The study presented in this article addresses the important issue of how older individuals undergoing orthopaedic surgery can be facilitated to improve their oral nutritional intake. It is well documented that older individuals in the community can be involved in their own nutritional care in terms of screening aspects of their nutritional status and initiating improvements in dietary intake. This is an integral part of the first stage (DETERMINE) of the three part nutritional screening and assessment process for older adults developed in the USA in the 1990s (White et al. 1992). Nutritional care of patients or clients on admission to a care setting should start with screening and assessment to identify needs. The screening and assessment process should include obtaining information, from the patient or carer, on dietary preferences and habits, and assessment of need of assistance to eat. This information is usually obtained by nurses in the UK. The assessment process described by Pedersen also included calculation of energy and protein requirements. This is a novel approach. However, in practice this type of detailed assessment of all individuals would not be practical, particularly in a busy hospital setting.
The results of the initial screening and assessment process are used to inform a nutritional plan of care. The patients’ or clients’ active involvement in the development and implementation of the nutritional care plan may be minimal, although this does depend on the care setting. In some care settings individuals may well experience most aspects of the intervention care described in the paper. Pedersen emphasises the importance of actively involving patients to ensure nutritional interventions are effective, but surely all nursing care should aim actively to involve patients in their treatment as much as possible? What is important about Pedersen's study is that it compares the effect of developing and implementing a nutritional care plan on patient's energy and protein intake. There is a paucity of research evaluating whether nutritional screening and assessment by nurses and nursing interventions to promote oral food intake actually do enhance nutritional intake.
Unfortunately it is not possible to determine the relative effectiveness of each part of the intervention described by Pederson. It may be possible that the leaflet received by post was completely ineffective at promoting nutritional intake and it was the daily assessment of need for nursing care in connection with dietary intake that was the effective component of the intervention. Further research into this area could define which aspects of the intervention were most effective at promoting nutritional intake.
The issue of cost is not really highlighted in the paper. Did the nurse who undertook the interventions do so as part of their nursing role on the ward? Basic nutritional interventions by nurses should be carried out as part of the normal nursing process without the need to employ a nurse specifically to address nutritional needs.
Whilst it is possible to criticise the methodology, in that the control group preceded the intervention group, leading to possible influences other than the variable under discussion, it must be recognised that undertaking this type of research within a clinical practice area is extremely difficult. The author should be congratulated on successfully completing the study with such a large sample. This gives confidence in the results obtained.
Pedersen suggests that the study examines the effectiveness of actively involving older patients in their nutritional care. However, the nutritional care described may not require the full involvement of the patient or client. Individuals who are confused or disorientated would also be likely to benefit from the interventions described. In addition, carers may want to be actively involved in the nutritional care of the hospitalised individual. The author highlights 37 patients were unable to understand the instructions issued. These patients may have particularly benefited from the interventions described, although the ethical issues surrounding research of this group of individuals are likely to have limited their participation in the study.
This paper is an important paper because it stimulates enquiry into how inpatients can be facilitated to improve their oral nutritional intake and justifies the need for further investigation in this important area of nursing care.