Doctor of Philosophy
School of Health Sciences
Walton, Karen L., Nutrition and food service systems for long stay elderly patients: a contextual analysis : "making every mouthful count", Doctor of Philosophy thesis, School of Health Sciences, University of Wollongong, 2009. http://ro.uow.edu.au/theses/1994
The ageing Australian population and the increased need for health care services have influenced many changes to hospital food service systems in an attempt to make them more cost effective. Food service departments have traditionally been viewed as ‘non clinical, hotel style’ services, and as such are often targeted to make budget savings. It is known that older patients have more frequent and longer hospital admissions, which creates a higher demand on hospital services. Patients are often admitted to hospital with multiple co-morbidities, with some already malnourished and many others ‘at risk’. Early detection of malnourished patients is critical due to its influence on complication rates, wound healing, immunity, length of stay, health care costs and patient outcomes.
This thesis represents a contextual analysis of the nutrition and food service systems available to long stay elderly hospital patients in Australian hospitals today. It involved exploring and interpreting social, behavioural and biological determinants of nutritional health. It aimed to explore the issues that influence the dietary intakes of long stay, elderly patients, identifying barriers to nutritional support and priority interventions to assist in a more effective and efficient food service provision in Australian hospitals.
The first study involved focus groups and individual interviews with six key stakeholder groups to investigate the context and to better understand the range of current practices, barriers and opportunities for improvement in nutrition and food services. Thematic analysis resulted in five key themes: food service, menu, medical condition, ward environment and management. A number of common barriers (e.g. lack of feeding assistance, lack of customisation, inadequate monitoring of intakes and increased use of pre-packaged foods and beverages) and priorities (e.g. additional feeding assistance, food fortification and more nourishing snacks) were identified. The findings from the stakeholder analysis formed the basis of a national survey that investigated the provision of food services across Australian public and private hospitals. It involved dietitians, food service managers and nurse unit managers and aimed to measure and quantify elements in the research context; and to quantify the barriers, and priority interventions to improve dietary intakes by long stay patients. A lack of choice due to a special diet, boredom due to length of stay, lack of feeding assistance, limited variety, packaging difficult to open and lack of meal set up assistance were the six barriers ranked within the top ten amongst all stakeholder groups. Five agreed priority interventions included food fortification, assistance with packaging, nutrition assessment of all patients, adequate monitoring of intakes and adequate flexibility of menu choices.
The results of both these studies lead to several more questions: 1. What are the patients eating? 2. What happens in aged care rehabilitation wards at meal times? and 3. What activities have a positive influence on dietary intakes and which ones have a negative impact? This lead to an ethnographic study that involved observations of activities at meal times in three rehabilitation wards, as well as a quantitative study of the estimated daily energy and protein requirements and the measured plate waste and resultant dietary intakes. Social and behavioural aspects were able to be explored by the observational method and it was evident that patients were provided with more than adequate amounts of energy and protein, however most patients failed to meet their estimated daily requirements due to factors such as: poor appetite, level of feeding assistance required, amount of packaging, meal and snack options available and interruptions to meals. Fifty-eight percent of supplements were wasted, yet they provided up to 21.5% of energy and protein requirements for patients receiving them. To see how these issues might translate into action a volunteer feeding assistance program was then evaluated in an aged care ward at Sutherland Hospital, South of Sydney. This was implemented in response to the need for additional non nursing mealtime assistance with setting up, feeding, socialisation and encouragement for patients. The pilot study reported in this thesis involved observations with meals, measurement of dietary intakes and surveys with nurses and volunteers. The protein intake was significantly increased at the week day lunches when volunteers were present (extra 10.1g; P=0.015 at lunch); while the energy intakes were increased, though not significantly so (439kJ at lunch). This study indicated the potential to improve dietary intakes with a targeted intervention.
Clearly there are numerous barriers to adequate dietary intakes, and a ‘toolbox’ of interventions is needed to assist individuals in different situations. Additional priority interventions include: food fortification, assistance with packaging, nutrition screening of all patients, adequate flexibility of menu choices, additional feeding assistance, more nourishing between meal snacks and an improved variety of menu options. A number of these interventions involve a significant financial outlay, however the cost of these should be balanced against the cost savings from enhanced nutritional care. It is time that food services were seen as a core component of holistic patient care and further longer term, outcomes focussed research is essential to provide the evidence. The complex web of relationships and institutional systems exposed in this thesis provides a basis for taking further action.