with<100 beds used a palm pilot. There was no significant asso-ciation with hospital size (P = 0.402). One- and two-weekmenu cycles were used in 53.7% of responding hospitals andwere more common in the larger hospitals (65% of those>100 beds), while a four-week cycle was more common forthe hospitals with �100 beds (40%), although overall therewas no significant association with hospital size (P = 0.094).
Ninety percent of FSMs felt that special dietary, religiousand cultural needs were adequately met in their hospitals,significantly higher than the proportions of NUMs (58%),and dietitians (48%) who were satisfied with the adequacy ofchoices available for patients on special diets (P = 0.001).
There was no significant difference between the stake-holder views that adequate serving sizes were offered:87.6% of dietitians, 96% of FSMs and 92.5% of NUMsagreed. There was also agreement that small serves wereavailable when required: 94% of dietitians, 88% of NUMsand 95% of FSMs.
Seventy-six percent of dietitians, 67% of NUMs and 78%of FSMs agreed that additional main meal options tothose on the standard menu could be offered to long-staypatients. Patients on high-protein, high-energy (HPHE) dietsappeared to have regular options of HP milk, HP commercialsupplements, yoghurt, dairy dessert, or cheese and biscuits.Most nurses (86.5%) reported that additional items werealso available on the ward for patients when required.Approximately 73% reported that long-stay patients oftenhad food and beverage items brought in for them by friendsor relatives, the most popular items being chocolates andlollies, fruit, soft drinks, main meals and desserts.
There was agreement that the setting up of patients toaccess their meals and assisting those unable to feedthemselves is primarily the responsibility of nurses. Approxi-mately 42% of patients in the current study were observed torequire some form of assistance with food and/or beveragepackaging.
The mean reported time available for each main meal was40 minutes. Almost all nurses (98.5%) felt that they hadadequate time to assist and feed patients who required it,
although they did report the need to divide their timebetween several patients when there were numerous patientson the ward requiring assistance. Fifty-five percent of dieti-tians and 59.5% of FSMs reported that some non-nursingfeeding assistance was provided, most often by food serviceassistants and visitors. Few dietitians (14.5%) or FSMs(21.5%) indicated that trained, non-nursing staff wasavailable to assist with feeding at meals and only one sitementioned a volunteer feeding assistance programme.
Only 60% of dietitians thought patients’ nutritional needswere adequately assessed, while a significantly greater pro-portion (87.5%) of NUMs agreed (P = 0.001). Dietitians(94.5%) reported that nurses used food records to recorddietary intakes, but the usefulness of these records varied:26.7% rated them very useful and 46.7% rated them useful.The reasons for limitations were that they were not alwaysfilled in at the time of the meal so they were not alwaysaccurate, or up to date.
More than 80% of hospitals offered nutritionally fortifiedversions of some foods and beverages, particularly soup,mashed potato, milk and juice. The most common fortifi-cants were protein powder, skim milk powder, glucose poly-mers and cream, with no difference between availability insmall or larger hospitals (P = 0.726).
Table 3 summarises the top 10 barriers to dietary intakesidentified by each stakeholder group and the combinedtotals using the raw and the weighted data. The combinedlist included the same top 10 barriers, whether the data wereunweighted or weighted, with only the order of barriers 3–4being changed by the weighting. Several other barriers wereidentified by two stakeholder groups only. Dietitians andFSMs both noted limited nutritional assessment and com-munication between staff as barriers, while dietitians andNUMs identified lack of flexibility of food service and tasteof food.
Table 4 summarises the top 10 priority interventions.The combined list included the same top 10 interventions,with only the order of priorities 4–5 and 9–10 changed by theweighting. Interestingly, both dietitians and FSMs identifiedadditional feeding assistance by nurses, non-nursing feedingassistants available at meals and additional assistance to setup for meals as priorities, while dietitians and NUMs both
Table 2 Food service systems surveyed in 2001 (NSW) and 2005 (Australia)
Food servicesystem
2005 200124
Hospitals with�100 beds(n = 29, %)
Hospitals with>100 beds
(n = 29, %)Total
(n = 58, %)NSW total
(n = 21, %)
Hospitals with<100 beds
(n = 47, %)
Hospitals with�100 beds(n = 46, %)
Total(n = 93, %)
Cook-fresh 65.5 34.5 50.0* 38.0 76.6 28.8 53.8Cook-chill 17.3 44.9 31.0 47.7 19.1 62.3 41.7Frozen 0 3.4 1.7 0 N/A N/A N/ACombination 17.2 17.2 17.2 14.3 4.3 8.9 4.5Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0
*P < 0.05.A chi-square analysis between hospital size (�100 or >100 beds) and cook-fresh versus all other systems (cook-chill, frozen and combination)for 2005 was statistically significant, with a P-value of 0.018.
