NHD CPD eArticle Vol 9.14 by NH Publishing Ltd

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Volume 9.14 7th November 2019

MALNUTRITION IN THE COMMUNITY SETTING: A NEW APPROACH TO TRAINING STAFF Malnutrition is increasing at an alarming rate, yet it is still often unrecognised and often untreated. Dietitian’s play a vital role in screening and treating patients. But can more be done? This article looks at a new concept in nursing home training to increase staff engagement. Current evidence suggests that in the UK at present, malnutrition is 93% in the community setting, 2-3% in patients’ own homes and 5% in care homes.1 Those numbers are no doubt steadily on the increase, with malnutrition, just like obesity, being part of the ‘public health crisis’. We know that the cost of malnutrition in both primary and secondary care is a significant burden on the NHS. Current expenditure is reported to be around 19.6 billion per year and more

than 15% of total taxpayers’ money is spent on malnutrition.4 Significant cost implications are focused in the over 65 years category and in the elderly, as these are the most vulnerable groups.5 WHAT CAN WE DO AS DIETITIANS?

Karen Voas Community Dietitian, Betsi Cadwaladr NHS Trust Karen is a Prescribing Support Dietitian with an interest in nutritional support and enteral feeding. Karen is also involved in the North Wales North west BDA Branch as Events Organiser.

Dietitians have a vital role as part of the multidisciplinary team to impart expert evidence-based advice in primary, secondary and social care settings. Dietitians also empower patients and carers by providing adequate nutritional

Table 1: Symptoms and consequences of malnutrition Signs and symptoms of malnutrition

Clinical consequences of malnutrition

• Pressure sores/poor wound healing • Dry, fragile skin • Sunken eyes • Loose fitting dentures • Increase in chest infections/urine infections • Dry mouth • Unplanned weight loss • Muscle wastage • Poor appetite • Altered taste changes

• Increase risk of falls • Impaired recovery from illness and surgery • Increased morbidity and mortality • Impaired immune response • Frailty • Impaired wound healing • Reduced muscle strength

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NHD CPD eArticle

Volume 9.14 - 7th November 2019

The 3D Model stays the same in any setting.

3D focuses on facilitating change and informing people correctly . . . The Model can be used for any topic and works in both clinical and non-clinical settings, as the concept stays the same.

input and the screening needed, with the aim to reduce malnutrition effectively and to improve the overall dietetic treatment of patients. Effective communication, clear management plans, alongside education strategies, can help to reduce the effects seen in patients who show clear signs of malnutrition. In a care-home setting, it can be difficult with dementia patients and those with other chronic conditions to maximise nutritional advice and, often, due to disease progression, it can be a challenging time for all involved in a patient’s care. Discussions with families and carers need to be had early on to explain the progression of the disease and the concept of rapid decline in oral intake of food and fluids. Aiming to help the nursing home to take as much responsibility as possible, really does show positive outcomes and better nutritional care for patients. This could be through offering additional milky drinks, nourishing homemade milkshakes, which are nutritionally balanced and also high-calorie and protein snacks, which can promote better wound healing for patients who may be suffering with pressure sores but

should be initiated by first line by the nursing home before dietetic input. NICE 20175 indicates that we should be screening for malnutrition using a validated screening tool such as ‘MUST’. This should be done within 24 hours of admission to hospital, or in the community setting on a weekly basis, and carried out by an appropriate trained professional. The use of a training schedule can help in educating and empowering all nurses and carers involved in the care of patients at risk of malnutrition. Promotional weeks, such as Nutrition and Hydration Week and Dietitians Week can not only raise the profile of the profession, but also initiate and raise awareness of malnutrition in the community setting. NURSING HOME TRAINING: A ‘3D’ APPROACH

The biggest challenge yet in dietetics I feel is training the wider staff members to implement an effective nutritional care plan. As part of my staff-engagement ambassador role, I aim to increase levels of engagement within staff and patient groups, to ensure that patients are

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NHD CPD eArticle

Volume 9.14 - 7th November 2019

Figure 1: The 3D Model – an overview6

Discover

Deliver

getting the best care. Evidence suggests that more engaged staff provide better healthcare outcomes for patients and for the overall organisation.6 There are many factors that contribute to employee engagement, including: • mutual respect in the workplace; • feeling of being trusted in what is done; • feeling of being listened to and of being involved; • feeling of empowerment to make effective changes within the workplace; • decision making; • ownership on change. THE 3D MODEL – BACKGROUND

