Introducing a nutrition screening tool: an exploratory study in a district general hospital

ISSUES AND INNOVATIONS IN NURSING PRACTICE

Introducing a nutrition screening tool: an exploratory study in a district

general hospital

Sue Jordan MBBCh PhD PGCE

Senior Lecturer, School of Health Science, University of Wales, Swansea, UK

Dawn Snow MA RGN RNT DipN DipN(Ed)

Lecturer, School of Health Science, University of Wales, Swansea, UK

Chris Hayes MSc BN RGN

Nursing Director (Acute Division), Pembrokeshire and Derwen NHS Trust, Withybush General Hospital, Haverfordwest, UK

and Anne Williams BA MA PhD RGN RM

Professor of Nursing, School of Health Science, University of Wales, Swansea, UK

Submitted for publication 25 October 2002

Accepted for publication 18 June 2003

Correspondence:

Sue Jordan,

School of Health Sciences,

University of Wales Swansea,

Singleton Park,

Swansea SA2 8PP,

UK.

E-mail: [email protected]

JORDAN S. , SNOW D., HAYES C. & WILLIAMS A. (2003)JORDAN S. , SNOW D., HAYES C. & WILLIAMS A. (2003) Journal of Advanced

Nursing 44(1), 12–23

Introducing a nutrition screening tool: an exploratory study in a district general

hospital

Background. Concerns have been raised that patients’ nutrition is a neglected

aspect of care. Accordingly, ‘nutrition screening tools’ have been devised to ensure

that all patients are assessed by nurses and, where appropriate, referred to dieticians.

The tool adopted in our hospital was the ‘Nursing Nutritional Screening Tool’.

Aim. To investigate the impact of this screening tool on: nutrition-related nursing

documentation; patient care at mealtimes; dietician referral.

Methods. This study was conducted on two similar general medical wards in a

United Kingdom (UK) district general hospital, with the help of staff and patients

(n ¼ 175) admitted during two study periods, May 1999 and January 2000. Data

were collected over 28 days before and after introduction of the screening tool on

one of the wards. For both wards, in each stage of the study, data were collected b:

review of patients’ notes, non-participant observations of mealtimes. Frequencies of

dietician referral and documentation of weight were compared by cross-tabulations

and v2 tests. Nine months later, the findings were discussed with ward sisters in a

group interview.

Findings. Introduction of the screening tool impacted on the process but not the

outcomes of screening. Use of the screening tool increased the frequency of nutri-

tion-related documentation: the proportion of patients with weights recorded

increased on the intervention ward (P < 0Æ001), and decreased on the comparator

ward. Frequency of dietician referral decreased on both wards, but differences were

statistically insignificant. There was no observable change in patient care at meal-

times. The nurses in charge of the wards felt that introduction of the screening tool

had raised awareness of nutrition-related care.

Conclusions. Meeting patients’ nutritional needs is a complex aspect of care which

may benefit from introduction of structured guidelines. However, the potential of

12 � 2003 Blackwell Publishing Ltd

screening tools to improve care is limited by diverse factors, which warrant further

exploration.

Keywords: clinical guidelines, nutrition screening tools, outcome evaluation,

referral boundaries, nursing

Background

‘Hungry in Hospital’ was a disturbing report: relatives

described how older patients developed malnutrition because

no-one fed them at mealtimes; this was attributed to nurses’

abrogation of responsibility for patient nutrition [Association

of Community Health Councils (ACHC) 1997]. Subse-

quently, several guidelines, checklists and ‘nutrition screening

tools’ were developed to direct and structure nutrition-related

care and to ensure that all patients are assessed by nurses and

referred to dieticians if appropriate. The tool selected for use

in our hospital was the ‘Nursing Nutritional Screening Tool’

[British Dietetic Association (BDA) 1993, Cotton et al. 1996,

Bond 1997].

Things can only get better

The biological consequences of undernutrition can be devas-

tating. Researchers have demonstrated associations between

malnutrition and wound healing (Haydock & Hill 1986,

Breslow et al. 1993), immune dysfunction (Kaiser & Morley

1994), sepsis (Potter et al. 1995), hypothermia and subse-

quent fracture (Bastow et al. 1983), delayed recovery from

illness (Volkert et al. 1996) and impaired drug elimination

(Walter-Sack & Klotz 1996).

In a study by McWhirter and Pennington (1994) many

patients admitted to hospital (200/500, 40%) were found to

be undernourished, and most of these (41/55, 75%) suffered

further weight loss and developed signs of malnutrition whilst

in hospital). Twenty per cent of older hospitalized patients

take in less than 50% of their energy requirements (Sullivan

et al. 1999). Brown’s (1991) survey found that 90% of

patients (83/92) lost weight during a two week hospital stay

(mean ¼ 6Æ3 ± 2Æ6 kg) and 91% (84/92) had sub-optimal

intakes. However, comparisons in this field are difficult,

because of the absence of agreed definitions of undernutrition

and nutritional risk (Corish & Kennedy 2000).

