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Nursing Practice Keywords: Nutrition/Hydration/
NMC Code/Revalidation
Discussion
●
Nutrition This article has been double-blind
peer reviewed
The revised Nursing and Midwifery Council code of conduct has restored some
responsibility to nurses for ensuring their patients receive good nutritional care
The nurse’s role in patient
nutrition and hydration
In this article... 5 key
How nutrition and hydration needs became overlooked points
Stipulations of the NMC’s revised code of conduct Nutrition and
1h ydration are
How nurses can ensure they comply with the Code key aspects of
patient care
Over the past
Authors Liz Evans is nutrition specialist There is no specific mention of nutri- 2150 y ears there
nurse at Buckinghamshire Healthcare tion and hydration in the previous version have been a
Trust; Carolyn Best is nutrition nurse of the code (Nursing and Midwifery number of changes
specialist at Hampshire Hospitals - in the roles and
Council, 2008), so why has it become nec
Foundation Trust. essary to be so specific in this new version? responsibilities of
Abstract Evans L, Best C (2015) Meeting Why are nurses being advised that they nurses in relation
patients’ nutrition and hydration needs. could be held to account for not providing to patient nutrition
Nursing Times; 111: 28/29, 12-17. - The NMC Code
adequate access to nutrition and hydra
The Nursing and Midwifery Council’s new tion. And how can we demonstrate that we 3no w includes
code was introduced in March 2015. For have provided appropriate care if asked? stipulations
the first time, nutrition and hydration are relating to patients’
mentioned specifically within the code. Previous shortcomings nutrition and
This article explores why this has become Nutrition and hydration have been increas- hydration
necessary and how nursing responsibility ingly discussed in national media. Various Nurses’
for the nutritional care of the patient has - 4r evalidation
organisations have attempted to set stand
changed over the past 150 years. It also ards for nutritional care, including chari- will be dependent
looks in more depth at how the nutritional table association BAPEN (Brotherton et al, on their abiding
care can meet the standards of the code. 2012) and the Department of Health (2010), by the nutritional
and organisations such as the Patients conditions set out
n March 2015, every registered nurse in - in the Code
Association have highlighted the short
England and Wales was sent the comings experienced by patients and their A patient’s
Nursing and Midwifery Council’s families in healthcare environments (2013, 5nutritional
I 2012). Unfortunately, during this process, status cannot be
(2015) revised cap code. It identifies
four key areas for nurses to uphold: the role that registered nurses play – or do judged on
» Prioritise people; not play – in helping patients meet this appearance alone
» Practise effectively; most fundamental aspect of care has led to
» Preserve safety; strong criticism.
» Promote professionalism and trust. Inadequate nutrition and hydration in
The code talks about fundamentals of care settings is not a new problem. In 1859,
care, which includes, but is not limited to: Florence Nightingale remarked in her
“Nutrition, hydration, bladder and bowel Notes on Nursing:
care, physical handling and making sure “Every careful observer of the sick will
that those receiving care, in all healthcare agree in this that thousands of patients
environments, are cared for in clean and are annually starved in the midst of
hygienic conditions. It includes making plenty, from want of attention to the
sure that those receiving care are treated ways which alone make it possible for
with respect as individuals, their dignity them to take food.”
upheld and that they have adequate access More than 150 years later, the Parlia-
to nutrition and hydration, including mentary and Health Service Ombudsman
making sure that help is provided to those stated (2011):
individuals who are not able to feed “It is incomprehensible that the
themselves or drink fluid unaided.” Ombudsman needs to hold the NHS
12 Nursing Times 08.07.15 / Vol 111 No 28/29 / www.nursingtimes.net
Copyright EMAP Publishing 2015
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Nursing For more articles on nutrition and
Times.net hydration, go to nursingtimes.net/nutrition
to account for the most fundamental
aspects of care: clean and comfortable
surroundings, assistance with eating if
needed, drinking water available.”
Where did it go wrong?
To understand why nurses do not appear
to be addressing patients’ nutritional and
hydration needs as is expected of the role,
-
it is necessary to look back at recent his
tory and explore the changes surrounding
nutrition and hydration in hospitals.
The nursing role
In the late 19th and 20th centuries the hos-
pital matron was the head of nursing staff,
and also responsible for the kitchen and
housekeeping staff. Indeed, many nurses
undertook related tasks such as cleaning,
providing food and laundry care. However,
as hospitals grew in size and complexity,
many of these aspects were taken over by
non-nursing staff, supervised by senior
nurses (Savage and Scott, 2005).
