Janet Scammell, Associate Professor (Nursing), Bournemouth University, asks whether nurse education places enough emphasis on the importance of ensuring good nutrition and hydration for patients

Scammell, Janet

Bournemouth University Research Online

BJN Education Matters: 20 February 2017  (984 words)  Food for thought: do student nurses have the knowledge and skills to deliver effective nutritional care?   It seems self-evident that to maintain health and wellbeing and to aid recovery in those who are ill, there are certain fundamental aspects that nurses must address; one of these is the provision of adequate nutrition and hydration.  Perhaps it is somewhat surprising therefore that the scale of malnutrition in hospitals in the UK continues to be of significant concern (Morison et al. 2015).  It is sobering to note that over 150 years ago, one of the founders of modern nursing Florence Nightingale observed that the availability of food is not so much the key concern but rather enabling it to be consumed: ‘Every careful observer of the sick will agree in this that thousands of patients are annually starved in the midst of plenty, from want of attention to the ways which alone make it possible for them to take food.’ (Nightingale, 1860:63). At that time nurse education was in its infancy and so such comments might be expected.  However nutrition and hydration have formed a key part of pre-registration education for many years; what’s the problem?  Despite high-profile UK policy initiatives focused on hospital and ward–level practices to improve food provision and nutritional care (for example NICE 2011), not only does nutrition and hydration remain inadequately managed in acute hospitals but both patients and relatives continue to report inconsistent or poor standards of dignified care (Morison et al. 2015).  Whilst other staff are involved, ensuring adequate nutrition and fluid intake in hospital patients is primarily a nursing responsibility.  Clearly inadequacies in staff education and training at all levels may contribute to this situation; are nursing students well prepared to address nutrition and hydration needs within care delivery?  The Essential Skills Clusters (ESCs) form an integral part of the Standards for pre-registration nurse education (NMC 2010).  These Standards form the basis of nursing curricula nationwide; two ESCs are pertinent to this issue – clusters four ‘Nutrition and fluid management’ and two ‘Organisational aspects of care’.  Education providers are obliged to develop programmes that enable students to develop the knowledge, skills and attitudes to enable them to perform care according to these Standards.  In relation to cluster two, this includes anatomy, physiology, pathophysiology plus constituents of a balanced diet, nutritional assessment and so forth.  Students will also undertake simulation activities to learn how to assist patients with their dietary and fluid needs at a fundamental level and learn skills to support more technical care such as parenteral and enteral nutrition.  These skills are then role modeled, supervised and assessed in clinical placements by mentors.   On the face of then nursing students receive the education they need for this important aspect of care; however evidence suggests that health care professionals consistently report inadequacies in nutritional knowledge (Murphy & Girot 2013).  Whilst acknowledging the value of the ESCs, Morison et al.(2015) add that nutrition and hydration needs particularly for vulnerable patients remains poorly covered both in nursing and medical programmes.  Moreover it is possible that in practice placements accountability for this area of care is not clear.  For example food and fluid choice, administration and monitoring of intake of those able to eat and drink involve a wide range of support, administrative and specialist dietetic staff.  Further an emphasis on meeting targets associated with the completion of more technical nursing tasks such as administering and monitoring enteral and parenteral nutrition may result in inadequate attention to fundamental care activities such as helping to feed patients (Francis 2013).  The provision of meals and monitoring intake may be perceived as an unskilled care activity leading to inadequate oversight by registered nurses. This is where ESC two ‘organisational aspects of care’ comes into play; even if the student is exposed to sufficient nutritional knowledge and skills during the programme, they need also to learn how to use systematic assessment skills, determine appropriate interventions based on these and then evaluate effectiveness (Pegram & Bloomfield, 2015); so in relation to nutrition and hydration, how to safely delegate aspects of nutritional care to support staff whilst remaining accountable for care delivery through staff supervision and monitoring of patient outcomes.    Over the last 150 years there have been significant technological and scientific advances in health care provision, leading to much improved mortality rates across the world.  This improvement is put at peril, if as educators whether based in universities or in clinical practice we fail to emphasise and role model sufficient attention to the fundamentals of care like the provision of adequate nutrition and hydration.  Whilst today we might claim that scientific advances enhance the role of what Nightingale calls nature, her observation is as true today as it was then: ‘Nature alone cures… and what nursing has to do... is to put the patient in the best condition for nature to act upon him.’ (Nightingale 1860:33)   References  Burchardt, T & Vizard, P. 2015. Older people’s experiences of dignity and nutrition during hospital stays: secondary data analysis using the Adult Inpatient Survery. CASE Brief 34, June Francis 2013 Francis, R. 2013. The Mid Staffordshire NHS Foundation Trust Public Inquiry http://webarchive.nationalarchives.gov.uk/20150407084003/http://www.midstaffspublicinquiry.com/report Morison, S., Machniewski, S., Purdy, J., Carlisle, K., Rea, M., Coleman, D. (2010) Exploring the Nutritional Needs of Older People in a Hospital Environment: The Educational Perspective. Report for the Belfast: Changing Ageing Partnership.   Murphy. J, Girot, E. (2013) The importance of nutrition, diet and lifestyle advicefor cancer survivors – the role of nursing staff and interprofessional workers.  Journal of Clinical Nursing, 22, 1539-1549. NICE (2011) Nutrition Support in Adults (32) Cost Saving Guidance (2011) http://publications.nice.org.uk/nutrition-support-in-adults-cg32/guidance Nightingale, F (1860) Notes on Nursing. What it is, and what it is not. New York: Appleton & Co. http://digital.library.upenn.edu/women/nightingale/nursing/nursing.html NMC (2010) Standards for pre-registration nursing education - annex 3; Essential Skills Cluster: Nutrition and fluid management.   https://www.nmc.org.uk/globalassets/sitedocuments/standards/nmc-standards-for-pre-registration-nursing-education.pdf Pegram A, Bloomfield J (2015) Nutrition and fluid management. Nursing Standard. 29, 31, 38-42.   Dr Janet Scammell, Associate Professor (Nursing), Bournemouth University 

Food for thought: delivering effective nutritional care.

 Janet Scammell, Associate Professor (Nursing), Bournemouth University, asks whether nurse education places enough emphasis on the importance of ensuring good nutrition and hydration for patients </jats:p

Food for thought: delivering effective nutritional care.

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