Healthcare professionals’ experiences of providing individualized nutritional care for Older People in hospital and home care: a qualitative study

Over the past 10 decades, studies have reported a high prevalence of malnutrition and inadequate nutritional care practices in healthcare institutions; in spite of these findings, the problem has persisted [1]. In 1999, the Council of Europe established a network of national experts within nutrition from eight member states in order to improve practices. The aim was to issue clinical guidelines (i.e. a framework for decisions supporting best practices to manage the risk of malnutrition in order to improve treatment outcomes) [1]. As a result, a number of European countries, including Norway, have published national guidelines on the treatment and prevention of malnutrition to ensure high-quality nutritional care throughout the continuum of care [2, 3, 4, 5, 6, 7, 8].

Several studies exploring nutritional care practices report a significant gap between recommended nutritional care and actual practices in many healthcare facilities [9, 10, 11, 12, 13, 14]. Researchers have identified problems such as lack of knowledge and priority among healthcare professionals [12, 14, 15, 16], institutional constraints, uncertainty about roles and responsibilities, lack of allocated time and lack of communication between professionals and services as possible causes [9, 10, 12, 13, 16]. In addition, a recent study found that healthcare professionals experienced a conflict between respecting a patient’s autonomy and practicing standardised nutritional care [14]. The nurses expressed concern that the individual patient was forgotten in the standardisation of nutritional care, as the treatment was not based on the patient’s particular needs and preferences. Healthcare services are complex and, the organisation of work may become rigid and compartmentalised, thus failing to do justice to the richness of people’s lives as well as the complex nature of specific health problems [17]. Healthcare professionals’ personal values and beliefs about what constitutes good nutritional care may conflict with the care they are able to deliver within these institutional constraints, resulting in a sense of inadequacy about their work. In addition, they are confronted with pressure from clients/patients with infinite needs [18].

In spite of the literature indicating little change in practice with regard to nutritional care, there is limited research exploring healthcare professionals’ views on how the organisation and standardisation of care allows them to individualise the nutritional care they provide to older patients. Thus, in this study we aim to explore how healthcare professionals’ experience providing individualised nutritional care within the organisational frames of acute geriatric hospital care and home care.

Our findings show that healthcare professionals meet with complex and challenging situations when providing nutritional care to older patients. Participants described the nutritional care in hospitals as highly prioritised, but inconsistent in terms of routines, lack of time and extensive use of temporary staff. In home care, the participants emphasised nutritional care as important; however, a lack of training, interdisciplinary support and time dedicated to food-related care limited the carers’ ability to provide quality nutritional care.

These findings are in line with previous studies in terms of the barriers to providing quality nutritional care to older patients [12, 14, 15, 16, 26]. These studies acknowledge healthcare professionals’ experiences of challenges, but they emphasise that the professionals can resolve many of these problems themselves by increasing their competence and awareness rather than contextualising their experiences in their larger institutional and organisational settings.

Healthcare professionals are not free to perform care as they wish. They work under organisational conditions and constraints that regulate their practice, and they are often torn between the demands of the care recipients to improve the responsiveness to their needs and the demands of their organisations to provide cost-effective and efficient care [18]. A systematic review by Fromholt Olsen et al. [27], found that home care providers experienced considerable ambivalence and stress related to providing care according to their older clients’ needs and preferences due to situations where they had to balance the needs of their older clients against their professional standards and the conflicting and competing demands of their organizations [27].

Both the hospital and home care staff described the need for a holistic approach to nutritional care in order to meet the older patients’ complex nutritional needs. They did, however find that they were unable to provide care according to these needs due to organisational conditions and limited resources. In particular, the home care staff found that this was challenging. They described having little time to get to know their patients and their needs. Additionally, their work was guided by clearly defined tasks and time schedules (i.e. the municipal decision letters), and they described how the limited resources to deal with the complexity of the situations resulted in care that was task- and routine-oriented.

Older patients are a diverse group, and each individual has unique nutritional needs and preferences. However, the routinisation of work makes it difficult for healthcare professionals to review needs and preferences and respond with individualised care [18, 28]. A previous study found that healthcare professionals found it demanding to address factors contributing to malnutrition, including social isolation, lack of supervision during meals and limited choice of food due to inadequate time allocated for nutritional care [16]. Moreover, Teeri et al. [29] found that nurses tended to disregard patients’ individual needs because the care they provided was regulated by strict routines and schedules. Another study reported that routine-driven practices constrained the quality of the psychosocial aspects of nutritional care [10].