At the time of the Salmon report Nurses are in a unique position to ensure appropriate nutrition for patients in their care
(Salmon, 1966), nursing staff were still very
much involved in all activities relating to immunity and the outsourcing of hospital A King’s Fund report stated that lack of
nutritional care. This included helping catering to private companies, food in nursing supervision at mealtimes could
patients to order meals, arranging special hospital had become a financial issue and leave a patient’s poor nutritional intake
diets and taking meals to patients who the extent to which nurses could influence unnoticed and, as such, uncorrected,
could not sit at the ward table. Staff would the standards of food provided to patients which would put the patient at an
monitor what patients had eaten and was limited. increased risk of developing malnutrition
drunk, and, in some hospitals, make sand- (Lennard-Jones, 1992). Lennard-Jones also
wiches for them for afternoon tea, as well Staffing levels suggested that malnutrition was often
as preparing breakfasts such as boiled eggs The Griffiths report of 1983 led to a change unrecognised because nurses and doctors
-
and toast. This continued in many hospi in the focus of the NHS: it needed to be were not used to looking for it.
tals until the mid-1980s. -
management led. Budgets, resource alloca This report was later supported by
However, in 1968, a Standing Nursing tion, strategic decisions and reports on McWhirter and Pennington’s 1994 report,
Advisory Committee report argued that it performance became key themes, and clin- -
which highlighted that in an acute hos
was no longer appropriate for nurses to ical managers were replaced with general pital of 500 beds, 40% of inpatients were
- managers, who had little or no NHS expe- found to be already malnourished on
spend time on “hotel services” to the detri
ment of their rapidly expanding “thera- rience (Day and Klein, 1983). At the same admission, and a further two-thirds of all
peutic role” and “technical nursing” skills time, with the loss of rostered students on patients studied had lost weight during
(Central Health Services Council?, 1968). the wards and the widespread failure to their hospital stay.
The most time-intensive of these “hotel provide housekeeping teams, nurses -
Two years later, the issue was exacer
services” were considered to be: began to struggle to provide all aspects bated by the falling number of nurses. The
» Distributing food and drinks at of patient care. Royal College of Nursing suggested that,
mealtimes;
» Collecting and clearing meals; Box 1. THe Mid STAffS iNquiry: NuTriTiON ANd
» Preparing patients’ food and drinks HydrATiON iSSueS
(except special diets).
The committee recommended that
these tasks be undertaken by non-nursing The inquiry into care failures at Mid ● Visitors having to assist other patients
staff, such as ward housekeepers, which Staffordshire Foundation Trust found: with their meals
essentially confirmed that nutritional care ● Inappropriate food given to patients in ● No water available at the bedside
of the patient was not an important light of their condition ● Water intake not monitored or
nursing consideration. The same report ● Patients’ meals placed out of reach encouraged
also failed to highlight the important and taken away, even though they had ● Problems with not addressed
role of nutrition in the recovery process, not been touched adequately
or mention supervision or feedback of ● Patients given no encouragement to eat ● Lack of monitoring and appropriate
care provided by housekeepers to ● Relatives and other visitors denied records of fluid balance and
nursing staff. access to wards during mealtimes nutritional intake y
By the 1980s, with the loss of crown Source: Francis (2010) Alam
www.nursingtimes.net / Vol 111 No 28/29 / Nursing Times 08.07.15 13
Copyright EMAP Publishing 2015
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Nursing Practice
Discussion
- delivering the care that met the standards
although 37,000 registered nurses quali hospital and their relatives were extremely
fied in 1983, it expected that figure to drop concerned by nurses’ apparent lack of the law said people should expect (Care
by between 8,000 and 9,000 by 1997-98 interest in helping them to eat and drink. It Quality Commission, 2011).
-
(RCN, 1996). It also suggested the “regis found that, despite a wealth of guidance However, staffing still seemed to be the
tered nurse’s role with regard to feeding is - main reason nurses gave for not helping
and standards, malnutrition and the pro
not clearly prescribed”. Yet no guidance vision of poor nutritional care in hospital their patients to eat and drink: three out of
was offered on how to clarify the nursing still seemed to be a huge problem. four reported not having the time to talk to
role in nutrition. As a result, in 2007 the RCN launched older hospital patients and many said they
As a result of the RCN’s report, the chief its extremely successful Nutrition Now were so rushed they could not help patients
registrar of the UK Central Council for campaign (bit.ly/RCNNutritionNowCam- to eat (RCN, 2012). The RCN’s report found
Nursing, Midwifery and Health Visiting paign). Supported by both the National that, typically, one registered nurse is
(the predecessor to the NMC) wrote to Patient Safety Agency and Age Concern, it expected to look after nine older patients
every trained nurse in the UK to remind aimed to empower trusts to improve the who may be frail, acutely ill and have com-
them that they had a responsibility to nutritional care they gave patients. plex medical needs.