Hospital survey of barriers and priorities
© 2012 The AuthorsNutrition & Dietetics © 2012 Dietitians Association of Australia
139
Tab
le3
Mai
nba
rrie
rsto
adeq
uate
hosp
ital
nutr
itio
nde
scri
bed
byst
akeh
olde
rs
Barr
ier
num
ber
Die
titia
nsR
aw No.
Wt.
No.
Food
serv
ice
man
ager
sR
aw No.
Wt.
No.
Nur
seun
itm
anag
ers
Raw No.
Wt.
No.
Com
bine
dst
akeh
olde
rto
tals
Raw No.
Wt.
No.
1La
ckof
feed
ing
assi
stan
ce83
766
0.4
Bore
dom
due
tole
ngth
ofst
ay35
944
8.8
Lim
ited
vari
ety
585
624.
2La
ckof
choi
cedu
eto
spec
ial
diet
1482
1434
.6
2La
ckof
flexi
bilit
yof
food
serv
ice
758
598.
1La
ckof
feed
ing
assi
stan
ce35
043
7.5
Lack
ofch
oice
due
tosp
ecia
ldi
et54
858
4.7
Bore
dom
due
tole
ngth
ofst
ay14
5614
31
3La
ckof
choi
cedu
eto
spec
ial
diet
689
543.
6La
ckof
mea
lse
tup
assi
stan
ce33
041
2.5
Pack
agin
gdi
fficu
ltto
open
543
579.
4La
ckof
feed
ing
assi
stan
ce14
5613
84.9
4Bo
redo
mdu
eto
leng
thof
stay
677
534.
2C
omm
unic
atio
nbe
twee
nst
aff
&pa
tien
ts
291
363.
8La
ckof
flexi
bilit
yof
food
serv
ice
498
531.
4Li
mit
edva
riet
y14
5113
95.5
5Li
mit
edva
riet
y67
553
2.6
Lim
ited
nutr
itio
nal
asse
ssm
ent
255
318.
8Bo
redo
mdu
eto
leng
thof
stay
420
448.
1La
ckof
flexi
bilit
yof
food
serv
ice
1408
1319
.4
6La
ckof
mea
lse
tup
assi
stan
ce61
348
3.7
Lack
ofch
oice
due
tosp
ecia
ldi
et24
530
6.3
Tast
eof
food
415
442.
8Pa
ckag
ing
diffi
cult
toop
en12
7112
50.1
7Pa
ckag
ing
diffi
cult
toop
en51
940
9.5
Lim
ited
mon
itor
ing
ofin
take
s22
728
3.8
Lack
ofcu
ltur
ally
appr
opri
ate
food
317
338.
2La
ckof
mea
lse
tup
assi
stan
ce12
2211
93.9
8Li
mit
ednu
trit
iona
las
sess
men
t50
139
5.3
Com
mun
icat
ion
betw
een
staf
f22
027
5La
ckof
mea
lse
tup
assi
stan
ce27
929
7.7
Lim
ited
nutr
itio
nal
asse
ssm
ent
994
968
9Ta
ste
offo
od47
037
0.8
Pack
agin
gdi
fficu
ltto
open
209
261.
3La
ckof
feed
ing
assi
stan
ce26
928
7Ta
ste
offo
od96
591
3.6
10C
omm
unic
atio
nbe
twee
nst
aff
387
305.
3Li
mit
edva
riet
y19
123
8.8
Tem
pera
ture
offo
od25
627
3.2
Com
mun
icat
ion
betw
een
staf
fan
dpa
tien
ts
881
887.
