Presentation given at the Department of Health Improving Hospital Food event by Liz Evans, Nutrition Nurse Specialist at Bucks Healthcare NHS Trust and Chair of NNNG

1. The nurse’s role in keeping
patients nourished
Liz Evans. Nutrition Nurse Specialist – Bucks
Healthcare NHS Trust.
Chair - NNNG

2. Who are the NNNG?
 We are a group of nurses
dedicated to promoting
excellence in all aspects of
nutritional care and
promoting good nutritional
practice for nurses across all
specialities.
 Established in 1986 our
membership stands at
nearly 300 at present but is
ever expanding.
 We believe that good
nutrition needs nurses!
 http://www.nnng.org.uk/

3. What is the nurse’s role in nutrition and
hydration? A brief history
 1980’s (Ref
http://www.dailymail.co.uk/news/article-
2082883/NHS-care-David-Cameron-
says-nurses-told-talk-patients-hospital-
wards.html)
 Today ( Ref
http://www.bbc.co.uk/news/health-
11097822

4. The story so far….
 Late 19th and early part of the 20th century
Matron and senior nursing staff were in charge
of the kitchen and domestic staff.
 Post 1948, the NHS developed strong
functional management structures in hospitals
and hospital groups. Senior nurses began to
change their ideas about roles and
responsibilities of nurse managers.

5. 1960’s-70’s
 1968 – the Standing Nursing Advisory
Committee declared that..
It was no longer appropriate for ward sisters to
directly manage non- nursing staff on the
wards, nor for nurses to spend time on “hotel
services” to the detriment of their rapidly-
developing “therapeutic role” and “technical
nursing” skills.

6. Hotel services included
 Preparing patients’ food and drinks ( except
special diets).
 Distributing food and drinks, including special
diets, at mealtimes.
 Collecting and clearing meals
 Preparing trays and setting up bed tables

7. Recommendations included
 Introduction of housekeeper teams to be
managed by senior grade housekeeper not
ward staff
 A formal career structure and standardised
national syllabus for housekeeping staff.

8. 1980’s
 Hospital catering services contracted out.
 Nurses’ were limited in influencing standards in
these areas.
 The role of the nurse in feeding patients was
no longer clearly defined.
 Student nurses no longer rostered as part of
the ward team which led to a decrease in the
numbers of staff carrying out care on wards.

9. 1990’s
 1994 McWhirter and Pennington report that
40% of patients were undernourished on
admission and two thirds of all patients lost
weight during their stay.
 The Community Health councils for England
and Wales (1997) suggest that no one is taking
responsibility for ensuring that patients are fed
or investigating why some patients are not
eating and drinking.
 The UKCC remind trained nurses that it is their
responsibility to ensure that the nutritional
needs of their patients are met.

10. 2000 -2006
 Essence of Care (2001) highlights food and nutrition
as one of the 8 fundamental aspects of care.
 Modern matrons are introduced (2001) to improve
not only the quality of nursing care but the total
environment for in patient care. This includes
ensuring that “patients’ nutritional needs are met.”
 The Department of Health recommends that all
Trusts should appoint ward housekeepers.
 National organisations such as BAPEN, Age
Concern, RCN, all highlight nutritional care as a
concern.

11. 2006-present (1)
 Age Concern releases “Hungry to be Heard”
 RCN launch Nutrition Now campaign with Age
Concern and NPSA support.
 NPSA highlights poor nutritional care as a safety
issue.
 Government issues the Nutrition Action Plan.
 Patient Environment Action Team recommends
that all Trusts should have Protected Mealtimes.

12. 2006- present (2)
 Department of Health release new standards
for Care settings to be compliant with. (Care
Quality Commission 2010). Nutrition and
hydration is high on the list – standard 5.
 Nutrition education is brought back into pre
registration nurse training.
 BAPEN nutrition screening week 2007-2011
indicates that 1 in 4 people admitted to a
care setting is malnourished.
 Malnutrition Task Force is launched.

