In the UK, it is estimated that approximately 3 million people are at risk of malnutrition (or undernutrition), and nearly half of these individuals are aged 65 years or over, with most (93%) residing in the community (Elia and Russell, 2009). Malnutrition and unintentional weight loss are costly (Elia et al, 2015) and have a significant impact on quality of life due to increased susceptibility to disease and mortality (Soderstrom et al, 2017). Moreover, malnutrition poses a strain on healthcare resources, as it leads to delayed recovery from illness, increased need for healthcare provision at home, more frequent visits by nurses and a greater number of hospital admissions (Guest et al, 2011). Malnutrition is largely preventable through appropriate screening using a validated tool, such as the Malnutrition Universal Screening Tool (‘MUST’) (Elia, 2003). National policy guidance (National Institute for Health and Care Excellence (NICE), 2012; 2017) recommends screening for malnutrition, which leads to substantial cost savings from early identification and treatment largely from reducing healthcare resources (Edington et al, 2004). Screening should be undertaken by trained care providers and integrated into existing pathways of care. After screening, appropriate action should be taken to manage those patients identified to be malnourished or at risk of malnutrition. Malnutrition in the community is optimally treated by providing first-line dietary advice—the ‘food-first’ approach—followed by possible combination with oral nutritional supplements (ONSs) when necessary (Dera and Woodham, 2016; Holdoway et al, 2017).
This article reports the barriers and facilitators to implementation of a new procedure for nutrition screening and care for older people in a selected business unit within Southern Health Foundation Trust (SHFT) and the lessons learnt for roll-out and spread. The procedure was informed by Wessex Academic Science Network's (AHSN) Older People's Essential Nutrition (OPEN) Toolkit (Wessex AHSN, 2018). The new procedure outlined the process of care for nursing teams as well as the nutritional advice and support that should be given to older people in accordance with their malnutrition risk, and it was developed to reflect local services. Existing policy established when a patient should be screened for malnutrition and the care that a patient should receive depending on their malnutrition risk (assessed by ‘MUST’). The new procedure introduced a number of updates to better reflect NICE guidelines (NICE, 2017). They were as follows:
At the same time, a research project was undertaken by Bournemouth University (funded by the Burdett Trust for Nursing)—Implementing Nutrition Screening in Community Care for Older People (INSCCOPe). The aim of the project was to explore the factors that may help or hinder implementation of the new procedure and its longer term embedding as a routine aspect of community care (using normalisation process theory; May and Finch, 2009).
Details of the protocol are published elsewhere (Bracher et al, 2019a). In brief, implementation was assessed through observation of staff from Integrated Community or Older People's Mental Health (OPMH) teams. Data collection occurred at three time points: baseline (T0), 2 months following completion of initial training (T1), and 16 months following the initial training as well as following deployment of a nutrition lead as part of embedding new developments in routine nutritional care (T2). Each observation point consisted of a 23-item questionnaire and follow-up semi-structured telephone interviews with staff. Bespoke training via a 1-hour session delivered by a dietitian was provided during the introduction of the new procedure to address the gaps in knowledge, with an emphasis on identifying the underlying causes of malnutrition and establishing a plan of care.
Findings after delivering training (T1)
The results after training at T1 showed high levels of non-completion of the training and trained staff members' vulnerability to attrition. Community-based nurses felt they had some knowledge to help care for patients at risk of malnutrition, but they lacked specialist support due to the absence of a community dietetic service in their geographical area. There was also a lack of monitoring of post-intervention compliance and oversight of the process to assess and treat malnutrition at a higher organisational level, because staff failed to make treating malnutrition a priority (Bracher et al, 2019b). Updates on compliance, training and resources should be provided to senior managers at regular intervals. The team suggested a process that links front-line monitoring and resource allocation directly to those with responsibility to ensure successful implementation of the new procedure, thus creating an ‘organisational feedback loop’.
The findings demonstrated what aspects of implementation were required to embed new developments in routine nutritional care for older people in community settings. Importantly, it informed the deployment of a nutrition lead to provide training and specialist support, as well as ‘nutrition link’ champion roles to help address these issues on a daily basis within teams. A new nutrition lead post for the project was created (Box 1).
The main role of the nutrition lead was to provide training to staff on malnutrition, ‘MUST’, the newly developed malnutrition care pathway within the trust and appropriate treatment. Face-to-face training was offered to every community nursing and therapy team within the selected business unit and was requested by all teams. The delivery of the training was extended to reach local enhanced recovery nursing teams and respiratory nursing teams during the 6-month intervention.
Findings after deployment of nutrition lead role (T2)
Data collected from surveys and interviews indicated that, where the procedure had been adopted, it was found to make the screening and treatment of malnutrition more straightforward and more actionable (Murphy et al, 2020). An electronic form supported improvements in recording and accessing information as well as guiding the assessment. The training on malnutrition and the ‘MUST’ screening tool had a positive impact on staff confidence and their understanding of the importance of nutrition, particularly in the context of its influence on other aspects of patient welfare. The new procedure was also perceived to make nutrition screening and treatment work less complicated. This finding was reflected in service improvement data collected, showing a four- to five-fold increase in the number of screens completed over the period of the project. Thus, patients who would otherwise have been unable to access specialist dietetic support had benefited the most from the project.
Key people identified were nutrition link nurses who were encouraged to attend study days and feed back to the teams, monitor screening rates and offer support, thus having a positive impact on the team's engagement. For the role to have lasting impact, it was suggested that these professionals should receive regular training updates and support from more senior staff. However, concerns were also raised about maintaining the existing knowledge levels among new staff, particularly with high staff turnover levels, and the need to make nutrition training mandatory.
The nutrition lead was perceived as extremely helpful for both supporting staff and providing specialised support to high-risk patients, and the lead had an important impact on bringing the importance of nutrition to the forefront. As such, a lack of access to community dietitians was a crucial gap identified in the ability of staff to provide appropriate treatment. Notably, while the procedure generated enthusiasm and brought the issue of nutrition to the forefront among competing demands, a strategic directive from senior management within the trust was identified as a further step necessary to embed the procedure as part of usual practice.
Conclusion
The project has shown that the delivery of nutritional care was considered to be of low priority in the community despite being perceived as important by many staff. It is recognised that nursing and therapy staff already have extremely busy caseloads, so are struggling to complete full and comprehensive nutritional assessments of patients. The introduction of a nutrition lead (together with localised nutrition link champions) offers significant benefits to: (i) drive the agenda for nutrition; (ii) provide support and guidance to help staff deliver quality improvements in nutritional care in the community; and (iii) offer specialist advise to high-risk patients. Where the procedure had been adopted, it led to improvements in the screening and treatment of malnutrition. Education and learning for malnutrition screening should be essential for all staff as part of their role. However, for the adoption of the procedure to be sustained, prioritisation by the senior leadership team and organisational support is vital. New training tools (workbook and film) were developed during the project and are freely downloadable from the following link: https://tinyurl.com/tl5oprr.