Data Processing and Analysis
A qualitative analysis was used on the interviews conducted. The interviews were divided between the two authors and then transcribed in direct correlation to the data, highlighting the questions asked to facilitate the process (Danielson, 2017). As stated by Graneheim and Lundman (2003) it is valuable to notice changes in the conversation that possibly could influence the meaning of what is said, such as long silence, sighs or laughter. Therefore, all sounds and pauses were transcribed in order make sure the meaning of the spoken word was not misunderstood during the transcription. The coding process was selective, meaning solely utterances related to the core variable were condensed (Polit & Beck, 2017). The data and the transcripts were read, processed and cross checked multiple times by both authors; thereafter essential formulations and utterances for the aim were highlighted and selected to be condensed for better overview and managing. The selected utterances were sorted into six thematic sub-categories, depending on the substance. This was done to group the utterances alike. The sub-categories were further comprised into two categories. The categories allowed future overview and easy comparison. The coding was processed by the two authors and discussed until consensus arose. All the processed material was written into an analysis scheme, example presented below in Table 1 (Danielson, 2017).
The main purpose of research ethics is to protect all people’s worth, integrity and autonomy. In accordance with the Declaration of Helsinki (The World Medical Association, [WMA] 2013), possible risks for the participants has been considered beforehand, and measures to minimize the risks has been taken. In this qualitative interview study the main ethical focus was on the confidentiality of the person being interviewed, therefore every precaution possible was made (Kjellström, 2017; WMA, 2013). The participants were informed beforehand of the individual protection claim codex, as well as the significance of informed consent, covering the rights to avoid certain questions or discontinuing the interview (WMA, 2013).
During the interviews and transcribing, names and workplaces were written down in a separate notebook to keep track of which interview were used, upon finishing the transcribing the material were destroyed. During the finished version of the transcribed material all names of people and workplaces were erased to maintain confidentiality. One of the main ethical aspects of the study were not applying our own subjective thoughts and values into the result. The participants answers were therefore presented as received without alterations. The interviews were recorded so no answers given by the interviewed persons could be altered due to the human factor of memory. Upon finishing the transcribing all audio files of the interviews were deleted to maintain confidentiality (Swedish Research Council, 2017).
Throughout the results, quotes from participants in the interviews were presented to support and clarify our findings, the quotes have been modified to become grammatically correct. Each headline in the result section represent the categories which answered the study’s aim. The categories emerged during the analysis of the interview data and describe the identifying work as well as the preventative work against malnutrition performed and the circumstances around this work. The presented results were summarized below two headlines for structural integrity as well as providing more clarity for the reader.
Identifying residents at risk of malnutrition
The ability to identify residents at risk of malnutrition comes down to routine and the work of the nurses. A majority of the nurses interviewed stated that they work with discovering difficulties before those become issues;
“We don’t have specific program to target malnutrition, mainly because we work hard to make sure it never goes so far”
Admission controls and assessments
The importance of admission controls was equally expressed by the nurses throughout all the conducted interviews. The significance of the process is according to the nurses in the ability to observe and track the residents’ health and well-being from time of admission and through their stay at the care home. The interviews have shown that although the thoughts on admission controls were the same, the process for carrying them out differs greatly. One nurse explained that the routines of admission included the residents’ private doctors measuring their vitals beforehand, leading to care home-nurses not being able to record for example weight themselves upon admission. The nurse, describing the admission policy, did not see any problems in not being able to record the residents weigh over time. Instead, she emphasized the importance of the care home giving the feeling of living at home. This led to better mental health, and in the long run affect the appetite positively, minimizing the risk of malnutrition. Another care home had routines with basic vital observation, mouth status and dental health, completed on the exact day of admission by the registered nurse. A full risk and functional assessment were done by nurses at the care home with the overall most policies among the nurses interviewed. These assessments included weighing and personal monitoring of food intake among the newly admitted, as well as tracking bowel movement. The nurse explained the close contact they had with the residents’ personal doctors, especially in the first period of time, making phone calls for guidance.
Observations to identify risk of malnutrition
By discovering changes in appetite among the residents or observing that residents were struggling to fulfil their nutritional needs, the nurses could take action and prevent even the early stages of malnutrition. The nurses disclosed that they rely on their own experience rather than guidelines when observing the residents and their well-being. They also felt that their close work with the residents ensured that they early on could discover changes in appetite, mood or functional abilities. Upon observing residents that have difficulties with food the nurses also looked into the possibly underlying causes for the changes. How the nurses aided the resident became dependent on if the cause were dementia progression or for example depression.
“We discuss why a person may lose weight, for example we had those who suffers from depression, or swallowing difficulties.”
