Factors for effective identification of patients at nutritional risk in clinical practice: Thematic analysis of qualitative research

Using the model PICO (Patient/ Problem, Intervention, Comparison and Outcome), we created the following keywords: nurses, health personnel, nutrition screening, nutrition assessment, malnutrition or protein-energy malnutrition, attitude, barriers and facilitators. Key words and the Boolean operators AND and OR were used for the search strategies. Documents were searched in online bibliographic databases: PubMed (MEDLINE), CINAHL, and ProQuest. The search was limited to English-language full-text articles published between 2011 and 2021.

We identified 1010 publications and 51 duplicates were excluded. During a quick review of the titles and abstracts of the included articles, we identified and included 6 additional relevant publications using the “link to similar articles” browser in PubMed. The PRISMA protocol (Preferred Reporting Items for Systematic Review and Meta-Analysis) was used to display the results of the literature review (14) (Figure 1).

Figure 1

We included descriptive qualitative research that reached the seventh level of evidence in Polit & Beck’s hierarchy of evidence (15). The quality of the included research was assessed using the established COREQ tool (Consolidated Criteria for Reporting Qualitative Research Tool) (16). Data analysis was conducted through content analysis followed by a thematic synthesis method based on the thematic analysis of the qualitative research findings (17).

The healthcare environment can have a significant impacton the implementation of nutritional care for patients in clinical practice. It is more likely to be carried out where the organization takes responsibility for its implementation, has clear expectations about it, and considers nutritional care as a priority of organizational and clinical leadership (18, 19, 20). Although nutritional screening was implemented in some clinical settings as a tool to assess patients at nutritional risk, healthcare professionals generally relied on their own subjective professional judgment, clinical experience and “common sense.” In some cases, nutritional screening was performed only after the patient reported weight loss or decreased appetite (18, 19, 21, 22). Existing clinical guidelines were often poorly applied in clinical practice, and nutritional treatment of patients was considered only as a form of nonmedical patient care. The quality of nutritional care and treatment of patients often depended on the individual interest of healthcare professionals in clinical nutrition (20).

Healthcare professionals expressed very different and also conflicting views about taking responsibility for the continuing nutritional care of patients at nutritional risk. They expressed uncertainty about the role that each professional group (physicians, nurses and dietitians) should play in the nutritional care of patients. They called for a multidisciplinary approach in which responsibilities and competencies for the nutritional care and treatment of patients are formally divided between the different professional groups, and for better communication and collaboration between them (19, 20, 21, 23, 24).

Dietitians defined physicians as those most able to identify malnourished patients and diagnose nutritional disorders. However, identifying patients with malnutrition was often of secondary importance to primary care physicians. Physicians recognized malnourished patients during primary treatment of their other clinical conditions or diseases rather than as a distinct clinical condition to be systematically diagnosed and followed up (22). Nurses frequently expressed frustration and feelings of loneliness at the lack of physician involvement in the nutritional care of patients. Dietitians were recognized by health professionals as useful and necessary professional collaborators in the nutritional treatment of malnourished patients, but their availability in certain healthcare organizations was too low (19, 21). With the implementation of nutritional screening, it has been shown that autonomy in providing comprehensive nutritional care to the patient allows nurses to use their clinical knowledge and skills more effectively in clinical practice (18, 23).

Poor prospects for referring patients for further nutritional assessment and treatment emerged as one of the most important barriers, especially when referral was not possible (18, 21). On the other hand, patients were sometimes referred to a physician only for the physician to prescribe an oral nutritional supplement (18). The lack of a protocol for follow-up of patients at nutritional risk has been shown to be an important factor contributing to poor continuity of nutritional care (21).

In the study by Verwijs et al. (24), the lack of exchange of written information about the patient’s nutritional status between different profiles of healthcare professionals was pointed out. In the study by Håkonsen et al. (20), the continuity and quality of nutritional care were mainly affected by the different use of nutritional terminology by different groups of healthcare professionals, and by different standards of nutritional care for patients in different health facilities within the same level of healthcare. Incorporating nutritional screening into clinical practice and nursing documentation can improve its implementation; however, continuity of nutritional care can be difficult when findings about the patient’s nutritional status are recorded in different documentation, reducing the transparency of the patient’s comprehensive nutritional care (19, 23). Nurses emphasized that the patient’s nutritional status was not adequately recorded in nursing documentation, which is necessary for continuity of the patient’s nutritional care between different levels of healthcare (18). Similar findings were found in a study by Verwijs et al. (24), in which information about the patient’s nutritional status was incomplete, delayed or not documented at all in discharge records. The quality of documentation of patients’ nutritional status was compromised by the lack of time of medical staff, and the poor quality of documentation proved to be a barrier to effective ongoing nutritional care of patients. This presented a deficit in the patient’s transition between different health care environments and levels of healthcare (21).