1
Raw
No.
refe
rsto
the
unw
eigh
ted
tota
lsfo
rea
chba
rrie
r,w
hile
Wt.
No.
refe
rsto
the
valu
esaf
ter
the
wei
ghti
ngs
are
appl
ied.
Aco
mpl
ete
desc
ript
ion
ofth
isis
avai
labl
ein
the
Met
hods
.
K. Walton et al.
© 2012 The AuthorsNutrition & Dietetics © 2012 Dietitians Association of Australia
140
Tab
le4
Mai
npr
iori
ties
for
adeq
uate
hosp
ital
nutr
itio
nby
stak
ehol
ders
Prio
rity
Num
ber
Die
titia
nsR
aw No.
Wt.
No.
Food
serv
ice
man
ager
sR
aw No.
Wt.
No.
Nur
seun
itm
anag
ers
Raw No.
Wt.
No.
Com
bine
dR
aw No.
Wt.
No.
1Fo
odfo
rtifi
cati
on11
993
.9A
ddit
iona
lfe
edin
gas
sist
ance
bynu
rses
5366
.3A
ssis
tanc
ew
ith
pack
agin
g47
50.1
Food
fort
ifica
tion
202
190.
9
2A
ddit
iona
lfe
edin
gas
sist
ance
bynu
rses
112
88.4
Ade
quat
em
onit
orin
gin
take
s53
66.3
Impr
oved
vari
ety
ofm
enu
opti
ons
4548
Ass
ista
nce
wit
hpa
ckag
ing
188
180.
3
3N
onnu
rsin
gfe
edin
gas
sist
ant
avai
labl
eat
mea
ls
106
83.6
Nut
riti
onas
sess
men
tof
all
pati
ents
5265
Ade
quat
efle
xibi
lity
ofm
enu
choi
ces
4042
.7A
ddit
iona
lfe
edin
gas
sist
ance
bynu
rses
188
179.
2
4A
ssis
tanc
ew
ith
pack
agin
g10
078
.9N
onnu
rsin
gfe
edin
gas
sist
ant
avai
labl
eat
mea
l
4961
.3Fo
odfo
rtifi
cati
on37
39.5
Non
nurs
ing
feed
ing
assi
stan
tav
aila
ble
atm
eal
179
170.
5
5N
utri
tion
asse
ssm
ent
ofal
lpa
tien
ts90
71Fo
odfo
rtifi
cati
on48
57.5
Mor
eno
uris
hing
betw
een
mea
lsn
acks
3739
.5N
utri
tion
asse
ssm
ent
ofal
lpa
tien
ts17
617
2.3.
5
6A
dequ
ate
flexi
bilit
yof
men
uch
oice
s84
66.3
Ass
ista
nce
wit
hpa
ckag
ing
4151
.3Im
prov
edta
ste
ofm
eals
3739
.5A
dequ
ate
mon
itor
ing
inta
kes
161
159.
8
7M
ore
nour
ishi
ngbe
twee
nm
eal
snac
ks81
63.9
Add
itio
nal
assi
stan
ceto
set
upfo
rm
eals
3543
.8N
utri
tion
asse
ssm
ent
ofal
lpa
tien
ts34
36.3
Ade
quat
efle
xibi
lity
ofm
enu
choi
ces
157
150.
2
8A
dequ
ate
mon
itor
ing
inta
kes
7861
.5A
dequ
ate
flexi
bilit
yof
men
uch
oice
s33
41.3
Add
itio
nal
cult
ural
lyap
prop
riat
em
eals
3335
.2M
ore
nour
ishi
ngbe
twee
nm
eal
snac
ks14
513
7.1
9Im
prov
edva
riet
yof
men
uop
tion
s73
57.6
Serv
esi
zeop
tion
s31
38.8
Ade
quat
em
onit
orin
gin
take
s30
32Im
prov
edva
riet
yof
men
uop
tion
s13
612
8.1
10A
ddit
iona
las
sist
ance
tose
tup
for
mea
ls66
52.1
Mor
ein
form
atio
nab
out
food
choi
ces
3138
.8A
ddit
iona
lfo
ods
from
hom
e28
29.9
Add
itio
nal
assi
stan
ceto
set
upfo
rm
eals
128
134.