During the interviews a subject that repeatedly surfaced was education about dementia and malnutrition among the staff. The majority of the nurses accentuated that feeding difficulties in persons with dementia often were expressed differently than in those without the diagnosis. For example, early signs of dementia may include forgetting to eat, motor command problems, distraction, resistance to eat as well as loss of the knowledge on or competence to chew and swallow food. By knowing the cause, the nurses could set up individual rectifying and preventative plans, such as meal supplements and dining aid.
These routines were however not standard practice at all care homes, some of the studied care homes relied on the experience of their nurses to observe malnutrition among their residents.
Significance of continuous controls
A majority of the care homes did not have as a policy to record any specific vitals regularly, the nurses interviewed described that doing so would affect the residents negatively, giving the impression of living in a hospital. Other nurses saw monthly weights as a strength in their work to acknowledge changes among the residents, feeling the routines gave them the possibility to rectify any issues before they could occur and cause problems for the resident. In one care home a special chart was used, on which the nurses recorded what and how much the resident ate and drank as well as the amount of bathroom visits and their bowel movements. The nurse explained that they evaluate this information after each shift in order to detect any changes among the residents.
“Every month we have a staff-meeting when we write the monthly weight next to the last monthly weight to see and discuss any changes”
The care home with most control-routines also charted blood pressure and did a urine analysis every month. Mainly to make sure not to weigh fluids among the edematous residents, or to discover urine tract infections which may lead to restlessness and added on confusion, especially among those with dementia. One nurse disclosed that they have residents that are on weight-management plans which required changes in routines for the staff. A resident on this plan was weighed every week and the nurse recorded all intakes and outputs from the resident in order to achieve balance in their diet. It was explained that the weight-management plan was used for both edges of the spectrum, for residents suffering from underweight as well as overweight.
Preventative work to avoid malnutrition among residents
During the interviews the nurses described that even though a majority of the them did not have fixed ideas of their preventative work regarding malnutrition it was nonetheless performed. The nurses described that they work continuously to rule out obstacles for good nutrition, such as poor dental status or residents’ inability to handle cutlery. These issues were dealt with through daily dental care and that struggling residents received help with feeding by nurses during meal-times. Preventative work does not only include actions directly related to food or food intake. A nurse expressed that there were many factors that can affect the resident negatively; “Making sure people sleep, people are not in pain, and making sure they are not depressed, so those are what we do” The nurses worked to ensure a positive environment for the residents through promoting healthy sleep routines, for example maintaining a proper number of hours of sleeping. As well as making sure the residents were not living with pain prevented them from entering a negative spiral of behavior. The nurses expressed that the mental status and wellbeing of the resident played an important role in their overall health, and therefore their nutritional status. Nurses observations for signs of depression were a preventative action that affected all aspects of the residents’ life, including appetite, weight loss and risk of malnutrition.
Nutrition and assistance
An aspect of health emphasized by all of the nurses when asked how they prevent problems and maintain good health was the food intake. Food and proper nutrition is vital to everyone, especially older persons. Majority of the kitchens at the care homes have therefore composed their menus in cooperation with a dietician to ensure that the residents received their daily intake of proteins, carbohydrates, fats, vitamins and minerals. However, few of the nurses had policies themselves regarding nutritional guidelines and caloric intake appropriate for the residents. It was described that only when a resident was placed on a weight-management plan food intake and calories were recorded. For the residents who were unable to fulfil their nutritional need the nurses prescribed a meal supplement. In order to stimulate appetite one of the nurses described that they had educated the staff in the environment of care, such as having soft music playing in the background during dining-hours. They also had a service etiquette covering the display and order in which the food is served. Several of the nurses explained how they have arranged their dining rooms to ensure the preeminent environment for the residents. Most of the care home facilities have two separate dining rooms, one where residents who were independent in their feeding eats and one where the residents in need of aid from the nurses ate. The aid given by the nurses could be anything from specialized cutlery to physically feeding the residents to secure their nutritional intake. The smaller care homes had one dining room, but the nurses explained that they made efforts to separate the residents’ dependent on needs to provide a harmonic dining situation.
One of the nurses interviewed had a bowel care policy including daily recordings of bowel movements and quality of the stool, connecting constipation to unwillingness to eat. Intake and output, regularity of the stool and eventual constipation was only evaluated after every shift by only a few of the nurses. Another consideration for health maintenance mentioned by the nurses was dental health, since dryness and sores may affect the eating habits and intake of food negatively. Therefore, majority of the nurses emphasized dental hygiene as a basis for maintenance of good health. An occupational therapist was often employed or consulted by the majority of the nurses. Activities were offered every day, and in some cases the residents had the opportunity to take a walk one-on-one with a personal caregiver. One nurse presented a preventative nutritional program that included daily exercise. The aim was to highlight and incorporate the correlation between movement, sedentary and appetite in the residents’ everyday life;
“I find that the more people move, the more likely they are to eat, the more sedate, the more they tend not to eat.”