Commentators have attributed this apparently institutio-

nalized neglect of patient nutrition to lack of awareness of

nutritional risk (Butterworth & Blackburn 1975, Lennard-

Jones 1992, Sizer et al. 1996, ACHC 1997, Wise 1997).

Weight loss, particularly in undernourished patients, has been

attributed in part to the non-intervention of nurses at

mealtimes (Carr & Mitchell 1991, Dickerson 1995, McClone

et al. 1995, ACHC 1997, Wykes 1997). Studies have

identified nutrition and elimination as aspects of care where

problems arise because of nurses’ prioritisations (Higgins

et al. 1992, Sitton-Kent & Gilchrist 1993). During an

observation study, qualified staff did little to assist terminally

ill patients in maintaining input (Mills et al. 1994), and

nurses’ tendency to undervalue the physical care they deliver

may be a contributory factor (Jordan & Reid 1997).

Something must be done

Active intervention, either oral supplementation or nasogas-

tric tube feeding, can prevent weight loss (n ¼ 86,

P < 0Æ001) (McWhirter & Pennington 1996) and reduce

overall mortality by about 30% (Potter et al. 1998, 2001).

However, intervention necessitates identification of need, and

professionals may be recognising only 30% of instances of

malnutrition (Burns 1995). Fewer than half (96/200) of

undernourished patients have their nutrition status or any

nutrition-related information documented (McWhirter &

Pennington 1994), and only 22% of patients are weighed

(Rasmussen et al. 1999).

In several settings, simply recording weight changes has

been associated with improved outcomes (Grunfeld 1995,

Gallagher-Allred et al. 1996, Giner et al. 1996). Therefore,

screening and assessment instruments of varying complexity

have been designed to trigger increased nursing and dietician

intervention (Reilly et al. 1995, Robshaw & Marbrow 1995,

Sizer et al. 1996, Hiller et al. 2001, Soderhamn & Soderhamn

2002). Standards and guidelines recommend monito-

ring patients’ nutritional status to identify those at risk

(Lennard-Jones 1992, Sizer et al. 1996, DoH 2001, 2002,

Kowanko et al. 2001) and recording nutrition screening and

care in nursing care plans (BDA 1993, Allison 1999).

Nutrition screening and assessment are also included in

structured nursing assessments (Martin & Scheet 1992).

Professional responsibility for prevention of malnutrition

in hospital has never been resolved (ACHC 1997, Lyne &

Prowse 1999), as it lies on the occupational interface between

medicine, nursing and dietetics. As so often with ill-defined

professional territory, all professionals may abrogate respon-

sibility, and this exposes a ‘care gap’ (Butterworth 1974,

Issues and innovations in nursing practice Introducing a nutrition screening tool

� 2003 Blackwell Publishing Ltd, Journal of Advanced Nursing, 44(1), 12–23 13

Jordan & Hughes 1996, Corish & Kennedy 2000). However,

ensuring that patients are appropriately fed is a recognised

nursing responsibility [United Kingdom Central Council for

Nurses, Midwives and Health Visitors (UKCC) 1997] and

pan-European guidelines identify professional responsibilities

for weighing patients, nutrition screening and care (Beck et al.

2001). One purpose of such guidelines and screening tools is

to ensure that nurses identify, and refer to dieticians, any

patients vulnerable to undernutrition, before deleterious

physiological changes occur. This signifies formalisation of

inter-professional boundaries between nurses and dieticians

and standardizes allocation of scarce professional resources

(Lyne & Prowse 1999).

The prevailing guidelines and outcomes culture dictates

that, to establish minimum standards of care, decision-

making should be devolved away from individual profes-

sionals towards ‘expert-generated’ protocols and algorithms

(Day et al. 1998). Although practice guidelines may improve

the process of care, evidence of their impact on clinical

outcomes remains scarce (Grol 2001). Reviewers have

identified 16 randomized studies investigating the impact of

guideline-driven care in nursing, none of which relate to

nutrition screening (Thomas et al. 2002).

The study

Aim

The aim of the study was to explore the clinical effectiveness

of the Nursing Nutritional Screening Tool by examining

changes in selected targeted processes and outcomes:

• nursing documentation;

• patient care at mealtimes;

• dietician referral.

Methods

This quasi-experimental study was undertaken on two wards

in the medical unit of a 336-bed United Kingdom (UK)

district general hospital; one of these two 30-bed wards was

the intervention ward, and the other the comparator. Adult

patients with medical conditions were admitted to either of

these wards on the basis of bed availability rather than

diagnostic criteria.

Teaching sessions were held in November 1999 to intro-

duce the Nursing Nutritional Screening Tool to staff of the

intervention ward. This tool comprises a form that scores

patients on a scale of 1–4 for mental condition, weight or

weight loss, appetite, ability to eat, gut function, medical

condition and pressure ulcers. The score is totalled and

interpreted as follows; <15, high-risk; 16–21, moderate-risk;

22–28, minimal-risk. Weekly weighing and re-assessment are

recommended for all patients. Dietary supplementation and

dietician referral are reserved for those of high or moderate

risk.