13. CQC Dignity and Nutrition for Older
People.
• A targeted inspection of 100 NHS
hospitals
• Older people ‘’dignity, food and drink’’
• Commenced in February 2011 and
carried out over 4 months
• Gives a snapshot of findings at the time of
the visit.
• Final report released states that 1 in 5
hospitals are failing to meet this standard.

14. So why are we still not getting it right?
What are the barriers?

15. Attitudes

16. Common excuses
 It’s not my job
 I have the drugs to do
 I have to finish this..
 The housekeeper should know
 “Not relevant”

17. Retorts
 Hospital Acquired Infections cost the NHS 7.3billion
pounds a year. Malnutrition costs 13 billion pounds a
year.
 You have time to do dressings, drug rounds, why is
food less important?
 You may know what the patient is eating but this may
not be sufficient to reassure relatives and other
members of the MDT.
 Poor nutritional care causes harm or has the potential
to cause harm to patients.
 So whose job is it?

18. However
 Three out of four nurses say they have no time
to talk to older hospital patients and many are
so rushed they can’t help them to eat.
 Typically, one registered nurse is expected to
look after nine elderly patients who may be
frail, acutely ill and have complex medical
needs.
(Ref Safe Staffing for Older People RCN 2012)

19. How can we overcome these barriers?
 Senior nurses at board level should make nutritional
care a priority and support protected mealtimes and
mandatory nutrition training.
 Ward routines should be re assessed to ensure that
patients are given the help they need at all times, not
just lunchtime.
 Trust boards should recognise that food is part of
treatment and allow time on the wards for staff to
ensure patients are helped to eat. We should be caring
for people – not caring about targets.

20. Effective leadership!
 We need
 Dynamic nursing managers
 Supportive matrons
 An organisation that sees the bigger picture and
supports good practice.

21. How can this be achieved?
 Education
 Education
 Education

22. Who needs educating?
 Hospitals – nutrition training should be
mandatory in all organisations for all
levels – not just nursing.
 It should be on level footing with
infection control and pressure area care
 It should not be seen as a hotel service
but as an essential part of treatment and
care.

23. How should nutritional care be
organised in hospitals?
 Nutritional care is a multi-disciplinary
responsibility, and an integration of
workforce activities is absolutely
essential. BAPEN 2007
 All hospitals Trusts should have a
nutrition steering committee working
within the clinical governance framework
NICE 2006

24. Who is involved?
Allied
Health
Profs
Trust
board
Matrons and
Senior nurses
Relatives
And
carers
pharmacists
dietitians
Nutrition nurse
specialist
Medical staff
Speech and
Language
therapists
Catering
Partners and
Soft facilities
manager
Patient

25. Florence Nightingale 1860
 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.

26. The Mid Staffordshire NHS�
Foundation Trust Inquiry 2010.
 Admitted to hospital in March 2005 for open
surgery for a cholecystectomy the patient was
expecting a short stay. The surgery went well
but her recovery was poor as she was not
eating or drinking. Her family were concerned
that she was dehydrated as she was not being
given regular fluids and there was no luid chart
even though she was on IV. Her nutrition was
also poor and caused her weight to plummet.
 This lady ended up going into a nursing home
with Clostridium Difficile

27. And finally…..the future
 Will this be the only way we can get
patients fed?

28. Thank you for listening
 Any comments/questions?

29. References..
 Age Concern (2006) Hungry to be Heard
 BAPEN (2010) Malnutrition Matters. Meeting Quality
Standards in Nutritional Care.
 BAPEN (2009) Combating Malnutrition –
Recommendations for Action.
 BAPEN (2007) Organisation of food and nutritional
support in hospitals.
 NCEPOD (2010) An Age Old Problem. A review of the
care received by elderly patients undergoing surgery.
 NICE (2006) Nutrition Support in Adults.
 Savage J,Scott C,(2005) Patient’s Nutritional Care in
Hospital. RCN Institute.