6
Raw
No.
refe
rsto
the
unw
eigh
ted
tota
lsfo
rea
chpr
iori
ty,
whi
leW
t.N
o.re
fers
toth
eva
lues
afte
rth
ew
eigh
ting
sar
eap
plie
d.A
com
plet
ede
scri
ptio
nof
this
isav
aila
ble
inth
eM
etho
dsse
ctio
n.
Hospital survey of barriers and priorities
© 2012 The AuthorsNutrition & Dietetics © 2012 Dietitians Association of Australia
141
identified more nourishing between mid-meal snacks, andimproved variety of menu options as priorities for change.
Table 5 provides the mean feasibility ratings of the inter-ventions. The top 10 priorities (from Table 4) are indicatedin bold. Food fortification, the highest-rated intervention,was also rated favourably regarding ease of implementation,closely followed by packaging assistance and provision ofmore nourishing between-meal snacks. However, interven-tions such as additional feeding assistance, improved menuvariety, nutrition assessment and greater menu flexibilitywere perceived as harder to implement, although on averagenone were rated as ‘very difficult’.
Discussion
A number of the trends in food service practices identified inthis survey may be barriers to the provision of adequatepatient nutrition. Firstly, while cook-fresh was the mostcommon food service system, it seems that the overall usagehas decreased (from 53.8% in 2001 to 38% in 2005 inNSW), while cook-chill and combination approacheshave increased. Cook-chill may limit the range of foodsthat can be provided on the menu and affect patient mealacceptance.25
Secondly, meal plating was still predominantly centra-lised, although some sites used bulk delivery carts in at leastsome wards. Kelly reported the benefits of decentralisedplating on the intakes of patients in medical wards,26 andseveral other recent studies have also supported this deliveryoption with various patient populations.27–29
Thirdly, more hospitals are offering menus with cyclelengths of one week or less (particularly the larger hospitals).This may be a result of changes to streamline production,and limit human resources and consumables in a bid to savecosts.4,6 This is likely to increase the problems of discontentwith menu variety.
Lastly, while almost all nurses felt they had sufficienttime to assist the feeding of patients, the other two stake-holders saw inadequate assistance as a barrier and feltfurther feeding support was required. The reported averagetime available (40 minutes) should be adequate for patientsto eat in an unhurried manner. However, it is acknowl-edged that some patients will need assistance and encour-agement from nursing staff and the number of patients andstaff will influence the time required. Seventy percent ofpatients in a Sydney hospital were reported as needingsome form of assistance with meals, and designated staffroles were not consistently assigned responsibility for thisimportant task.30
All stakeholders agreed on six key barriers: lack of choicedue to a special diet, boredom due to length of stay, limitedmenu variety, lack of feeding assistance, packaging difficultto open and lack of meal set up assistance. The first threeissues relate to a lack of customisation in hospital foodservices while the last three barriers relate to a lack of time byfood service and nursing staff.
All three stakeholders agreed on five feasible priorityinterventions: food fortification, assistance with packaging,nutrition assessment, adequate monitoring of intakes andflexibility of menu choices. Of note were the additional
Table 5 Feasibility rating for each priority intervention and stakeholder group
Priority interventionMean feasibility
ratingDietitian
ratingFSMrating
NUMrating
Serve size options (small offered) 1.7 2.0 1.7 1.3Food fortification 2.3 2.4 2.0 2.4More information on menu choices 2.3 2.3 2.4 2.3Packaging assistance 2.5 2.4 3.0 2.7Adequate time allowed 2.5 2.5 2.1 2.8Improved communication staff & patients 2.7 2.7 2.5 3.0More nourishing between meal snacks 2.7 2.6 3.0 2.5Additional foods brought from home 2.8 2.6 3.3 2.9Improved communication between staff 2.8 2.7 3 2.7Improved layout and appearance of meal tray 2.9 3 3.3 2.7Adequate monitoring of intakes 3.0 3.2 3.0 2.6Additional assistance to set up for meals 3.0 2.7 3.2 3.3Additional feeding assistance by nurses 3.2 3.6 3.2 3.3Improved taste 3.2 3.3 3.1 3.2Additional culturally appropriate dishes 3.2 3.6 2.4 3.1Dining room 3.3 3.2 3.4 3.3Adequate flexibility of menu choices 3.3 3.5 3.1 2.9Improved variety of menu options 3.3 3.4 3.2 3.3Nutrition assessment of all patients 3.5 3.8 3.5 3.2Non nursing assistant available at meals 3.6 3.7 3.3 3.5
1 = very easy, 2 = somewhat easy, 3 = possible, 4 = somewhat difficult, 5 = very difficult.The bold text indicates the top 10 cumulative priorities for the three stakeholders (Table 4).FSM, food service manager; NUM, nurse unit manager.