Patient sample

All patients admitted during study periods (May 1999,

January 2000), and considered by nurses to be able to give

informed consent, were approached for permission to review

their notes and observe mealtimes. Acutely ill or confused

patients were not approached. Four patients declined to

participate in the study.

In all, 175 of a possible 628 patients were recruited who

were predominantly older (mean age ¼ 67Æ5; SDSD 17Æ0) and

were hospitalized for 1–56 days (mean ¼ 9Æ1). Age, length of

stay and gender of patients in the four study groups (two

wards at each of two study times) were compared, and no

statistically significant differences were apparent. Unequal

recruitment in the two wards and increase in throughput of

patients between the two stages of the study resulted in a

statistically significant difference in numbers amongst the

four groups. Differences in numbers between wards remained

statistically significant when ‘before’ and ‘after’ stages were

compared separately (Table 1).

Data collection

We adopted an interrupted time-series design, with a com-

parison group (Campbell & Russo 2001, p. 348). Data were

collected on both intervention and comparator wards before

and after introduction of the screening tool on the interven-

tion ward (Cook & Campbell 1979). Although comparison

groups are essential (Friedman et al. 1998), a double-blind

randomized controlled trial is not necessarily the optimum

method for investigating practice change and patient out-

comes (Grimshaw & Russell 1993, Hester et al. 1997).

Enrolling intervention and comparator groups from different

wards avoided data contamination by regular use of the

screening tool (Thomas et al. 1998). However, recruiting

patients from different wards introduced confounding vari-

ables, such as enrolling different proportions of patients,

although this should not affect the validity of the findings

(Cohen et al. 1982, Hulscher et al. 1999).

As in many small-scale investigations, a multi-method data

collection strategy was adopted (Meyer 2001). Important to

this paper are review of patients’ notes, non-participant

observation of mealtimes and a group interview with all four

ward sisters to review findings.

S. Jordan et al.

14 � 2003 Blackwell Publishing Ltd, Journal of Advanced Nursing, 44(1), 12–23

All patients’ notes were retrieved, reviewed, and numbered

consecutively (P1–P175). In addition to demographical and

case data, information was extracted on extent of documen-

tation in relation to nutritional care, including weighing, and

dietician referral. All documentation relating to nutrition care

was transcribed verbatim. To ensure that no dietician

referrals had been made without documentation in the notes,

hospital numbers were cross-checked against dieticians’

records.

Non-participant observation of mealtimes aimed to

identify factors that could impact on nutrition intake, such

as availability of staff to feed patients (Kayser-Jones &

Schell 1997), interruptions of mealtimes (Deutekom et al.

1991). One six-bed unit was observed at each meal on

both wards during both stages of the study. Observations

were recorded using structured templates and longhand

fieldnotes.

Study findings were passed to all four ward sisters (SI1, SI2,

SC1, SC2), and discussed in a group interview in October

2000, in accordance with their rights as stakeholders (Guba &

Lincoln 1981). This served to contextualize the findings and as

a member-check.

Ethical considerations

The Local Research Ethics Committee approved the study.

Information letters were sent to all staff and verbal

presentations were arranged; subsequently, all staff consented

to participate. Written and verbal information was given to

all patients considered capable of giving signed informed

consent. Qualified nurses countersigned patients’ consent

forms. Welsh-language forms were available. All participants

were assured that all data would be anonymized and treated

in confidence.

Data analysis

Data were entered into SPSS version 10. Demographical

data were subjected to tests of normality and compared.

Frequency counts and cross-tabulations were used to com-

pare the incidence of documentation and referral on both

wards in the two study periods. For the key variables of

weight documentation and dietician referral, the v2 test,

with Yates’ continuity correction for 2 � 2 tables, was used

to assess the likelihood of any differences between groups

being because of chance (Altman 1991). Where cells

contained fewer than the minimum expected count Fisher’s

exact test was substituted, but results must be interpreted

cautiously as the number of subjects included was rather

high (Anthony 1999).Table

1C

om

pari

sons

of

dem

ogra

phic

data

and

recr

uit

men

tin

the

four

study

gro

ups

Sta

ge

1M

ay

1999

Sta

ge

2Ja

nuary

2000

All

pati

ents

Inte

rven

tion

ward

Com

para

tor

ward

Inte

rven

tion

ward

Com

para

tor

ward

inth

est

udy

Tes

tand

resu

ltSta

tist

ical

sign

ifica

nce

Age

inyea

rsm

ean

(SD

SD

)

and

range

64Æ8

(20Æ3

)17–94

66Æ3

(18Æ2

)27–95

68Æ8

(15Æ1

)19–90

69Æ5

(15Æ1

)32–96

67Æ5

(17Æ0

)17–96

F¼

0Æ7

15

AN

OV

AA

NO

VA

(d.f

.¼

3)