ensure the nutritional needs of their It can be argued that it is not solely the
patients were met. The situation today nurse’s responsibility to ensure patients
- In 2010 Age Concern (now rebranded as receive adequate nutrition and hydration
Unsurprisingly, the Association of Com
munity Health Councils for England and Age UK) issued its second report, which but, as the professionals who are with
Wales (1997) reported nurses as stating that: suggested that the nutrition and hydration patients 24 hours a day, we are in the best
» They did not have time to help patients needs of older people in hospital were still position to ensure our patients receive
to eat; unmet (Age UK, 2010). Groups such as appropriate care and attention.
» There did not seem to be anyone taking BAPEN and the RCN reacted to this with a -
Other members of the multidiscipli
responsibility for nutrition at ward level. flurry of reports and guidance, while the nary team – dietitians, catering staff,
- -
Despite the fact that nutrition and government asked the Care Quality Com speech and language therapists, and med
hydration were recognised as problems in mission to make unannounced inspec- ical staff – are vital components of patients’
the 1990s, little progress appeared to have tions of 100 hospitals in England to explore overall nutritional care, but nurses are the
- dignity and nutrition. The inspector ones who must ensure appropriate care is
been made until a 2006 report by Age Con
cern. This stated that older people in reported that a fifth of hospitals were not provided. Even if they are not directly
helping the patient to eat and drink, and
Box 2. AvOid MAKiNg ASSuMPTiONS: CASe SCeNAriOS have allocated the task to another member
of the ward team, registered nurses are
● Joan Smith, 1.6 metres in height and ● Gerald Thomson is 79 years old. He is responsible for ensuring each patient
weighing 78 kg, is admitted to your 1.88 metres in height and weighs 64kg. -
receives timely and appropriate nutri
ward/nursing home for assessment. His BMI is calculated to be 18.1, making
tional care that is accurately documented
Your visual assessment says she is obese. him underweight. and monitored.
You calculate her body mass index (BMI) Mr Thomson insists on having Unfortunately, while many areas pro-
to be 30.5, confirming porridge every night for his evening
vide good standards of nutrition and
she is in the obese range. meal but is seen to eat little else hydration care, it is still not universal – as
question 1: Based on this information throughout the day. was highlighted in the report of the inquiry
alone, what should be your plan of care question 1: Should you try to change
into care failings at Mid Staffordshire
for Mrs Smith? Your initial thought may Mr Thomson’s diet or work around Foundation Trust (Francis, 2010) (Box 1).
be that you do not need to worry about his individual choices to increase The report highlighted that, despite all the
Mrs Smith’s nutritional state. Indeed, you his nutritional intake? Involving recommendations made and standards
may think she needs to lose weight. If Mr Thomson in decision making published, good nutritional care was not
you factor in that she has, for example, to improve his nutritional or fluid intake -
embedded in every healthcare organisa
pressure ulcers, has mobility problems is likely to be more effective than tion (Francis, 2010).
caused by pain in her knees and finds it dictating to him what you think he In 2013, an independent review of
difficult to shop for food or make meals should do and when you think he
the Liverpool Care Pathway made a
at home, the picture changes. should do it. number of recommendations to improve
question 2: With this additional question 2: What additional action end-of-life care, one of which was to
information, how should you change could you take to try to improve
develop an individual care plan
your original plan of care? Although
Mr Thomson’s nutritional intake? that included food and drink intake and
Mrs Smith is obese, she has more A nursing assessment should be should be agreed, supported and delivered
immediate health issues that need to be holistic, and nutrition and hydration with compassion (Department of Health,
addressed in which nutrition and may be affected by pain that is not 2013). This stemmed from reports from
hydration play an integral role: the adequately managed, constipation, relatives who told the review body of their
healing of her pressure ulcers. In changes in routine and environment, an experiences – their family members did
addition, managing her pain more inability to read or understand menu not have their nutrition and hydration
effectively may improve her mobility, choices, and food dislikes. You should needs met appropriately during their last
and initiating a referral to appropriate complete a full assessment to ascertain hours – and raised their concerns that, in
social services may make it easier for her the reasons behind Mr Thomson’s low some cases, patients suffered needlessly
to obtain appropriate food at home. food intake. through lack of adequate nutrition
and hydration.