The concept of the 3D Model is mainly focused on staff engagement sessions, involving all staff (including nursing staff and healthcare professionals) to come together for a facilitated discussion and structured debate. The aim is to encourage more of a sense of ownership, innovation and productivity, ultimately leading to service development, or sometimes getting the views of others to facilitate change within their workplace. Best practice is for the attendees to come up with their own action plans and to have the autonomy to take things forward and facilitate change, not necessarily with a manager’s say so. The Model can be used for any topic and works in both clinical and non-clinical settings, as the concept stays the same.

Debate

THE 3D STAGES

Discover The Discover stage is all about finding out where you currently are against a certain topic that has been identified by yourself as a team member, or engagement ambassador.7 This allows all staff to contribute by using post-it notes and jotting down all the ideas that come to mind during the session. This should be a positive stage where we aim to facilitate answers to change. Debate The Debate stage is about taking a first step towards your preferred future, enabling staff to consider the issues mainly identified in the Discover stage. The post-it notes are themed up and prioritised in order of personal importance. In this stage, it is vital to explain that this needs to be within their control: everyone can make change happen! Deliver The Deliver stage is about reaching an end goal and getting things done, aiming to empower the attendees. Clear and timed action plans and delivery timescales are identified to move any actions forward. Other issues not in the group control need to be reported and fed back to other stakeholders involved. REFLECTION

I have done several ‘3D events’, including one on ‘Nutrition and Food First techniques’, implementing it into the care home setting. At the time, the residential home was in special measures

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NHD CPD eArticle and they needed to show improvements. I decided to facilitate a 3D event so that they could start to take ownership of their residents’ nutrition and hydration and ensure that there was a nutritional champion at the end of it. Initially, organising a specific date with the residential home, in order to allow me to run the event, proved problematic. This resistance from the start didn’t fill me with much hope for change! Nevertheless, the outcomes were extremely positive. During the event, it appeared that a lot of the carers seemed to have a ’poorer’ education level than the nurses, which I didn’t expect, so I had to quickly adapt the education session to suit them. They soon took on board the advice given and the result was better outcomes for the residents in terms of a reduction in

Volume 9.14 - 7th November 2019

hospital admissions, increase in weight and better hydration levels, with a knock-on in terms of less antibiotic prescriptions. I am hoping to plan the next event soon on a larger scale within my health board. CONCLUSION

I think that having an ongoing relationship with care homes and being able to use and implement a valuable new way of working, has proved to encourage better outcomes with residents. The 3D Model aims to get people involved as much as possible and for the organisations to take responsibility for the care provided to patients. Consider using the same method in your dietetic practice. it really can have a positive impact on malnutrition.

References 1 (BAPEN, 2012). Accessed at: www.bapen.org.uk/ 2 Managing Malnutrition in the Community. Accessed at : www.malnutritionpathway.co.uk/ (27/5/19) 3 Gandy (2018). Manual of Dietetic Practice 4 BAPEN (2014). Accessed at: www.bapen.org.uk/ 5 NICE guidance (2017). Nutritional support 6 Betsi Cadwaladr University Health Board (2018). The 3D Model: A Framework for Staff Engagement: Discover, Deliver and Debate 7 Betsi Cadwaladr University Health Board (2018). Role of Staff Engagement Ambassador

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NHD CPD eArticle Volume 9.14 - 7th November 2019

Questions relating to: Malnutrition in the community setting: a new approach to training staff Type your answers below, download and save or print for your records, or print and complete by hand. Q.1

Summarise the current evidence for malnutrition in the UK and its cost to the NHS.

Q.2

What is the dietitian’s role in the MDT management of malnutrition?

Q.3

How can a dietitian support a care home in malnutrition management?

Q.4

Give four factors that contribute to employee engagement.

Q.5

What is the main aim of the 3D Model?

Q.6

Describe the ‘Discover’ stage of the 3D Model.

Q.7

Why is ‘taking control’ an important part of the 3D approach?

Q.8

What positive results can come out of this approach for a care home?

Please type additional notes here . . .