P¼

0Æ5

44

KS

Z¼

1Æ1

74

P¼

0Æ1

27

indic

ate

sth

at

anorm

al

dis

trib

uti

on

isli

kel

y

Len

gth

of

stay

indays

mea

n( S

DSD

)and

range

7Æ7

(8Æ0

)1–54

8Æ3

(6Æ7

)1–29

9Æ3

(8Æ1

)1–56

11Æ0

(9Æ1

)2–42

9Æ1

(8Æ1

)1–56

v2¼

4Æ0

35

(d.f

.¼

3)

Kru

skal–

Wall

is

P¼

0Æ2

58

KS

Z¼

2Æ8

51

P<

0Æ0

01

indic

ate

sth

at

anorm

al

dis

trib

uti

on

isunli

kel

y

Gen

der

num

ber

of

fem

ale

s22/4

613/2

733/6

425/3

893/1

75

v2¼

3Æ2

98

(d.f

.¼

3)

P¼

0Æ3

48

Num

ber

of

pati

ents

part

icip

ati

ng/n

um

ber

adm

itte

d

46/1

25

(36Æ8

%)

27/1

30

(20Æ8

%)

64/1

78

(35%

)38/1

95

(19Æ5

%)

175/6

28

(27Æ8

7%

)v2

¼16Æ6

57

(d.f

.¼

3)

P¼

0Æ0

01

Sta

ge

1(t

wo

ward

s

com

pare

d)

v2¼

4Æ9

45

P¼

0Æ0

26

Sta

ge

2(t

wo

ward

s

com

pare

d)

v2¼

6Æ6

27

P¼

0Æ0

10

KS¼

Kolm

ogoro

v–Sm

imov

test

for

norm

al

dis

trib

uti

on.



The interview was transcribed and scrutinized for themes

and concepts. This allowed exploration of responses, which

were then related to case-note and observation data to

ascertain the degree of support for the ideas generated (Tesch

1990). The impact of the screening tool on targeted processes

and outcomes was followed thematically through the three

data sets. Data from different sources were juxtaposed and

related to the emergent findings to evaluate and reassess the

overall picture. The diverse perspectives of the three data sets

afforded opportunity to corroborate and integrate findings

(Denzin 1970, Bryman 1988, Denscombe 1998).

Findings

On the intervention ward, introduction of the Nursing

Nutritional Screening Tool increased documentation of

patients’ weights and nutrition-related problems. No such

changes were seen in the comparator ward. Referrals to

dieticians and patient care at mealtimes remained largely

unchanged. Nine months later, the ward sisters indicated that

some clinical gain had arisen from introduction of the

screening tool. This raises the question of how much can

realistically be expected from paper guidelines and screening

tools.

Screening process – documentation

On the intervention ward, completion of the screening tool

increased the number of patient records with documentation

related to nutrition issues, as specified on the tool. Docu-

mentation of the potential impact of pressure ulcers and

mental condition on nutritional status showed most change.

Increases in documentation in relation to gut function and

medical condition were less marked. There was little change

in documentation of appetite. On the comparator ward,

frequency of documentation decreased slightly (Table 2).

On the intervention ward, the number of patients weighed

increased following introduction of the screening tool

(Figure 1). Before the introduction, 12 of 46 (26Æ1%) patients

were weighed during their stay. In contrast, with the tool,

46 of 64 (71Æ9%) patients had weight recorded [v2 ¼ 20Æ712,

P < 0Æ001 (two-sided), odds ratio (OR) ¼ 0Æ138, confidence

intervals (CI) ¼ 0Æ059–0Æ325]. Of the 12 patients who

remained on the ward for over 10 days, two had weekly

weights recorded as recommended on the form.

On the comparator ward, 8 of 27 (29Æ6%) patients were

weighed during the ‘before’ stage and 3 of 38 (7Æ9%) during

the ‘after stage’ [Fisher’s exact, P ¼ 0Æ041 (two-sided)]. At

interview, ward sisters assured us that all patients’ weights

were now recorded.

Not all postintervention patients had completed screening

tools or weights recorded in their notes. Screening tools were

absent for 7 of 64 patients (P85–P91, inpatient stays 9, 7, 1,

4, 2, 11, 3 days). Eleven further patients had forms comple-

ted with everything but weight recorded. Ward sisters

explained that time-pressures and additional documentation

were important factors:

Initially, because of the workload and documentation that nurses

have to do already, it was just another bit of paper. You went

through your paperwork, did your nutritional assessment once and it

was never referred to again.

On both wards, in both stages of the study, most patients’

records contained some nutrition-related documentation. The

number with no documentation in the intervention ward

increased from zero to 1 of 64 (inpatient stay 1 day, P87),

and in the comparator ward, from zero to 3 of 38 [inpatient

stays 9 (P150), 3 (P151) and 7 (P164) days].