K. Walton et al.
© 2012 The AuthorsNutrition & Dietetics © 2012 Dietitians Association of Australia
142
priorities identified by the dietitians and the FSMs (addi-tional feeding assistance by nurses, non-nursing feedingassistant available at meals and assistance to set up for meals)and by both the dietitians and the NUMs (more nourishingbetween meal snacks and an improved menu variety). Thefirst three items concern the ward environment, while thelast two concern the food service system. This indicates thatstakeholders tended to focus on solutions outside of theirown areas of control.
Food fortification was ranked as the most feasible inter-vention (mean 2.3), and more than 83% of hospitals werealready using this in some form. This intervention has beenevaluated favourably in the literature15,16,31 and is valuablebecause it can increase the intakes of small eaters. However,it is reliant on other strategies such as assistance with feedingand opening packaging to be successful.
Improved packaging had a feasibility of 2.5, suggesting itmight be relatively easy to address. Forty-nine percent ofpatients surveyed in two Queensland teaching hospitals haddifficulty opening packaging7 and this problem was identi-fied also in our previous study.23 The use of packaged itemsappears to be increasing, which can adversely affect thevisual appeal of the meal, the environment and negativelyimpact food consumption. Further research is required toinvestigate what types of packaging patients find easiestto open.
The priority of more nourishing snacks (feasibility rating2.7) reflects literature that indicates that many patients findmeals too large and less appealing.7,32 Items such as choco-late, cheese and biscuits, high-energy cakes, and sandwichescould be incorporated as mid-meal snack offerings, and arerecommended in the new nutrition standards for NSW hos-pitals.33 Trials are needed to examine the cost-effectivenessof this strategy compared with the use of more traditionalcommercial supplements.
Nutrition assessment of all patients (mean feasibility 3.5)and monitoring of intakes (3.0) were rated harder to imple-ment, although regarded as high priorities by dietitians.However, the systematic implementation of nutrition screen-ing and monitoring for all inpatients would be a more prac-tical priority in the first instance.34
Three of the identified barriers (lack of choice due to aspecial diet, boredom due to length of stay and limitedvariety) could be addressed by improved menu variety(mean feasibility 3.3). Other research suggests that customi-sation is an important determinant of overall patient satis-faction with hospital food services.35
Additional feeding assistance by nurses or trained volun-teers and additional meal set up assistance were ranked morehighly as priorities by the dietitians and FSMs, than theNUMs. Nurses in the survey reported that they could assisttheir patients when required in most instances. This is incontrast to the findings of many others researchers whosuggest that busy nurses have little time to encourage andassist those who need it.36–38
These three potential strategies (nutritional assessment,improved menu variety and feeding assistance) were alsoviewed as more difficult to implement. Implementation of a
‘protected meal times’ could help in addressing these threeissues because meal times would be prioritised and nursingstaff would be available to assist with setting up, feeding andmonitoring.39 The possible role for trained volunteers inassisting with feeding assistance, opening of packages andmonitoring also requires further consideration. Trained vol-unteers have assumed this role in one aged care ward of aSydney hospital, with apparent improvements in patients’intakes.40
Although the survey response rate was low, it includedresponses from hospitals with almost half the hospital bedsin Australia. There were more responses from dietitians thanfrom FSMs or NUMs, but the weighted results take accountof the differing numbers of responses from each stakeholdergroup. Hospitals smaller than 20 beds were not included;however, the responses from 20 hospitals with less than 100beds provided information on issues likely to affect thesmallest sites.
