Under nutrition is common in older people who undergo changes in organ systems, body composition and metabolism. The National Diet and Nutrition Survey (1998) of people aged 64 years and over has demonstrated a number of nutritional deficiencies amongst a population of elderly living in residential and nursing homes. Deficiencies in iron, vitamin C, vitamin D and folate have been documented.
Residential care
Approximately five per cent of older people live in nursing or residential care homes. It is estimated that 25 per cent of residents in non-specialist registered homes suffer from dementia. People with dementia are also more at risk of nutritional deficiencies as a result of the effects of dementia on the body systems.
Elderly entering residential homes and nursing homes are often frailer with multiple pathologies. Older people recovering from strokes can be left with disorders of swallowing which can also affect their nutritional status.
Elderly people are also at increased risk from drug induced nutrient deficiencies due to their pre-existing nutritional status, chronic illness and polypharmacy. The effects of medication can reduce appetite or sensory awareness and limit nutrition. Certain drugs can also interact with the absorption and metabolism of nutrients.
Undernutrition is associated with recognised physical and social/psychological effects these include increased risk of infection, poor wound healing, skin problems and pressure sores as well as apathy and depression, confusion and altered body image.
The Caroline Walker Trust has produced guidelines detailing nutritional standards for meal provision in residential and nursing homes. In addition, the National Service Framework for Older People has set standards of care that cover older people in their own homes, residential units and hospital, recognising that diet is important for a healthy lifestyle.
The Project
Frequent requests were being received from staff in nursing and elderly people's homes for advice, visits and training concerning residents with swallowing problems, who were taking a modified consistency diet and/or enteral nutrition via the nasogastric and percutaneous gastrostomy route. Many of these requests identified shortfalls in knowledge and a lack of confidence on behalf of the staff in dealing with these situations. In some instances the requests were directed to the wrong healthcare professional, reflecting a lack of role understanding.
A grant was sought from Greater Manchester Workforce Development Confederation, to pilot and provide training to staff from residential homes. The aim of the project was to deliver a training package consisting of three one-day modules repeated three times over a twelve month period to staff from nursing and elderly peoples homes. The project commenced in June 2000 and was completed in May 2001 (Table 1).
Training team
The project training team was multidisciplinary. Training staff with the appropriate expertise from acute and community NHS settings ran each module (Table 3).
Staff of all grades from nursing and elderly peopleÕs homes in the Tameside and Glossop area attended. It was encouraging to see a cross-section of staff grades from care assistants to unit managers. Homes were encouraged to send at least two staff to provide mutual support and more cascading of knowledge/skills gained once back in the workplace. We were particularly pleased to see that the presence of higher grades and managers did not inhibit discussion forums.
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| Table 1: Training schedule | |
| Module | Title |
| A | Nutritional needs of elderly people |
| B | Acquisition of skills to promote safe swallowing |
C | Competencies and safe practice in enteral nutrition via the nasogastric and percutaneous gastrostomy routes |
| Table 2: Training team | ||
| Module | Health Discipline | NHS setting |
| A | Dietitians | Acute and Community |
| B | Speech and Language Therapy Dietitians Dental Health Occupational Therapy | All staff from acute and community |
C | Dietitians Nursing Speech and Language Therapy | All staff from acute |
Method
A questionnaire was sent to the managers of all elderly people's homes and nursing homes in the Tameside area, registered with social services. The aim of the questionnaire was to establish the level of interest for running a training course and how it should be designed. The questionnaire included topic ideas so that managers could choose the areas they felt were appropriate or add their own.
From this a course programme was designed along with an application form. These were sent to the homes that responded to the initial questionnaire.
Applications were accepted on a first come first served basis as places were limited by the size of the training venue. Two members of staff were invited to attend from each home - a manager or carer and a caterer. This was to encourage a 'team' approach to food within a home from ordering through to preparation and service.
Where more than two places were requested, names were kept in reserve in case of cancellations or places not being filled. As it turned out all the modules were well attended with some being over subscribed for the number of places available. No charge was levied to the homes for the training as the grant money received covered all costs.