Table 2 Incidence of nutrition-related documentation and referrals in the four study groups

Intervention ward Comparator ward

Stage 1, May 1999 (%) Stage 2, January 2000 (%) Stage 1, May 1999 (%) Stage 2, January 2000 (%)

No nutrition-related

documentation

0/46 1/64 (1Æ6) 0/27 3/38 (7Æ9)

Weight documented 12/46 (26) 46/64 (72) 8/27 (29Æ6) 3/38 (7Æ9)

Mental condition 0/46 57/64 (89) 0/27 0/38

Appetite 40/46 (87) 62/64 (97) 25/27 (92Æ6) 33/38 (86Æ8)

Ability to eat 2/46 (4Æ3) 57/64 (89) 0/27 1/38

Gastro-intestinal function 11/46 (24) 57/64 (89) 8/27 (29Æ6) 1/38 (2Æ6)

Medical condition 12/46 (26) 59/64 (92) 9/27 (33Æ3) 5/38 (13Æ2)

Pressure ulcers 2/46 (4Æ3) 57/64 (89) 0/27 0/38

Dietician referral 7/46 (15Æ2) 6/64 (9Æ4) 5/27 (18Æ5) 4/38 (10Æ5)

S. Jordan et al.


Much of the documentation reviewed consisted of stereo-

typical reports of patients’ progress. Recurrent phrases

included:

• Diet and fluids taken and tolerated;

• Eating and drinking well;

• Poor/fair/good appetite;

• Loss of appetite.

This format remained unchanged throughout the study,

and sisters explained that such documentation was primarily

a strategy to communicate patients’ clinical state to the next

nursing shift:

If you write ‘diet and fluids’ it’s like putting ‘bowels open’. You’re

putting information there for the next nurse, so they know they’ve

eaten. I don’t think it’s a habit. Relatives will say, ‘Did they eat

today?’. Then you have some indication that patients have eaten,

rather than looking in the notes and there’s nothing there.

This routine documentation continued alongside the screen-

ing tool. Its purpose was to describe ongoing situations for

other nurses. It was not intended to be synthesized or

analysed for screening or assessment of need.

Screening outcomes – patient care at mealtimes

Fieldworkers (SJ, DS) perceived no change in care delivered at

mealtimes. Meals were served and cleared away almost

exclusively by housekeepers. Where patients needed to be fed,

this was undertaken by health-care assistants, visitors and

nurses. This fieldnote extract suggest that apparently there

were not always enough staff available to help all patients

when meals were served.

Patient 8 (age 80, stay 54 days) appears very ill, sitting on his bed,

struggling to breathe, with prominent sternocleidomastoid muscles.

As he strives to eat, the meal gets cold. The tea trolley arrives while

he is still trying to eat; the drink is refused. The meal remains

uneaten. Patient 8 says he does not feel hungry and does not wish to

eat the meal. A care assistant is feeding another sick patient in the

same room. [Fieldnotes: evening meal (intervention ward May

1999).]

While this extract could be variously interpreted, the sisters

also reported staff shortages:

Let’s be honest, there have been times when the patients’ food has

gone back without them being fed because of the workload on the

ward.

We did not observe any recording of intake, even for

patients whose notes indicated nutrition problems. Follow-

ing introduction of the screening tool, six of the 16 patients

observed had nutrition problems noted in their documenta-

tion. Three of these were offered verbal and/or practical

support by staff, students and visitors. Two others ate their

meals, but one did not. For none of these patients was

intake recorded.

Mealtimes were subject to interruptions. Three of four

lunchtimes observed were interrupted by doctors’ rounds.

This data extract illustrates the difficulties:

The housekeeper waits outside the room for 15 minutes while the

team of five doctors complete their round. She complains that the

meals are getting cold and hard, but seems resigned, saying: ‘It’s like

this every day – you’ll never change the doctors.’ Despite interrup-

tions, deterioration in meals (as reported by patients), and an ambient

temperature of 80�F/26�C most of the meals are eaten. [Fieldnotes:

lunchtime (intervention ward, May 1999)]

Problems of fieldnote interpretation notwithstanding, all four

sisters were concerned that doctors’ rounds were interrupting

patients’ main meal of the day. However, under existing

working arrangements, three of the four sisters saw this as

almost inevitable, because of demands placed on medical

teams:

Although we don’t like it, they’ve got just as big a workload as us.

They can’t always be on the ward at a time that you want them

because they go round four or five wards…They’ve got patients all

over the hospital, and clinics at 2Æ00 p.m.

This prioritization of medical consultation over nutrition was

influenced by pressures imposed by escalating numbers of

emergency admissions and corresponding efforts to make

beds available:

The pressure is to get beds free, so if you don’t get consultants to see

that patient…

Meals were also interrupted by tea trolleys, which arrived

before patients had finished eating, and by nurses’ ‘drug

26.1

71.9

29.6

7.9

0

10

20

30

40

50

60

70

80

Stage 1 (before)Per

cent

age

ofpa

tient

sw

ithw

eigh

trec

orde

d

Stage 2 (after)

Intervention wardComparator ward

Figure 1 Recording weights: percentage of patients weighed before

and after the introduction of the Nursing Nutritional Screening Tool.



rounds’. Sisters and staff nurses handing patients their oral

medication offered verbal encouragement with meals, and

two sisters explained that the drug round was the one activity

that took them to the bedsides and ensured that they observed

patients at mealtimes:

If I’d already done the drug round, I’d be thinking ‘they’re all eating

very nicely’ and go off and do my paperwork, assuming they’ve

eaten. So I don’t go along with the idea that it’s a bad idea to do the

drug round at meal times.