There was significant agreement between stakeholdersregarding many key barriers and priority interventions toimprove dietary intakes of long-stay patients. Limited menuvariety, boredom due to length of stay, food packaging, anda lack of feeding and set up assistance are particular barriersthat warrant further consideration. Priority interventionsinclude the application of food fortification, additionalassistance with packaging, meal set up and feeding whenrequired, improved menu variety, more nourishing betweenmeal snacks and an increased use of nutritional assessment.Clearly, there are numerous barriers to adequate intakes byhospital patients, and a ‘toolbox’ of interventions is requiredas no one approach will fix all the problems. Further, cost-benefit and outcome studies will enhance support and advo-cacy for feasible food service interventions in the future.
Acknowledgements
Funding was provided by the Smart Foods Centre, Univer-sity of Wollongong. Our thanks to Greg Abernethy (webdesigner), Prof David Steel (statistical advice) and threedietetics research students (Christine Wirtz, NatashaAinsworth and Lauren Lynch) who assisted with the dataanalyses.
References
1 Beck E, Patch C, Milosavljevic M et al. Implementation of mal-nutrition screening and assessment of dietitians: malnutritionexists in acute and rehabilitation settings. Aust J Nutr Diet 2001;58: 92–7.
2 Middleton M, Nazarenko G, Nivison-Smith I, Smerdley P.Prevalence of malnutrition and 12-month incidence of mortalityin two Sydney teaching hospitals. Intern Med J 2001; 31: 455–61.
3 Visvanathan R, Penhall R, Chapman I. Nutritional screening ofolder people in a subacute facility in Australia and its relation todischarge outcomes. Age Ageing 2004; 33: 260–65.
4 Lazarus C, Hamlyn J. Prevalence and documentation of malnu-trition in hospitals: a case study in a large private hospitalsetting. Nutr Diet 2005; 62: 41–7.
Hospital survey of barriers and priorities
© 2012 The AuthorsNutrition & Dietetics © 2012 Dietitians Association of Australia
143
5 Neumann S, Miller M, Daniels L, Crotty M. Nutritional statusand clinical outcomes of older patients in rehabilitation. J HumNutr Diet 2005; 18: 129–36.
6 Vivanti A, Banks M. Length of stay patterns for patients of anacute care hospital: implications for nutrition and food services.Aust Health Rev 2007; 31: 282–7.
7 Vivanti A, Banks M, Aliakbari J et al. Meal and food preferencesof nutritionally at-risk patients admitted to two Australianteaching hospitals. Nutr Diet 2008; 65: 36–40.
8 Garrow J. Starvation in hospitals. BMJ 1994; 308: 934.9 Kowanko E, Simon S, Wood J. Energy and nutrient intake of
patients in acute care. J Clin Nurs 2001; 10: 51–7.10 Lipski P. Improving delivery of food services for acute geriatric
inpatients: a quality assurance project (Letter to the Editor).Australas J Ageing 2003; 22: 4.
11 Walton K, Williams P, Tapsell L, Batterham M. Rehabilitationinpatients are not meeting their energy and protein needs.E Spen Eur E J Clin Nutr Metab 2007; 2: e120–e126.
12 Dickinson A, Welch C, Ager L, Costar A. Hospital mealtimes:action research for change? Proc Nutr Soc 2005; 64: 269–75.
13 Gazzotti C, Arnaud-Battendier F, Parello M et al. Prevention ofmalnutrition in older people during and after hospitalisation:results from a randomised controlled clinical trial. Age Ageing2003; 32: 321–5.
14 O’Flynn J, Peake H, Hickson M, Foster D, Frost G. The preva-lence of malnutrition in hospitals can be reduced: results fromthree consecutive cross-sectional studies. Clin Nutr 2005; 24:1078–88.
15 Gall M, Grimble G, Reeve N, Thomas S. Effect of providingfortified meals and between-meal snacks on energy and proteinintake of hospital patients. Clin Nutr 1998; 17: 259–64.
16 Barton A, Beigg C, Macdonald I, Allison S. A recipe for improv-ing food intakes in elderly hospitalised patients. Clin Nutr 2000;19: 451–4.
17 Kondrup J, Johansen N, Plum L et al. Incidence of nutritionalrisk and causes of inadequate nutritional care in hospitals. ClinNutr 2002; 21: 461–8.
