Article first published online: 5 JAN 2002
Journal of Advanced Nursing
Volume 28, Issue 5, pages 931–932, November 1998
How to Cite
Palmer, D. (1998), Guest editorial. Journal of Advanced Nursing, 28: 931–932. doi: 10.1046/j.1365-2648.1998.00826.x
- Issue published online: 5 JAN 2002
- Article first published online: 5 JAN 2002
THE PERSISTING PROBLEM OF MALNUTRITION IN HEALTHCARE
Despite a wealth of evidence identifying that poor nutrition results in ill health and a restricted pathway to recovery, the problem persists. Studies continue to identify high numbers of patients in malnourished states. Up to 40% of people admitted into hospital are nutritionally at risk and others may become so during their stay ( McWhirter & Pennington 1994). Nearly 10% of people with cancer and chronic disorders in general practice are malnourished ( Edington et al. 1996 ). There is a need for nurses to recognize when nourishment advice is required and this must be addressed by both the hospital and community nurses. Costs to the patient and to the health services associated with increased length of hospital stay and further treatment cannot be overlooked.
It is difficult to know where to apportion blame. This is not a new problem; over 20 years ago the high incidence of protein-energy malnutrition in hospitals was being reported ( Bistrian et al. 1974 ). Unfortunately the subject of nutrition has not been extensively included in the curriculum of either nurses or doctors and therefore many have continued to practice in ignorance.
Most final year medical students know less about nutrition than about other branches of medicine ( Parker et al. 1992 ). Staff providing clinical care are often not aware of fundamental factors which may well be contributing to the overall poor condition of a patient. A survey conducted in the United Kingdom (UK) identified that 50% of nurses and doctors do not weigh patients on admission, although this is recognized as a vital measurement in the assessment process to identify malnutrition (Lennard-Jones et al. 1995). An individual with a recent weight loss is less equipped to recover from illness, and may need to be considered for nutrition support.
Limitations to basic education in nutrition were identified in a study of practising midwives. They felt unable to fulfill their roles, when women raised specific concerns, as they had inadequate knowledge to promote effective nutrition ( Mullner et al. 1995 ).
An overburdened and under-educated workforce has resulted in responsibility for distribution of nutrients being delegated often to the junior, and frequently to the least well qualified members of the hospital ward team. A survey of nurses from a district general hospital in the UK found that almost half of the nurses questioned did not recognize responsibility for patients’ nutrition as part of their role ( Burnham 1996).
Administration of nutrients is not given the same attention to detail as administration of medicines, yet the morbidity and mortality associated with failure to provide adequate nutrition cannot be ignored. Clinical consequences of malnutrition, whatever the cause, can be serious and result in a poor response to drug treatment, reduced immunocompetence and increased morbidity and mortality.
The majority of food for hospital patients is prepared away from the ward environment. To ensure that demand for food can be met, patients often have to select their menus 24 hours in advance. The meal presented the following day for the patient may not be suitable to their palate at the time of serving, often resulting in an unstimulated appetite and poor nutrient intake. A ward or unit may not have the provisions to quickly prepare a␣snack for the patient who cannot tolerate the meal provided. Furthermore, hygiene regulations restrict preparation and storage of food in hospital ward kitchens ( Holmes 1996).
In the health services, where resources are scarce, it is essential to consider all available options. People often confess to having a favourite soup or light meal, which they rely upon at times of illness. A particular flavour of sandwich filling can stimulate taste buds thought to have vanished indefinitely. These gastronomic ‘first aid kits’ can be easily supplied and there is often a willing relative or friend keen to assist if availability is a problem. The role␣of good nutrition should never be underestimated, a␣creative approach should be adopted to the provision of␣nourishment.
Initial assessment of patients
The responsibility of the nurse to consider nutritional status as part of the assessment procedure must be accepted. Assessment tools, both elaborate and simple, have been launched but there is some controversy over which are appropriately validated and likely to be effective, and indeed which healthcare professional has the responsibility for carrying out the assessment and initiating action.
Basic questions asked by the nurse at the time of initial assessment would ensure that patients in a malnourished state are detected and receive appropriate treatment ( Lennard-Jones 1995).
Recommendations from The British Association for Parenteral and Enteral Nutrition (BAPEN) advise that assessment should include weighing the patient and asking four simple questions:
1 Have you lost weight recently?
2 Have you been eating less than usual?
3 What is your normal weight?
4 How tall are you?
The answers to these simple questions would ensure that where necessary a plan for nutritional care could be developed ( Lennard-Jones 1995).
The nutrition needs of patients should be on the agenda of every teacher of nurses, midwives and health visitors. Throughout the curriculum, nutrition education should be incorporated. The multi-professional approach is a useful concept ensuring that body chemistry, socio-economics and biomedical issues are all considered. Training and resource packages have been developed by many nutritionists and dietitians which could be utilized in nursing education programmes.
In addition to incorporating nutrition throughout the curriculum, educational establishments should encourage students to study research findings in nutrition, and ultimately we may be able to look forward to more evidence-based practice and early detection of the vulnerable patient.
There is almost a danger of some patients suffering as a result of undetected starvation. For patients admitted to hospital in an undetected malnourished state, the problem will persist and, possibly, become greater. This situation surely cannot be allowed to continue.
- 51995) Screening by Nurses and Junior Doctors to Detect Malnutrition when Patients are First Assessed in Hospital. BAPEN, London.(
- 81992) Final year medical students’ knowledge of practical nutrition. Journal of the Royal Society of Medicine 85, 338., , (