At a glance
SCIE Guide 15: Dignity in care
This section was updated in March 2009
Nutritional care
Nutritional care is a consistent feature in the research on dignity and there is a profusion of information and guidance on the subjects of food, mealtimes, nutrition and hydration. Despite this there are still serious concerns about nutrition in the health and social care sectors. The Department of Health is taking these issues very seriously; in October 2007 it published a joint action plan, ‘Improving nutritional care’ (see Resources), and set up a delivery board to ensure implementation. The Council of Europe’s 10 Key Characteristics of good nutritional care (see Resources) offers a concise summary of the meaning of good nutritional care. The characteristics were initially for healthcare and are currently being adapted to support the social care sector.
Some of the guidance available gives conflicting advice and information, particularly with regard to specific nutritional matters. Good nutrition depends on the needs of the individual. People may be over or under eating and may have health conditions that affect their needs. Obesity is increasingly a problem and obese people can also be malnourished through eating the wrong sort of diet. Messages about ‘healthy eating’ need to be understood in the context of individual needs. ‘Healthy eating’ usually refers to the consumption of foods that are low in fat, salt and sugar but, for an older person who is at risk of malnutrition, healthy eating could mean increasing their calorie intake. It is very important to assess each person to ascertain their needs and preferences and to tailor their diet accordingly.
See the Food Standards Agency's general guidance on healthy diet and Nutrient and food-based guidelines for UK institutions and also the Council of Europe’s 10 Key Characteristics of good nutritional care in the Resources section.
Resources section.
For social care staff, only a basic knowledge of nutrition is necessary in order to tackle malnutrition in older people. The fundamental point is that older people should undergo routine screening and have access to food that:
- is adequate in amount and of good quality
- is well prepared in a safe environment
- meets any specific dietary, cultural and religious requirements
- is provided in an environment conducive to eating.
Most important of all, older people should receive the time, help and encouragement they need in order to eat the food provided.
This section of the Dignity in Care guide aims to:
- examine why the problem of malnutrition in older people persists, despite a raft of policy and guidance
- offer some solutions to the various problems that prevent change from happening
- highlight the key messages from guidance on nutrition (see Practice points)
- ensure that guidance is accessible to the social care sector by providing links to key documents (see Resources).
Hydration is addressed in a further subsection.
Background
Much of the media attention and campaign focus to improve nutrition has been on hospitals. A report by the Patient and Public Involvement Forums entitled ‘Hospital food, could you stomach it?’ (Commission for Patient and Public Involvement in Health, 2006) found that more than a third of hospital patients have left their food uneaten, and issues were raised about choice, the temperature and presentation of food and people not receiving the help they need to eat their meals. Age Concern also published a compelling report ‘Hungry to be heard’ (see Resources) into the scandal of malnourished older people in hospital which strongly argues that it is a change in culture and practice that is required. It is clear, however, that the problem also exists for many older people who access social services, including residential, day care, extra care and domiciliary care.
Older people, for a number of reasons, are more likely to suffer from malnutrition and this increases for those using health and social care services. The largest nutritional screening survey, Nutrition Screening Survey in the UK 2007 was carried out by BAPEN, the British Association for Parenteral and Enteral Nutrition. The survey found that between 19 and 30 per cent of all people admitted to hospitals, care homes or mental health units were at risk of malnutrition. The 2008 survey is now published and available on the BAPEN website (PDF file). The UK Home Care Association estimates that up to 90,000 people who receive home care services could be at risk of malnutrition (Grove, 2008).
Some conditions that affect people in later life, such as stroke, Parkinson’s and Alzheimer’s disease, can affect a person’s ability to feed themselves and to swallow. Even where there is no particular health condition other age related issues, such as ill-fitting dentures or loss of appetite, can affect the older person’s nutritional intake. Consideration should also be given to the impact of eating difficulties on the social aspect of mealtimes. A Swedish study (Sidenvall, 1999) noted that older people affected by debilitating physical or mental conditions strive to retain their independence and dignity when eating, and that such loss of skill can be painful and can cause embarrassment. It is important that support is provided in a discreet, sensitive and respectful manner that does not draw attention to the person’s difficulties.
Mealtimes and nutrition are important to older people in relation to their quality of life and as a measure of the quality of service they receive. Evidence for this comes from a range of studies into different types of health and social care provision. Mealtimes and nutrition ‘have been raised repeatedly... as an opportunity to respect residents’ dignity, or undermine it’ (see Research overview).
Meals and mealtimes affect the quality of life for older people and are indeed the ‘Highlight of the day’ for many people in residential care (Commission for Social Care Inspection, 2006) (see Resources). A small study into care homes found that, for residents, food is a definer of the quality of a home (PG Professional and the English Community Care Association, 2006). In the Department of Health (DH) online survey (DH, 2006d) respondents complained that not enough help is available to those who need assistance with eating. The analysis of British data from the Dignity and Older Europeans study supports this: ‘participants said patients were often not fed by nurses and this was often a problem for older people who could not feed themselves’ (Calnan et al, 2003). As the Research overview found, not having appropriate help with eating and drinking can have more serious consequences for people with dementia or depression.