18 Larsson J, Unosson M, Ek A et al. Effect of dietary supplementon nutritional status and clinical outcome in 501 geriatricpatients—a randomised study. Clin Nutr 1990; 9: 179–84.
19 Potter J, Landhorne P, Roberts M. Routine protein energysupplementation in adults: systematic review. BMJ 1998; 317:495–501.
20 Nolan A. Audit of supplement use on care of the elderly andrehabilitation wards. J Hum Nutr Diet 1999; 12: 453–8.
21 Roberts M, Potter J, McColl J, Reilly J. Can prescription ofsip-feed supplements increase energy intake in hospitalisedolder people with medical problems? Br J Nutr 2003; 90: 425–9.
22 Schenker S. Briefing Paper. Undernutrition in the UK. Nutr Bull2003; 28: 87–120.
23 Walton K, Williams P, Tapsell L. What do stakeholders considerthe key issues affecting the quality of food service provision forlong stay patients? J Foodserv 2006; 17: 212–25.
24 Mibey R, Williams P. Food services trends in New South Waleshospitals, 1993–2001. Food Serv Technol 2002; 2: 95–103.
25 McClelland A, Williams P. Trend to better nutrition on Austra-lian hospital menus 1986–2001 and the impact of cook-chillfood service systems. J Hum Nutr Diet 2003; 16: 245–56.
26 Kelly L. Audit of food wastage: differences between a plated andbulk system of meal provision. J Hum Nutr Diet 1999; 12:415–24.
27 Marson H, McErlain L, Ainsworth P. The implications of foodwastage on a renal ward. Br Food J 2003; 105: 791–9.
28 Carr E, Mitchell J. An assessment of factors affecting consump-tion of entree items by hospital patients. J Nurs Stud 1991; 28:19–25.
29 Pietersma P, Follett-Bick S, Wilkinson B et al. A bedside foodcart as an alternative food service for acute and palliative oncol-ogy patients. Support Care Cancer 2003; 11: 611–14.
30 Tsang MF. Is there adequate feeding assistance for the hospit-alised elderly who are unable to feed themselves? Nutr Diet2008; 65: 222–8.
31 Kennewell S, Kokkinakos M. Thick, cheap and easy: fortifyingtexture-modified meals with infant cereal. Nutr Diet 2007; 64:112–15.
32 Barton A, Beigg C, Macdonald I, Allison S. High food wastageand low nutritional intakes in hospital patients. Clin Nutr 2000;19: 445–9.
33 NSW Health Greater Metropolitan Clinical Taskforce.Nutrition Standards for Adult Inpatients in NSW Hospitals. 2010.(Available from: http://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0004/160555/ACI_Adult_Nutrition_web.pdf,accessed 14 March 2011).
34 Watterson C, Fraser A, Banks M et al. Evidence based guide-lines for the nutritional management of malnutrition in adultpatients across the continuum of care. Nutr Diet 2009; 66 (3):S1–S34.
35 Dube L, Trudeau E, Belanger M. Determining the complexity ofpatient satisfaction with foodservices. J Am Diet Assoc 1994; 94:394–8.
36 Xia C, McCutcheon H. Mealtime in hospital—who does what?J Clin Nurs 2006; 15: 1221–7.
37 Kowanko I, Simon S, Wood J. Nutritional care of the patients:nurses’ knowledge and attitudes in acute care settings. J ClinNurs 1999; 8: 217–24.
38 Ross LJ, Mudge AM, Young AM, Banks M. Everyone’s problembut nobody’s job: staff perceptions and explanations for poornutritional intake in older medical patients. Nutr Diet 2011; 68:41–6.
39 British Dietetic Association. Delivery nutritional care through foodand beverage services. 2006. (Available from: http://www.bda.uk.com/publications/Delivering_Nutritional_Care_through_Food_Beverage_Services.pdf, accessed 13 March 2011).
40 Walton K, Williams P, Bracks J et al. A volunteer feedingprogram can improve dietary intakes of elderly patients—a pilotstudy. Appetite 2008; 51: 244–8.
K. Walton et al.
© 2012 The AuthorsNutrition & Dietetics © 2012 Dietitians Association of Australia
144
Recommended