Healthcare professionals frequently expressed a lack of knowledge and skills to identify and treat patients at nutritional risk. Continuing education and training were highlighted as important for improving the implementation of nutritional screening in clinical practice, and the importance of practical training in the use of screening tools when working with patients was emphasized (18, 19, 24). Nurses and physicians emphasized that there is a lack of basic education in the field of nutrition in undergraduate education (22, 23). Håkonsen et al. (20) found that functional education and training to develop and deepen expertise in nutritional support is not systematic and regular, and that training is usually conducted as “decoding of practices from peers” when working with patients. In the study by Hestevik et al. (21), healthcare professionals highlighted that organizations do not provide sufficient support for nutrition training and they often have to attend it in their spare time as part of food company promotional events.

Nurses cited lack of time and human resources as one of the most important barriers to effective implementation of nutritional care for patients, especially in relation to the large number of patients treated, extensive nursing and medical documentation, the large number of priority medical treatments for patients, and entering data in the information system (18, 20, 21, 23). The increased time to perform nutritional screening in clinical practice was also significantly affected by the availability of appropriate and functioning weight scales (19). Primary care physicians pointed out the problem of limited time to treat patients, which affected the quality of nutritional care provided to patients (22).

The findings of the systematic literature review of qualitative research highlighted key factors that healthcare professionals consider important for the effective identification of patients at nutritional risk and their ongoing nutritional care in daily clinical practice. The systematic review included research conducted in different healthcare settings and at different levels of healthcare delivery, and we identified five main factors common to all.

Our findings showed that poor continuity of nutritional support was one of the most important factors negatively affecting the quality of nutritional care provided to patients. In particular, the following were highlighted as important components of this factor: poor chances of referring a malnourished patient for further treatment; lack of protocols for nutritional care; lack of exchange of written information about the patient’s nutritional status between different healthcare professionals; inconsistent use of nutritional terminology between different healthcare professionals; inconsistent standards of nutritional care for patients; and incomplete documentation of patient discharge (18, 20, 21, 24). A similar conclusion was reached in the study by Mersini et al. (25), which examined the impact and success of Albanian nutrition policy implementation. Lack of institutional/infrastructural support, lack of intersectoral coordination, and lack of effective collaboration between different sectors and institutions were obstacles to the implementation of their nutrition policy plan.

The implementation of clinical nutrition pathways, their integration at all levels of the health system and the establishment of a multidisciplinary team that includes a clinical dietitian in addition to the physician and nurse, must become one of the priorities of health systems. Implementation should be guided by clinical guidelines for the prevention, diagnosis and treatment of malnutrition and other nutritional disorders (2, 26). Nutritional screening, performed with a validated screening tool, provides the basis for further evidence-based nutritional treatment of the patient. Some studies have shown that the lack of a “key person” with specific knowledge in clinical nutrition (nurse) to support, promote and control the development of new procedures may hinder the effective implementation of nutritional screening in clinical practice (27). In addition, clinical dietitians who are frequently present on the wards and educate nurses and physicians can act as motivators and promoters of successful nutritional care (28).

Our findings show that health professionals expressed uncertainty about their roles, responsibilities and competencies due to the indeterminate structure of nutritional care for patients, and emphasized the need for formal regulation in this area and the introduction of an effective multidisciplinary approach (19, 20, 21, 23, 24). The multidisciplinary nutrition team is a group of specially trained and educated health professionals in clinical nutrition, including physicians, dietitians, nurses, pharmacists and other relevant professionals (2). When there is no specialized nutrition team, nutritional care is provided by the basic team of physicians, nurses, physiotherapists, pharmacists, etc. Nutritional care provided by multidisciplinary teams is effective when their work is focused on solving the patient’s individual problems, is based on evidence-based practice, and a collaborative approach is taken in clinical practice (29). According to our findings, the lack of knowledge and skills among health professionals is another important barrier to effective nutrition-related care for patients (18, 19, 20, 22, 23, 24). Healthcare professionals often have to rely on their own professional judgment and clinical experience when assessing patients at nutritional risk (18, 19, 21, 22). Therefore, health professionals emphasized the lack of support from the health facility management in providing nutrition-related care to patients and considered the influence of the facility management as a crucial factor in assuming professional responsibility (18, 19, 20).

The results of our systematic literature review identified barriers that may significantly impede the implementation of effective nutritional care for patients at nutritional risk. Our findings can help healthcare providers consider and implement appropriate strategies to improve this clinical practice. According to our findings, it is important to examine organizational culture, multidisciplinary collaboration, roles and responsibilities of health professionals, continuity of nutritional care for patients, and protocols and standards currently used in clinical practice.