Fieldworkers were concerned about drug/food interactions

affecting absorption of certain drugs: frusemide, calcium

antagonists, erythromycin, tetracyclines, iron preparations

and analgesics (Stockley 1999).

Screening outcomes – dietician referral

One purpose of the Nursing Nutritional Screening Tool is to

promote appropriate dietician referrals (Cotton et al. 1996).

Evidence for this came from the sisters:

I think referrals on more poorly patients are picked up quicker[sic].

The importance wasn’t placed on nutrition status before as much. We

raised the profile with the nutrition study. Nurses are identifying that

it could be a problem by the end of the week and are referring straight

away.

Review of patients’ notes did not indicate any change in

patterns of dietician referral during the study periods

(Figure 2). On the intervention ward 7 of 46 (15Æ2%)

patients were referred without and 6 of 64 (9Æ4%) with the

screening tool. This decrease did not reach statistical signi-

ficance [v2 ¼ 0Æ406, P ¼ 0Æ524 (two-sided), OR ¼ 1Æ735,

CI ¼ 0Æ542–5Æ554]. On the comparator ward, corresponding

numbers were 5 of 27 (18Æ5%) and 4 of 38 (10Æ5%), a

statistically insignificant decrease (v2 ¼ 0Æ308, P ¼ 0Æ579

(two-sided), OR ¼ 1Æ932, CI ¼ 0Æ467–7Æ992].

There were many examples of good practice and prompt

referral, but these occurred on both wards and in both stages

of the study; we found little evidence linking these to use of

the screening tool, as the following example shows:

A woman of 61 was referred to dieticians on the first day of her stay

and by the end of follow-up, five weeks later, was taking supplements

and had regained body weight. (P13, before, intervention).

Where referrals occurred, patients benefited: for example,

prescription of supplements by the dietician was followed by

improved oral intake in two older women (P78, P79), (tool

scores 23 of 28 and 21of 28, after intervention).

Indications for referral in the notes included: ‘need to reduce

weight’, ‘food allergies’, ‘poor intake’. However, some patients

with such nutrition-related problems were not referred:

A man of 45 with poorly controlled diabetes had not, according to his

records, eaten for five days prior to admission. He was also noted to

be obese and have a serum creatinine of 256 micromol/l (P27, before,

intervention)

None of the patients with hypercholesterolaemia were

referred to dieticians. Examination of patient records offered

no evidence that the research project encouraged dietician

referral. The presence of investigators did not ensure that

nutrition care was always prioritised. For example:

A woman of 86 was not referred to dieticians during her eight-day

stay, and had no documentation in relation to nutrition, including

recorded weights, despite medical notes requesting ‘daily body weight

please’ and an admission history of ‘not eating and drinking well’.

(P142, after, comparator)

Such instances also arose despite introduction of the screen-

ing tool:

A man of 90 with long-term cardiovascular problems and diabetes

scored 23/28 on the screening tool, but was neither rechecked nor

followed-up during his 13-day stay. (P126, after, intervention).

The relationship between tool scores and referral appeared

unpredictable. Only one patient (P79) was scored outside the

‘minimal-risk’ category (21/28) and she was referred. Of two

patients with borderline scores (22/28), one (P84) was

referred, whereas the other (P94) was not. Two patients

(P78, P109) with ‘minimal-risk’ scores (23 and 26) were, in

the opinions of fieldworkers, justifiably referred. Two of seven

patients with no documented score were justifiably referred.

The sisters confirmed that tool score was combined with

professional judgement when determining referral:

15.2

9.4

18.5

10.5

0

2

4

6

8

10

12

14

16

18

20

Stage 1 (before) Stage 2 (after)

Stage of studyPer

cena

ge o

f pat

ient

s re

ferr

ed to

die

ticia

nst

InterventionwardComparator ward

Figure 2 Dietician referrals: percentage of patients referred to dieti-

cians before and after introduction of the Nursing Nutritional

Screening Tool.

S. Jordan et al.


For patients who were low or no risk, they (screening tools) became

bits of paper. Those at low risk, admittedly, I did off the top of my

head, looked at the patient; I’d seen them eating, would take it on

myself to score them. But patients that were at risk, obviously not

eating, losing weight, with nutrition-related problems, then it was a

good score-sheet and would prompt you to make a note and add to

the care plan to refer to dietician, offer supplements. So, because you

had something in front of you, the score, it was good.