Each module was run as a full day session. To ensure a greater number of care staff could attend the training, each module was designed as a stand-alone topic or linked to the other modules for a complete training package. Structuring the training modules in this way kept the training relevant to all grades of staff irrespective of their role in the workplace.
Table 3 gives the total number of staff trained during the three training courses we ran. Certificates of attendance were issued for staff attending the training at the end of each module.
Evaluation and achievements
Each training module was evaluated at the end of the day by the following methods:
- An evaluation form modified to a scored evaluation system in 2001 (see appendix).
- Verbal feedback on the day to trainers.
- Observation of group dynamics, discussions generated and individual/ group participation by the trainers.
- Two-way discussions to address problems identified by participants at grass root level.
The results of the scored evaluation for the three training modules completed in 2001 are listed in Table 4. Everyone who attended a training module enjoyed the day with 79.3 per cent of those who completed an evaluation form grading the day as excellent or good. Pre-existing knowledge would vary amongst the participants so this may account for modules B and C registering average or below average scores if the topic did not add anything to this level of knowledge. It is also possible that the modules, which received lower scores, did not meet the expectations of the participants. Other achievements from the evaluation and post training included:
- Further requests and an identified need for an ongoing programme of training due to staff turnover in residential care homes coupled with new treatment technologies that impact on practice.
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| Table 3: Numbers trained | |
| Training course | Number of staff trained |
1 June to July 2000 2 September to November 2000 3 April to July 2001 | 63 35 58 |
| Table 3: Numbers trained | |||
| Score | Module A (n=21) | Module B (n=16) | Module C (n=16) |
Excellent Good to excellent Good Good to average Average Average to poor | 47.6% - 47.6% - 4.8% - | 31.3% 6.2% 43.8% 6.2% 12.5% - | 18.7% 6.3% 50.0% - 18.7% 6.3% |
- Discussions that enabled trainers and residential care staff to gain a better understanding of each other's respective roles.
- More appropriate requests for support and intervention from the nursing and elderly people's homes that participated in the training. This reflected greater confidence and knowledge amongst the staff post training.
- Better working relationships between the trainers and staff in the residential care settings.
- Production of a training manual for health professionals, which can be purchased.
Future developments
This project has identified opportunities and targets for the future which include:
- Specialist nutrition support staff who can provide seamless care between acute and community settings.
- Continuation of the training programme.
- Inclusion of nursing homes and elderly people's homes in an offshoot of our Healthy Choice Award Scheme. The emphasis would be to focus on quality of food issues and the provision of therapeutic diets.
Conclusion
The project described has addressed the issue of impaired nutritional status in elderly people through a programme of training. This approach can only work if residential care settings have involvement in the planning of a training programme and the topic is relevant to all staff involved in the care of their residents. In addition, a sense of ownership is more likely to encourage participation and changes in practice. Isolated training programmes are unlikely to keep the profile of nutrition raised in residential care settings because of staff turnover rates.
It is important to provide an ongoing programme of education for staff involved in the care of elderly people, to ensure that care remains evidence-based and the nutritional status of elderly people remains improved. Allocating resources to such initiatives offers health professionals the opportunity to be proactive with more effective use of resources rather than only reacting to requests for help that can then result in crisis management and a less effective outcome.
References
British Dietetic Association Nutrition Advisory Group for the Elderly (NAGE). (2001) Older People, Manual of Dietetic Practice, 3rd edition (Thomas B., ed). Blackwell Science Chap 3.7: 263-276.
Buttriss J. (1999) 'Nutrition in Older People -the findings of a National Survey'. Journal of Human Nutrition and Dietetics, 12; 5: 461-466.
Caroline Walker Trust. (1995) Eating Well for older people. Practical and Nutritional Guidelines for Food in Residential and Nursing Homes and for Community Meals. Report of an expert working group.
Department of Health. (2001) National Service Framework for Older People. DoH, London.
Voluntary Organisations involved in Caring in the Elderly Sector (VOICES). (1998) Eating Well for Older people with dementia - report of an expert working
group.
White R., Ashworth A. (2000) 'How drug therapy can affect, threaten and compromise nutritional status'. Journal of Human Nutrition and Dietetics, 13; 2: 119-129.
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