Most of the healthcare providers described having set procedures for nutritional care. They performed regular weightings, nutritional screenings, documentation of food intake, etc.; however, this did not always seem to benefit the patients. For instance, they described spending time screening and calculating calorie intake, but they lacked procedures to follow up on these results. It seems that this is done because it is recommended as a best practice nutritional care in the clinical guidelines, without considering how this could be used to improve patient care. Clinical guidelines are the most common way to ensure the provision of equal and evidence-based treatment, and they can help to ensure safe nutritional care for patients. It is, however, important that healthcare providers are aware that clinical guidelines are guidelines, not rules, in order for them to give optimal nutritional care [30, 31]. However, guidelines have been criticised for failing to address the needs and preferences of older patients with complex health problems [32]. They also constitute a form of standardisation of professional clinical care, and the patients’ needs are probably not the only priority during the making of these recommendations, as they may also be influenced by the need to save costs, serve societal needs or to protect special interests [33, 34, 35]. Care should be based on the patient’s health needs and preferences and be adapted appropriately [30, 31, 35].

Many previous studies have suggested that developing healthcare professionals’ knowledge and skills in nutritional care will improve nutritional care practice [12, 14, 15, 16, 26]. Contrary to findings of poor knowledge about nutritional care among healthcare professionals in these previous studies, in the present study, the participants’ descriptions of how to perform nutritional care indicate that they possess rich knowledge about the topic. They did however; point out that temporary staff lacked the necessary nutritional knowledge. Suominen, Kivisto and Pitkala [36] found that nutritional education could improve practice and increase patients’ energy intake. Thus, increasing competence among healthcare providers seems to be a good initiative. However, knowledge alone is unlikely to result in practice changes as long as the municipal healthcare context in Norway is characterised by a mismatch between caring responsibilities and allocated resources [37]. Unless the organisational frames for providing care are addressed, increasing knowledge may just increase the gap between theory on the best practices in nutritional care and what is realistic in practice (and an increased feeling of professional inadequacy).

The home care staff also described lacking interdisciplinary support in nutritional care. Nutritional problems among older patients are often complex and are determined by physiological, psychological and social changes; they lead to poor appetite, insufficient food intake and poor health. The complexity of the problems makes treatment challenging and often requires a multifactorial and multidisciplinary approach [38]. Having available dieticians or staff with special nutritional competence to assist in challenging situations could increase the time for and quality of the nutritional care and be beneficial to the home care staff and their care recipients.

The hospital healthcare professionals described spending considerable resources on nutritional care. In 2016, the average length of a hospital stay in Norwegian hospitals was four days [39]. Treating malnutrition is, however, a prolonged process. In the home care setting, where many patients recover from a hospital stay and spend the majority of their time, there seem to be limited resources to follow up on the nutritional initiatives taken in hospital and to promote good nutritional health. In addition, studies report that poor communication and coordination of nutritional care between hospital and municipal services affects the quality of nutritional care [13, 40]. If the nutritional treatment from the hospital is not followed up at home, it is worth asking whether the time and effort spent on nutritional care during the short hospital stay is a sensible use of resources. It may be more demanding and costly to provide high-quality interdisciplinary care in the patients’ home than in an institution, where patients and resources are together under one roof. However, it is fair to assume that people who become malnourished and admitted to hospitals are even more costly [2, 41]. In addition, malnutrition and its consequences cause suffering and reduced quality of life for many older people [42]. It seems that the focus continues to be on the way healthcare professionals provide care’ and less on how organisations create structures and cultures that allow for person-centred care [17]. We need to begin a conversation about whether we as a society are comfortable with a situation in which older people are denied their human rights for proper nutritional care.

The healthcare professionals described having a high focus on and priority of nutritional care when caring for older patients. They experienced meeting challenging and complex nutritional problems among their older patients and expressed the need for an individualised and holistic approach to nutritional care. However, they did find it challenging to practice individualized nutritional care due to the complexity of the patients’ nutritional problems and constraints in the way nutritional care was organised. By describing the challenges the healthcare professionals face when trying to individualize the nutritional care, this study may provide important knowledge to health professionals and policy makers on how to decrease the gap between older patients’ preferences for care and nutritional care practice.