A subject discussed by some of the nurses was the importance of mental health, and how it affects the individual with dementia, in the aspect of eating patterns and willingness to eat. Three main aspect were discussed; lack of sleep, influence of pain, and depression. Whereas pain could be measured with pain assessment scales, sleep patterns and foremost depression could be difficult to evaluate. By observing and sometimes charting these areas, the nurses described a convenient way to maintaining a satisfying nutritional status.
A majority of the participating nurses emphasized the importance of a familiar environment as one of the most important aspects for overall-health, avoiding the impression of an industrial or hospital-like setting.
One nurse declared that it was not only a familiar environment that made a difference for the resident. Having relatives visit them had a large impact on both their mood and appetite. The nurses reckoned that it was because the families usually brings food and sweets from home that the residents like and are used to. According to the nurses this is not true among all the residents, they testify that some residents respond negatively to visits from relatives. It is most common among new residents who has not yet to settle into the new environment of the care home. The visits reminded them of their “real” home and placed them in a bad mood that often led to a disinterest in eating. Many of the nurses shared the same opinion, namely; “This is the people’s home, we become their family”
The main finding in this study was the vast difference in policies regarding identification of malnutrition among the residents with dementia, and that a great deal of the preventative work relied on the nurses’ observations. The result shows that not all nurses do the admission controls themselves, and that in some cases, all controls are done by a private doctor.
Solely one of the care homes visited had policies regarding controlling and charting vitals regularly. A couple care homes had a close relationship with the residents’ private doctors, a few even weighing the residents monthly themselves and then turning to the private doctors for consulting. A few care homes did not chart any vital data, nor kept in touch with the private doctors. Some nurses claimed that repeated weighing and monitoring of the residents would lead to them feeling more ill and the feeling of being hospitalised.
Studies however show that weighing patients is vital to nutritional screening, especially those with dementia since they are at higher risk of malnutrition (Evans & Best, 2014), rendering the nurses’ routines not scientifically based. The fact that the nurses do not base their work on scientific studies created a different standpoint from the European model, where a majority of the nurses’ responsibilities are evidence-based.
Eating difficulties among persons with dementia is expressed as forgetfulness, distraction, resistance, motor command problems or not being able or knowing how to chew food (Steele, 2010). All nurses agreed that knowing how dementia expresses itself is mandatory in the work of preventing malnutrition. By observing the residents during dining, the nurses argued that they did not need any forms to aid them when identifying malnutrition. The care standard in Sweden includes assessments and forms, monitoring health and vitals, for example with the MNA-form tracking the nutritional intake and possible risk of malnutrition (Nestlé Nutritional Institute, n.d.). The form could be an effective tool to use by nurses in care homes since it is predictive of nutritional outcome as well as follow-up evaluation of outcome (Guigoz, Lauque, Vellas, 2002). Routines regarding weighing residents or patients regularly, for example monthly in care homes, are encouraged when identifying and preventing malnutrition (Evans & Best, 2014).
The concept of person-centered care is a subject that within Swedish health care is described as the patient or resident being a valuable and equal partner in their own health and care (Ekman, 2014). The South African nursing home care places the focus on the residents’ comfort and autonomy.
The nurses at the interviewed homes empathized that the atmosphere should be of home and not a hospital. The South African view on the residents adheres to Brook´s (2014) view on the social environment being of great importance in the care of older persons. Another way this expressed itself was how the nurses spoke about their work at the care home, they said that the nursing staff becomes like the residents’ family over time. The familiar perspective expressed by the nurses erases the line between being personal and private in the relationship with the residents.
The result shows that a main focus for the care homes and the nurses were the residents’ nutritional status and self-sufficiency when eating. During the study it became clear that the nurses placed a large focus and amount of resources on ensuring that the residents reached a sufficient nutritional status. Among the residents who were incapable of feeding themselves the nurses assisted them during mealtimes either with specialized cutlery or through physical feeding. According to Brook (2014) it is shown that older people have an increased food intake when assisted with eating. Brook (2014) therefore proves that the practical work performed by the nurses is proven efficient through research, despite the nurses claiming to not work according to guidelines but simply on the basis of their own experience.
Table of contents :
Registered Nurses core competencies – Preventative work
The South African context
Data Processing and Analysis
Identifying residents at risk of malnutrition
Preventative work to avoid malnutrition among residents