Introduction
Nutritional issues, especially Malnutrition has been an ongoing challenge for the Long-Term Care industry. During the 20th century, the United States witnessed an 11-fold increase in the elderly population, summing it up to 33 million (Crogan & Evans, 2001). Out of the 33 million, an estimated 5% of the people aged 65 years and above reside in nursing homes across the country. Nursing homes and other long-term care facilities house an assortment of elderly populations suffering from dementia, diabetes, dysphagia, and many others. In most of cases, people come to these facilities only after they have been extremely sick and need assistance with daily activities. As no two people are identical in either their behavior or medical requirements, it becomes extremely important for healthcare professionals to take care of their specific medical and nutritional needs. An intentional or unintentional nutritional negligence toward these patients can put them at a greater risk for infections, pressure sores, ulcers, and even higher mortality rates (Nelson et al., 1993). Malnutrition is a condition of nutrition where either a lack or an excess of nutrients such as energy, protein, vitamins, and minerals can cause adverse effects on the composition and functions of the body, or on clinical outcomes (“Nutritional guidelines and menu checklist,” 2014). To combat such nutritional issues, the U.S. Department of Agriculture (USDA) and the U.S. Department of Health and Human Services (DHHS) has published a set of dietary guidelines for the nursing homes to follow. These guidelines provide specific dietary recommendations for elderly people to promote nutritional suitability (“Dietary Guidelines for Americans, 2010,” 2010). Unfortunately, even after these guidelines, nursing homes are unable to reduce malnutrition rates. According to Rowe & Kahn (1998), the amount of malnutrition in nursing homes range from 35% to 85% and is projected to increase if proper measures are not taken to reduce the rates. Facilities with compromised nutritional availability not only generates greater malnutrition cases but also deteriorates the quality of care and safety for its residents. When healthcare professionals lack in providing basic nutritional care to its residents, it negatively impacts patient outcomes, safety measures, patient and family satisfaction rates, quality of service, quality of life at nursing homes, and many more. This paper discusses some of the root causes of malnutrition in nursing homes and analyzes its effects on the quality of care and on the future of long-term care.
Causes of malnutrition in nursing homes
The dietary branch is the second most important department after nursing services at nursing homes, and yet somehow it is one of the most poorly established one. An investigation was conducted to understand how healthcare professionals perceive nutritional competencies and documentation in nursing homes with the help of 2 focus groups comprising of 14 healthcare professionals each (Hakonsen et al., 2019). The investigation analyzed 5 main causes that lead to such nutritional issues. The first category was a lack of organized communication amongst healthcare professionals. Documentation procedures such as daily monitoring, updating, and communicating about the residents’ nutritional information with other healthcare professionals is not taken seriously by the staff. This not only affects the nutritional care practices, but also breaks the continuity of care, reduces transparency amongst the staff, and decreases staff performance. For instance, if a nurse incorrectly documents or fails to inform the other nurse about a resident’s 5-meal diet plan, the resident may end up receiving less nutrition (3-meal diet plan) because of written and oral discrepancies. The second category explained that healthcare professionals see nutrition as just a ‘form of food service’ and therefore, disregard the dietary guidelines provided by USDA and DHHS. In association to this, the third category states that the quality and service of nutritional care highly depends on the personal interest and attitude of the professionals. If the staff is not interested to begin with, they will not take care of the residents’ nutritional requirements, contributing towards malnutrition. The fourth category states that lack of nutritional care responsibilities amongst healthcare professionals negatively affects quality of care. One of the members of focus group 2 said that the problem is not the availability of officials, rather the problem is “...who you should get a hold of if an issue arises...” (Hakonsen et al., 2019). The last category outlines that additionally, there is also a lack of clinical leadership as there is no training and education provided to the staff about observing proper nutritional care. In a nutshell, it can be narrowed down to three key roots: 1) Lack of documentation and communication amongst healthcare providers, 3) Personal attitude towards nutritional care, and 4) Lack of leadership towards nutritional care management.
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Nursing homes also observe challenges with staffing and food service, which are two other noteworthy factors leading to malnutrition. In a survey conducted amongst nurses and nursing assistants, it was found that around 93% nurses and 73% nursing assistants agreed that residents were deprived of appropriate nutrition when the nursing staff was low and when there was no one to assist them (Crogan & Evans, 2001). It is also said that most of the nursing homes fail to adhere to the staffing levels established by the Center for Medicaid and Medicare Services (CMS). As there are less people attending the residents, their meal time and assistance to meal services reduces. Nutrition for the residents who strictly need assistance in feeding can be highly compromised due to a lack of staffing. As a result, residents will end up receiving inadequate nutrition which will increase further malnutrition possibilities.
As an assignment for our Long-Term Care Management class, we visited Parker Health in New Brunswick, NJ on October 6, 2019. We were given a tour of the facility and were also able to interact with a few residents over there. While talking to one of the residents in the dining room, we asked her, “What do you not like about this place?”. She quickly replied, “The food. It doesn’t taste good”. Later when I researched about what she said, I found that this is a very common problem in all nursing homes. Residents often dislike the taste, quality, and appearance of the food served to them. The food is often bland, overcooked or undercooked, and does not seem homely. Being in a nursing home, away from home, food is the one thing that residents look forward to. If they don’t get homelike food, they are more likely to not eat in appropriate quantities suitable for their health. Moreover, nursing homes have a tendency to cut back on prices by reducing the food choices and availabilities (Crogan & Evans, 2001). Due to all these reasons, residents end up taking less nutrition, ultimately contributing towards a higher risk of malnutrition. The following section discusses some of the initiatives that can be taken to prevent malnutrition in nursing homes.