This selective use of the tool was corroborated by the number

of incomplete forms found (11/57). In other instances, the

tool may have given a false sense of security:

A man of 77 (P127) with renal failure, poorly controlled diabetes and

heart failure was not referred. For his 11-day stay, his notes

contained one reference to ‘not much appetite of late’, no reference

to diet and a tool score of 26/28.

A woman (P98) of 86, weight 7st 7lbs, who scored the maximum 28

on the tool was not referred during her 5-day stay, despite

documentation of poor appetite and poor swallow.

Discrepancies may have arisen because screening tools and

other documentation were not completed simultaneously and

served different purposes. The ‘minimal-risk’ scores may have

influenced nurses’ decisions not to refer. Failure of the

screening tool to have an impact on dietician referral, as

evidenced by quantitative and case data, may have been

because of low sensitivity of the tool; over-reliance on the tool

at the expense of professional judgement; apparent disregard of

the tool for patients perceived as ‘low-risk’; nurses’ resistance

to increase in paperwork; or any combination of these factors.

Discussion

The Nursing Nutritional Screening Tool improved the

process of screening, in that awareness of nutrition and

documentation, including recorded weight, was increased.

However, there was little evidence that this translated into

changes in the outcomes of screening, particularly dietician

referral and patient care at mealtimes, other than verbal

suggestions that patients were referred to dieticians more

promptly. Reviewers of practice guidelines studies have

reached similar conclusions in this field (Lyne & Prowse

1999) and others (Grol 2001).

As with all observation research, our data are limited by

bias in subject selection, data collection and confounding by

external factors, including change in patient throughput or

seasonal factors such as ‘winter bed-pressures’ (Grimes &

Schulz 2002). We were unable to explore any links between

this and the (statistically insignificant) decrease in referrals.

The need to obtain fully-informed consent limited the patient

population studied. The low proportion recruited reflected

the medical condition of patients on the wards. Many of

those with the most pressing need for help with feeding,

including patients who were very ill or confused, were

excluded from the study as they were unable to give

meaningful consent. Consequently, of 53 patients referred

to dieticians during the study periods, we were able to review

notes of 22.

Dissonance in the data

When evaluating health service innovations, multi-method

approaches are becoming increasingly popular with pragma-

tist health-service researchers aiming to strengthen internal

validity (Bryman 1988, Polit & Hungler 1999); however,

diverse data sources frequently yield conflicting findings

(Ziebland & Wright 1997). The sisters reported that the tool

was useful and improved nutrition-related care. They were

well-placed to observe subtle changes in practice affecting all

patients over time, whereas our case-note review was limited

to the least ill patients over two 28-day periods, and our

observations included only 12 mealtimes. Documentation

offers only a partial record, making case-note review a

relatively blunt research instrument compared with observa-

tion (Denscombe 1998). However, respondents often strive to

present themselves in a favourable light, and as reasonable

participants in the process of health care delivery (Baruch

1981). Our data conflict could also be explained by the

9 month interval between case-note review and interview:

practice may have changed during this time. Unfortunately,

resources did not allow follow-up data collection to link

respondents’ accounts with simultaneous observation and

documentation (Jordan 2000).

An infallible instrument or the best available option?

Many guidelines for nutrition care were developed before the

introduction in the UK of national standards for guideline

development (Cluzeau et al. 1999, Agree Collaboration

2001). Assessments of nutritional status are strengthened by

inclusion of objective data, such as serum albumin concen-

tration and body mass index (Carney & Meguid 2002).

Other screening instruments recommended by the UK DoH

(2002) entail physical examination, for example, the Sub-

jective Global Assessment (Detsky et al. 1994) and Mini

Nutritional Assessment (Vellas et al. 1999). For this study,

instruments entailing laboratory tests and/or physical exam-

inations were not considered. We found that the aspect of the

screening tool most frequently omitted from the records was

patients’ weights.



The focus of this screening tool is risk of undernutrition. It

is not designed to facilitate referral of patients with other

nutritional needs, such as obesity, hypercholesterolaemia and

diverticular disease, and this was reflected in the data.

Subsequent to adoption of the Nursing Nutritional Screen-

ing Tool, its authors published data (n ¼ 185) indicating that

it has poor construct validity and interprofessional inter-rater

reliability (McCall & Cotton 2001). Low inter-rater relia-

bility between nurses and dieticians is relatively common

(Richardson & Davidson 1996). Although this screening tool

does not meet standards for guideline development (Agree

Collaboration 2001), we met established criteria for intro-

duction of guidelines into practice (Grimshaw & Hutchinson

1995). The tool was generally well received, despite any

design flaws, and represented the most realistic option for our

busy wards.

Evaluation of the ability of guidelines to achieve specified

outcomes, such as dietician referral, is an important approach

to health-service research (Sizer et al. 1996, Lyne & Prowse

1999). In addition to statistical considerations, impact

evaluation encompasses the needs of clinical settings,

organizations and staff (Cole et al. 2000). In balancing

academic and biomedical rigour with the practicalities of

patient care on busy wards, and the difficulties of altering

some aspects of ward routine, clinicians agreed that this

screening tool remained the best available.

