Developing practice: mealtimes and nutritionBelinda Dewar, Senior NurseDr Stephen Smith, Lead NurseLeadership in Compassionate Care Programme (LCCP)

Aim

Aim of presentation• Understand the practice development work within the LCCP

programme • Understand the techniques used to explore and develop

mealtimes and nutrition with staff, patients and relatives• Consider the challenges and value of developing local practice

based theory

Aim of LCCP programme

Embed compassionate care as an integral aspect of all nursing practice and education in NHS Lothian and Edinburgh Napier University.

Theoretical approaches adopted

Practice development activities

• Beliefs & values clarification groups• Image work• Stories: Patients, Relatives & Staff• Emotional touch points• Observation: informal / formal

Practice development activities

• Action Learning• Focus groups using RCN Dignity Resources• Role modelling• Development of positive care practices• Facilitating practice development projects

Evidence from patients, relatives and staff

We did not know where we could get things to eat at night, if we could use the kitchen to make a cup of tea. Some staff were really good about this and others maybe were not happy it was difficult to know. (Relative story)

Sharing & moving to action ........

I think it is a bit silly that you don’t know what is for tea tonight as you work here – I wish you could remember (Patient)

Sharing & moving to action ........

Evidence from patients, relatives and staff

One of the nursing auxiliary's was trying to give one of the patients who had a cognitive impairment a choice about what to eat. He said that there was meatballs, pasta or vegetable roulade. After saying this he then went on to say – vegetable roulade is like a big sausage roll but with vegetables in it.

Sharing and moving to action ......

CSW sitting alongside a patient who was reluctant to drink, she was having a drink with her to try and encourage her to drink.

Sharing and moving to action ........

Sharing and discussing the evidence with staff

A staff nurse asked a patient who had cognitive impairment what he would like for lunch. She gave him 3 choices, He did not respond. She went over to

the trolley and put a little bit of everything on the plate, some tasters

she called it, and went on to try to give him some lunch. He did not really

respond to any of the food but she had tried hard to offer a range of options.

(Observation)

One nurse went to give a man who was blind his lunch and said to him your potatoes are at 12 o’clock, your stew is at 4 o’clock and your carrots are at 9 o’clock. (Observation)

Developing positive caring practices

We make a point of going round after the meals have been given out to check if people need some additional support e.g. opening jam

We try to offer patients a choice of where they would like to sit at mealtimes

and negotiate with them when this is not possible

We all make a commitment to helping out at meal times and if we are unable to do so we will inform others.

Offering choice at mealtimes is a priority on this ward. We are creative about how we do this. For example,

for those patients who are unable to tell us what their choice is we offer taster plates where they

can sample the range of food on offer, to help them to make a decision.

 

We take the time on the ward to find out the things that matter to patients

and families at mealtimes

Discuss positive caring statements in relation to:

– How does this make you feel?– Does this happen most of the time ?– What could help it to happen more of the time ?

Changing practice at the coal face ......

• What can we work on / what can wait?• Discuss and decide on action• Share with team• Implement and evaluate

Sounds easy but ..........

Developing actionsand practice .......

Patient Dignity:We believe that patients should be

able to enjoy their meal without interruption

Why is protected mealtimes important to the patients and staff of ward 3?

Jossie Pearson , Joyce Malone, Liz Adamson

Nutrition:Patients who are unwell

require a balanced diet in order to recover. Their

appetite may be affected by interruptions during meal

times

Support: Many patients within the ward

require assistance or supervision at meal times. If nurses have to answer

the telephone during mealtimes it takes them way from patients

Welcome to ward 3 Royal Victoria Hospital

The challenges of changing practiceThe case of the milk jugs

Tips for productive meal times (Releasing Time to Care Module)

– Mobile trolley– Display dietary status in kitchen– Red tray for those needing help– Clear responsibilities at

mealtimes– Staff ready 2 minutes before

mealtimes– Define parking space for trolley– Plated meals ready to go

IMPORTANT but we must focus on this and the patient, staff and family experience to get the balance of quality and efficiency right

Excerpts from best practice statement on nutritional care for frail elderly (NMPDU 2002)

Positive Care Practices from Leadership in Compassionate Care Programme

Furniture, napkins, cutlery and crockery that promote dignity, choice and independence are available and used appropriately.

Menus are provided in a range of formats, for example large print and should include accurate descriptions and photographs of dishes.

We take care to call the protective clothing that some of the patients use at mealtimes ‘a pinny’ rather than using the term ‘bib’. We encourage relatives to bring in specific tools or equipment e.g. for one lady she wanted her tea out of a china cup.

We recognize the limitations of filling out menus a day in advance and make sure we share with everyone on a daily basis (using a white board) the menu for the day.

Age UK Seven steps to end malnutrition in hospitals

Positive Care practices, Leadership in Compassionate Care Programme

Step 2All ward staff must become 'food aware'Ward staff need to take responsibility for our food needs in hospital.

Age UK (2010) Still hungry to be heard: the scandal of people in later life becoming malnourished in hospital, Age UK, London

We all make a commitment to helping out at meal times and if we are unable to do so we will inform others. We make a point of going round after the meals have been given out to check if people need some additional support e.g. opening jam containers

wheel

Outcomes • Be curious about practice• Work with best practice statements and development

initiatives, with eyes wide open and feel brave to integrate local context and make it real

• Develop local practice theories about mealtimes that are based on experience, where people have ownership, where people are willing to defend

wheel

Re-invent the wheel ?