Strategies and recommendations
Healthcare organizations need to work with its staff on several aspects to improve its delivery of nutritional care and its quality of care for nursing home residents. As discussed earlier, documentation and communication amongst healthcare professionals plays a major role in ensuring quality of care. Organizations should implement a standardized documentation and communication approach in order to increase knowledge and understanding of nutritional care practices. This standardized approach will have 2 main features. The first feature will require forming strict protocols for documentation of nutritional information and patient care actions. The second feature will include establishing a “common terminology and language that [is] understood and applied in the same way by all healthcare professionals thus ensuring that patients receive better standard of care in daily clinical practice” (Hakonsen et al., 2019). Consistent terminology and specific documentation protocols will create a more effective and safer environment for the prevention of malnutrition.
In order to improve compliance to the dietary guidelines provided by USDA and DHHS, organizations should start a rewards and incentives program for the employees. For instance, if a healthcare professional successfully obeys to these guidelines for a period of 3 months, he/she gets a reward or incentive, which will mostly be a monetary benefit. Such rewards or incentives can be set at regular intervals throughout the year to ensure continuity of good work by the professionals. This will encourage them to follow the guidelines and make sure that the residents are being fed well, reducing the rates of malnutrition.
A strong leadership and organizational structure have the ability to turnaround bad outcomes of an organization into good outcomes. Along with communication, nursing homes also lack in clinical leadership and management skills that could reduce malnutrition rates. A well-established, hierarchical nutritional care unit should be created with responsibilities assigned specifically for each professional. In this way, people will become more mindful of who to reach out to in case of an issue. Moreover, interactive in-house educational sessions should be conducted for all the employees which should cover topics ranging from malnutrition management, nutritional care practices, time management, effective communication, team building, and many more. Furthermore, ‘nurse-developed rehabilitation’ programs should be implemented by the management. These programs will focus on the importance of staff participation and staff assistance with meals and snacks for the residents (Crogan & Evans, 2001). Nursing assistants are the ones who recognize resident complaints the best because they know the residents the closest. Therefore, efforts should be made to include nursing assistants in conferences and planning committees so they can contribute towards quality improvement and malnutrition management.
Nursing homes can improve the problem of low staffing by implementing 3 variations in their management. The first change will be to hire part-time employees that will only work for meal services. These employees will be hired solely for the purpose of providing assistant to the nurses and nursing assistants so that they can spend more feeding time per resident. The second change will be to incorporate staggered shifts to “… ensure that more personnel are present at mealtime” (Crogan & Evans, 2001). The third change will be to introduce unusual shift times for better staff allocation. For instance, instead of a 3 pm to 11 pm shift, create a 12 pm to 8 pm shift so more staff can be present during mealtime for assistance. Making such small changes to staff scheduling can ensure better assistance during mealtime, thus, reducing the risk of malnutrition.
The primary requirement for nursing home residents is to feel at home, both in terms of environment and food. A satisfying dining experience can increase the nutritional intake of the residents. To improve the food service, dieticians and food service managers should personally observe and talk to the residents about their preferences (Singh, 2016). This will familiarize them about what the residents want, which items on the menu are appreciated and which ones are not, and what improvements are needed in the menu. This will also allow them to find solutions to make the food more attractive and tastier. Several innovative ideas such as changing the dining room lights, using bright colors, making dining mats more colorful, etc. can also increase the food intake. Moreover, aromatherapy and soothing music has proved to be useful in enhancing the dining experience for people with dementia. Sometimes, serving meals in a family style or in the residents’ apartments will provide a sense of independence to the residents, create a homely effect, and reduce agitation. Lastly, instead of buffet style serving, employees should serve the residents on their table to avoid the feeling of restriction. Such small alterations to food services and dining experience can significantly increase the food intake which will prevent further malnutrition cases in nursing homes.
Conclusion: future impacts and implications
In the past century, an increasing amount of the elderly population has opted for nursing homes in the United States. Nursing homes are now required to ensure greater quality of care and safety due to this increase in population. Malnutrition is one the most common issues faced by residents in nursing homes due to reasons such as lack of documentation, lack of communication, poor management and leadership, lack of knowledge and awareness, lack of willingness to serve the elderly, poor food services, low staffing, and many more. These problems not only increase malnutrition rates but also degrade the quality of care in nursing homes. In order to fight malnutrition, several applications and strategies were recommended in the previous section. Some of the changes included improvements in food services, staff participation, documentation and communication methods, and management and clinical leadership. Evidently, a lot of nursing homes have already started changing their approach towards nutritional care to improve the well-being of its residents. In the future, better nutritional care practices will lead to a significant decline in malnutrition rates as the facilities start focusing on the residents’ priorities and necessities. A high-quality nursing home with a focus on nutritional as well as medical care will attract more families and patients, increasing overall admission rates. A happy and supportive staff will keep the residents even happier, increasing their life span. With the application of these processes, the future of nutritional care in nursing homes looks much brighter.
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