The guideline–practice gap

Nurses and doctors do not always adhere to nutrition

guidelines (Rasmussen et al. 1999), and guidance alone is

not enough (ACHC 1997), particularly if guidelines are vague

or demand practice change (Grol et al. 1998). Where

guidelines indicated a degree of nutrition risk (22 of 64

patients scored below maximum) action, including re-weigh-

ing, was not always taken. Similarly, in Reilly et al.’s (1995)

study no action was taken in response to identification of

high nutrition risk (12/40, 30%) and moderate risk (23/36,

64%).

Any impact of screening tools can be overshadowed by

organizational constraints and routines. Unless these can be

addressed, it is unlikely that paper screening tools and

guidelines will influence patient outcomes. During some

studies, guidelines on minimizing disruption of mealtimes

(Allison 1999) were, of necessity, sacrificed to other priorit-

ies. The number of staff available is a crucial determinant of

quality of care at mealtimes (Kayser-Jones & Schell 1997),

and resource constraints detract from availability of staff to

feed patients (McClone et al. 1995). Recording weights at

regular intervals is stressed in several guidelines (Lennard-

Jones 1992, Sizer et al. 1996). We observed discrepancies

between tool guidelines and their implementation in practice,

most notably failure to record patients’ weights (11/57),

re-score after 7 days’ hospitalization (10/12) and record

intakes. Initially, the screening tool was regarded as a ‘paper

exercise’, with the status of ‘another bit of paper’. Comple-

tion of the tool entailed extra paperwork as it did not replace

ongoing descriptive recording of patients’ nutrition-related

actions and status. Guideline researchers need to explore the

feasibility and clinical impact of increasing the bureaucratic

burden in busy wards, with many acutely ill patients at

nutritional risk.

How effective are guidelines?

Nutrition screening, risk assessment and documentation

alone may not improve outcomes. Our study offers no

evidence that the structured support and accountability of

such guidelines obviates the need for professional judgement

(Day et al. 1998). Screening findings need to be incorporated

into care plans in order to restructure care to address

problems identified (Allison 1999, Beck et al. 2001). In

previous work, even where 90% of patients (n ¼ 268) were

weighed, only 30% of malnourished elders were referred to

dieticians (Burns 1995).

By co-ordinating across interprofessional boundaries,

guidelines aim to reduce uncertainty over patient referral

(Day et al. 1998). However, it appeared that some patients

who were not referred would have benefited from dietician

input. We found instances where patients with similar

circumstances were treated differently; for example, patients

(P84, P94) who scored 22 of 28. Only one of 64 patients

scored outside the ‘minimal-risk’ category, indicating that

this tool may lack sensitivity for our client group. Some

patients who needed referral scored relatively well on the

tool, which thus possibly gave a misleading sense of security

and hindered referral.

Guideline algorithms that fail to capture the complexity of

clinical reality may be deleterious to patient care (Woolf et al.

1999). Screening is concerned with ‘identifying patients who

are already malnourished or at risk of becoming so’ (DoH

2001, p. 78), rather than gauging the extent (DoH 2002, p. 2)

or calculating the severity of problems identified (Bond

1997). Decisions to refer or not may have been confused by

an artificially constructed scale and reified ‘scoring system’.

Researchers need to explore whether quantification and

summation of risk construct artificial ‘referral boundaries’

which, by displacing professional judgement, could

compound problems of under-referral (McWhirter &

Pennington 1994, Burns 1995, ACHC 1997).

S. Jordan et al.


Conclusion

There are suggestions in the literature that nursing care could

be directed to optimize patients’ nutritional status, for

example by weighing and assessing all patients and recording

intake (DoH 2001). However, our findings do not suggest

that screening tools and guidelines are the ‘magic bullet’ for

nutrition-related care. Completing the Nursing Nutritional

Screening Tool focused nurses’ attention on patients’ nutri-

tional needs, and represented an incremental improvement in

the process of nutrition screening, if not the outcomes. In the

light of this study, our hospital has reviewed staff availability

at mealtimes and accelerated transfer of referrals to hospital

dieticians. A larger, longitudinal study is needed to explore

whether structuring care by guidelines and ‘screening tools’

can have an impact on patient outcomes in busy hospitals.

There should be no assumption that the burgeoning ‘guide-

lines industry’ is immune from clinical effectiveness scrutiny.

Acknowledgements

We should like to acknowledge the help received from Julie

Black, Senior Dietician, Withybush General Hospital, Mandy

Davies, Clinical Service Manager/ Nurse Advisor, Medicine

and Rehabilitation Directorate, Withybush General Hospital,

Tim Baines, Hotel Facilities’ Manager, Withybush General

Hospital, Shan Davies, statistician, School of Health Science.

Thanks are due to the clients and clinicians who facilitated

this study.

This study was funded by a small grant from the Dyfed

NHS Research and Development Consortium.

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Documents

Introducing a nutrition screening tool: an exploratory study in a district general hospital