FormalPara Learning Outcomes

At the end of the chapter, the reader will be able to:

  • Describe why ‘best practice’ nursing care should consider individualised nutrition care actions across age, disease and care setting spectra.

  • List key opportunities for nurses to coordinate, lead, deliver and evaluate supportive nutrition care processes.

Aunty Esther lived on a small island in the Torres Strait. Aunty was fit and healthy across her early adult years, living a traditional lifestyle including growing and harvesting local fruits and vegetables, fishing and collecting shellfish. However, over the years, as the island became progressively ‘westernised’, Aunty’s diet changed, she reduced her exercise, and she consequently gained weight. By the time she had reached her early 50s, Aunty had developed obesity (class 3), type 2 diabetes, chronic kidney disease and heart disease. Aunty did not want to leave the island for any medical care and instead chose to entrust her healthcare to Mia, the community nurse. Over the next decade, Aunty and Mia worked together to manage her multiple conditions with a ‘diet-only’ approach, in line with Aunty’s treatment preferences. In her mid-60s, Aunty essentially stopped eating for several months after her two sons were lost at sea. With support and care from nurse Mia, Aunty eventually recovered some of her lost muscle stores and enjoyed living with her granddaughter and extended family until her early 70s. Following a severe stroke, Aunty was cared for by her family and nurse Mia for a short time before she passed away, sitting outside on her woven coconut mat, surrounded by those she loved. Aunty Esther was proud to have never left her island home, and the only healthcare she ever consented to was provided by Mia, the community nurse.

1 What Is ‘Best Practice’ Nursing Nutrition Care?

Best practice is characterised as ‘directive, evidence-based and quality-focused’ care [1]; surrogate terms and related concepts include optimal care, evidence-based guidelines and practice, practice development and standards of care [1, 2]. To achieve best practice in nutrition care in older adults, evidence-based guidelines, recommendations and standards of care should underpin patient-focused care that is implemented into daily nursing practice [1]. Across global settings, evidence-based guidelines and care standards that are relevant and appropriate to direct care in multimorbid older adults may be absent, competing or even contradictory. What is ‘optimal care’ will also need to consider the value of healthcare, which is defined primarily by care that matters to the older adult, with consideration given to the resources required to provide that care, in addition to diverse other barriers and enablers to care [3, 4]. As highlighted in Chap. 1, best practice should also support transitioning towards transdisciplinary care approaches, where [1] traditional professional boundaries are transcended; [2] knowledge, skills and accountabilities are integrated and shared; and [3] the focus is on solving real-world, complex nutrition problems, in partnership with the older adult and those who care for them [5].

How does this apply to nursing best practice in nutrition care? In many settings, nutrition specialists, for example, dietitians, medical nutrition specialists and nutrition support nurse practitioners, have been considered best qualified to deliver nutrition care processes [6, 7]. A recent systematic review has demonstrated that nurses can safely provide oral nutritional supplements, food or fluid fortification or enrichment, give education and dietary counselling to geriatric patients and patients’ carers and administer nutrition care across professions; as such nurses are well placed to support essential processes of nutrition care to older adults [8]. As highlighted in our case study above, nurses are often best positioned to lead, coordinate and/or deliver ‘best practice’ nutrition care processes (Chap. 1) [9]. However, we also suggest that nurses should not be required to do this in isolation; for our case study above, in all but the most under-resourced settings, it would be important for nurse Mia to be embedded in a broader interdisciplinary team including medical and nutrition specialists.

Our case example builds on previous chapters highlighting that the spectrum and progression of nutrition care is evolving and can range from dietary management of lifestyle diseases to preventing, screening, identifying and managing malnutrition or other nutrition-related conditions and, ultimately, caring for those in the last stages of life by supporting food and fluids for comfort. It highlights that what should be defined as ‘best practice’ changes over the course of life and disease processes and fundamentally should be measured by delivering care that matters to the patient [10]. This emphasises a key point; in older, multimorbid adults, the actual individual care provided will at times be different to nutrient or disease-specific treatment recommendations endorsed by individual professions, societies or nations particularly where these have not been co-designed with culturally diverse, multimorbid, older adults.

Globally, nurses support coordination of patient-centric care processes across aging, disease and care setting spectra that require tailoring of care to the individual patient [11]. Nurses are highly attuned to individual patient’s care needs and preferences; have highly developed skills in working across disciplines, systems and healthcare settings; and routinely translate evidence-based guidelines and recommendations into best practice, patient-centred care. A pivotal role for nursing is also to manage care conflicts and unrealistic expectations, whether these are directed from older adults and carers or individuals and teams caring for them [12]. Nurses actively support shared decision-making and goal setting and are well placed to observe where previous goals or care recommendations require review and recognise and encourage specialist care [re]referral where this is appropriate [13]. Finally, in many settings globally, nurses are firmly established in clinical, policy, education and research leadership, governance and advocacy roles [14].

We consequently propose that nurses are well connected, brokering interdisciplinary team members, who are particularly well placed to coordinate, lead and deliver ‘best practice’ nutrition care processes and improvements.

2 Leading Supportive Nutrition Care for Older Adults with or at Risk of Malnutrition: An Example of Best Practice in Nursing Care

Nutrition care screening pathways exist that support triaging malnutrition care according to nutrition risk screening outcomes [15,16,17]. One example is the Systematised, Interdisciplinary Malnutrition Program for impLementation and Evaluation (SIMPLE) [15]. This approach triages screening three risk categories: standard, supportive or specialised nutrition care. What ‘supportive’ nutrition care processes look like should ultimately be determined by local teams with consideration to patient- and context-specific factors; this should consider different stages of nutrition care process models applied internationally (Fig. 6.1) [15,16,17,18,19]. Across settings, enabling systematised, interdisciplinary ‘supportive’ nutrition care processes where appropriate, rather than relying on specialist care delivery, has demonstrated improved and sustained patient-reported nutrition experience measures and healthcare outcomes, whilst simultaneously directing specialist resources to where they are most urgently required [20,21,22].

Fig. 6.1
figure 1

A SIMPLE approach to supportive nutrition care [9]

Take-Home Checklist

  • Table 6.1 provides a supportive nutrition care checklist for older adults with or at risk of malnutrition [15, 18, 19, 23]. We note that each and every one of these will not necessarily provide a useful grounding point for nurses aspiring to lead, coordinate and model best practice supportive nutrition care in older adults.

Table 6.1 Supportive nutrition care checklist for older adults with or at risk of malnutrition [9, 15, 18, 19, 23]