14 Nursing Times 08.07.15 / Vol 111 No 28/29 / www.nursingtimes.net
Copyright EMAP Publishing 2015
This article is not for distribution
Nursing Practice
Discussion
-
In response to this report, was Leader
ship Alliance for the Care of Dying People
published One Chance to Get it Right (2014).
It stated registered nurses’ responsibilities
in nutritional care as to:
» Be able to assess and monitor
nutritional and fluid status;
» In partnership with patients and their
carers, formulate an effective plan of
care to ensure people receive adequate
food and fluid;
» Identify when nutritional status
worsens/signs of dehydration and act to
correct them;
» Ensure appropriate assistance is
available to enable people to eat and
drink;
» Ensure people unable to take food by A red tray alerts nursing and other staff that the patient has particular nutritional needs
mouth receive adequate fluid and
nutrition to meet their needs. change and create an environment assessed. Assessment should begin at the
The issues discussed above explain why where staff are not afraid to speak out; first consultation, be that in a GP surgery,
the NMC has included nutrition and » Training and development for all staff; outpatient department or hospital ward.
hydration as part of the fundamentals of » A culture where people are encouraged Nursing assessment should comprise:
care in the revised code and reinforces the to “go the extra mile” and challenge » A full medical history , including
importance of the nurse’s role in patients’ current practice to improve the quality social issues/support (if appropriate);
nutritional care. of care provided to patients; » Completion of a nutrition screening
» A working environment that enables tool.
The revised code -
staff to deliver the best care for people; Once the assessment stage is com
The first section of the revised code, Priori- » A clear communication strategy and pleted, an individualised care plan should
tise People (NMC, 2015), states that nurses collaborative workforce. be made, documented and communicated
must treat people as individuals and Each of these statements can be applied to all those involved in caring for that
uphold their dignity. To achieve this, to the provision of nutrition and hydration patient. If additional support is needed,
nurses should: to patients. appropriate referrals should be initiated.
» Treat people with kindness, respect Good leadership is required to have a
and compassion; clear awareness of who is providing what Avoid making assumptions and
» Make sure they deliv er the care and to whom. As an example, patient recognise diversity and individual
fundamentals of care effectively; choice
mealtimes can be chaotic if staff are
» A void making assumptions, and unaware which patients require special It is easy to make an assumption about a
recognise diversity and individual diets, thickened fluids or assistance to eat. person’s nutritional status and ability to
choice; Clear communication between all staff manage their nutrition and fluid intake
» Make sure tha t any treatment, involved in patient mealtimes is essential. orally, based on first appearance. Two fic-
Changes in the level of care required or tional scenarios look at how our assump-
assistance or care for which they
are responsible is delivered without referrals needed may be missed if they are tions can affect the nutritional care we
undue delay; not communicated effectively to the provide to patients (Box 2).
» R espect and uphold people’s appropriate person. Exploring the two cases in more detail,
human rights. Staff who have not been trained in it becomes clear that, although nurses are
Using these five statements as a basis, nutritional care may not realise the signifi- not providing direct assistance to help
how can we, as nurses, ensure we are cance of, for example, a “red tray” (issued their patient to eat, their role is essential to
to patients who need assistance with -
upholding the code when dealing with our avoid incorrect assumptions, and to recog
patients’ nutrition and hydration needs? eating or drinking, or whose dietary intake nise and address problems to improve
is being monitored), how to safely help nutritional intake.
Treat people with kindness, respect someone to eat or drink, or what issues
and compassion they should feed back after a meal. Ensure that any treatment, assistance
The DH has dedicated an entire document or care for which you are responsible is
to compassion in nursing practice (DH, Deliver the fundamentals of care delivered without undue delay
2012) and outlines six fundamental values effectively As discussed earlier, registered nurses
– known as the “six Cs”: care, compassion, Nutrition and hydration are fundamental must retain responsibility for interven-
competence, communication, courage to life, and, as such, consideration must be tion, even when they have been delegated
and commitment. It suggests that, to meet given to the nutrition and hydration needs to an unregistered member of staff
-
the six Cs, there should be: of every patient in the nurse’s sphere of including healthcare assistants, volun
» Clear leadership a t every level; responsibility, even if they are nil by mouth. teers, housekeepers, or members of
y -
» Clear expecta tions for all staff to Effective care can only be provided if domestic staff. As responsible profes
Alam manage performance, champion the patient’s needs have been fully sionals, registered nurses are expected to
16 Nursing Times 08.07.15 / Vol 111 No 28/29 / www.nursingtimes.net
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