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Can care homes overcome barriers to implementing nutrition guidelines?
Despite increasing recognition, older people living in care homes remain vulnerable to malnutrition, this has significant negative impacts on their physical and emotional well-being. In terms of social and health care costs, malnutrition is estimated to cost £13 billion annually in the UK, and these costs are disproportionately incurred in care homes. While less than 5 per cent of older people live in care homes, around one third of the healthcare costs of malnutrition has been reported for this client group.
Nutrition guidelines may be important in ensuring a nutrient-rich diet for service users
Interventions to improve nutritional status in care homes have included education programmes, provision of snacks and/or oral supplements, improvement of mealtime ambience and assistance. Relatively little attention, however, has been paid to the quality of food provided in this setting. Additional concerns have been raised over the levels of minerals and vitamins provided and whether residents eat enough to meet their energy requirements. Maintaining good nutrition in older people can be challenging as their vitamin and mineral requirements typically remain stable or even increase, but their energy requirements and appetite decrease. A nutrient-dense diet, adequate in energy, is required; however, few practical guidelines on achieving this type of diet in care homes are available. The UK Food Standards Agency (FSA) therefore devised nutrient and food based guidelines specifically addressing the needs of older people (aged 75+) in residential care.
Study to highlight barriers to implementation of nutrition guidelines in care homes
Reviews of guideline implementation in healthcare settings have identified a range of factors influencing implementation but few have considered nutrition guidelines. Implementation of nutrition guidelines in care homes is quite a complex intervention, involving a range of actions and staff with different roles. In order to add some insight into this important area, a qualitative study (one that relies on in depth interviews rather than measurements) was undertaken by researchers at Newcastle University which explored the facilitators and barriers to implementation of nutrition guidelines. The researchers, using a study dietitian, looked at implementing the FSA nutrition guidelines in five care homes in North East England, and modifying their menus to be compliant with these. Interviews were conducted pre and post implementation with staff including home managers, head cooks and catering staff and care and domiciliary staff. The use of observation, as well as informal conversations, allowed the effects on and opinions of a wider group of staff to be considered.
Nutrition guidelines and personalisation
The findings of the study showed that many staff contested the value of external guidelines, perceived them as incompatible with existing goals and priorities, and questioned the benefits of dietary change for older people. For example a senior staff member revealed, ‘if you make the wrong choice as an 80 or 90 year old on what you’re eating, does it matter as much as making the wrong choices when you’re 10, 15 or whatever, there’s a difference isn’t there?’ Some staff also perceived a tension between UK policy emphasis on personalisation and nutrition guidelines. Staff wanted to provide a homely environment where clients were free to choose favourite foods, and perceived that the guidelines prioritised nutrients over the emotional, social and cultural qualities of food and mealtimes. Whilst some staff viewed external guidelines as a beneficial resource for improving care, others argued that menus should be locally derived between cooks and service users.
A further barrier was the perception that staff skills and expertise were not valued. Some cooks found suggestions to amend their recipes disempowering and insulting. Additional barriers were satisfaction with existing menus, a perceived threat to expertise and independence, and a lack of drive to implement the guidelines. A number of staff expressed that changes devalued their detailed knowledge of their service users (‘we know then probably better than our own parents’). However, on observation it was noted that staff rarely explicitly asked the residents about their preferences and rejected suggestions to offer, for example, brown bread before white and polyunsaturated-rich fat spread rather than butter.
Uncertainty over the value of the nutrition guidelines was found to have a clear impact on staff to engage with implementation. Whist some staff took pride in menus, and were reluctant to make changes, particularly when a home had a good reputation for food, others expressed reservations about the current menus. The researchers also commented that despite diversity of staff views it may have been possible to create a collective investment in the guidelines with strong management support.
Staff knowledge of nutrition
A consistent barrier in all homes was that staff responsible for developing menus lacked detailed knowledge of the nutritional content of foods and the nutritional needs of older people. Although some cooks had an interest in healthy eating on a personal level, nutritional knowledge was variable and was not always considered in the context of work. Few cooks or care staff were familiar with the eatwell plate, which provides guidance on the relative portions of different food groups required for a healthy diet. While all cooks were aware of guidelines on 5-A-Day, potatoes were incorrectly seen to count towards portions of fruit and vegetables.
The process of menu development, preparing new dishes and changing orders created significant extra work. The situation was exacerbated by staff shortages. Additionally there were no formal systems for monitoring implementation following development of the modified menus, rather staff were individually responsible for putting them into practice. Within all homes, the extent to which different cooks complied with the modified menus varied. This lack of consistency often reflected the cooks’ personal preferences and the extent to which they were signed up to the nutrition guidelines, rather than necessarily reflecting service user preferences. Despite their reservations about the value of the nutrition guidelines, the majority of the cooks showed considerable commitment to developing modified menus and made some changes.
Encouraging engagement of staff in implementation of nutrition guidelines
Factors that might ideally foster the engagement of staff are listed along with the real conditions that were found, and with suggested strategies that might promote implementation of guidelines:
In summary, the researchers reported that strategies that may facilitate implementation of nutrition guidelines include:
- Ensuring that all staff are well briefed on the rationale for, and short and long term benefits of, the nutrition guidelines
- Facilitating ownership of the modified menus and focusing on working towards rather than implementing the nutrition guidelines
- Providing ongoing training in the principles underlying the nutrition guidelines, menu analysis, and strategies for adapting recipes (collective action)
- Agreeing on outcome measures and a process for collecting information to review the impacts of the modified menus (reflexive monitoring).