REVIEW

Nurturing and nourishing: the nurses’ role in nutritional care

Diana Jefferies, Maree Johnson and Jennifer Ravens

Aims. Researchers collaborated with clinicians, consumers and dietitians to develop a policy defining how nurses could support
their patients’ nutritional care.
Background. A high prevalence of hospital malnutrition has been reported in Australia, Europe and the UK. A patient’s
nutritional status can deteriorate during admission. Malnutrition can increase complications, length of stay, mortality rates and
health care costs. As the nursing role has become increasingly complex, traditional nurturing activities such as serving the
patients’ meals have devolved to other categories of staff leaving the role of nurses in their patients’ nutritional care ill-defined.
Design. The research team systematically reviewed relevant research literature using the principles of qualitative metasynthesis
to identify appropriate nursing strategies that would assist in reducing the prevalence of hospital malnutrition.
Method. The policy was developed using a systematic review approach: devising a clinical question, searching the literature,
appraising research evidence, analysing existing policy documents, synthesising evidence into dominant themes and once the
policy was drafted, initiating a wide ranging consultation and ratification process.
Results. A literature search located 147 articles. Forty articles were identified as being within the scope of the clinical question.
Most were reports of audits or observation studies. The dominant themes were developed into standards that assisted nurses in
supporting the oral nutrition of their patients. These included the following: a focussed mealtime, management of mealtime
environments, management of staff mealtimes and a designated nutrition support nurse in each clinical area to monitor and
evaluate the implementation of the policy.
Conclusions. There is a distinct role for nurses that will assist in reducing the prevalence of hospital malnutrition but successful
implementation can only occur with the support of the multidisciplinary team.
Relevance to clinical practice. This policy provides a framework to define and invigorate nursing’s role in supporting the
patient’s nutrition care.

Key words: hospital malnutrition, nursing, nutrition, policy, qualitative metasynthesis

Accepted for publication: 12 August 2010

assistance, patients may be unable to consume their meal, not

Introduction
Good nutrition is essential to patients’ well-being (Sketkowicz
1992, Brogden 2004). Many patients require assistance either
to feed themselves or, if necessary, to be fed by another person
(Wright et al. 2008, Webster & Healy 2009). Without such
only leaving them hungry but increasing their risk of devel-
oping malnutrition (Kowanko 1997). Most hospitals employ
staff to collect patients’ menu choices and/or to deliver the
meals to the patient’s bedside (Kowanko et al. 1999, Xia &
McCutcheon 2006). However, as these dietary support roles

Authors: Diana Jefferies, BA, PhD, RN, Nurse Educator – Clinical
Research, Centre for Applied Nursing Research, Sydney South
Western Area Health Service, Liverpool, BC; Maree Johnson,
BAppSci, MAppSci, PhD, RN, Research Professor, School of
Nursing & Midwifery and Director, Centre for Applied Nursing
Research (Joint facility of SSWAHS & the University of Western
Sydney), University of Western Sydney, College of Health & Science,
School of Nursing & Midwifery, Penrith South, NSW; Jennifer
Ravens, BSc, MHM, DHSM, Dip N&D, APD, Director of Nutrition
and Dietetics, SSWAHS, Department of Nutrition and Dietetics,
Royal Prince Alfred Hospital, Camperdown, NSW, Australia
Correspondence: Diana Jefferies, Nurse Educator – Clinical
Research, Centre for Applied Nursing Research, Sydney South
Western Area Health Service, Locked Bag 7103, Liverpool BC,
NSW 1871, Australia. Telephone: +61 2 9612 0605.
E-mail: Diana.Jefferies@sswahs.nsw.edu.au

 2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 317–330 317
doi: 10.1111/j.1365-2702.2010.03502.x
D Jefferies et al.
have developed, the role of the nurse in patient mealtimes has
diminished, with nurses in many health facilities now believ-
ing that this is no longer their responsibility (Brogden 2004,
Wilson 2007, Dickinson et al. 2008). Nurses are less focussed
on their patient’s nutritional status and/or their patient’s
ability to feed themselves (Kowanko et al. 1999, Kowanko &
Simon 2001). This paper will report on a metasynthesis
focusing on the role of the nurse in nutrition care.
Background
Several studies have identified the prevalence of hospital
malnutrition in Australian and international health services
(Middleton et al. 2001, Adams et al. 2008, Bavelaar et al.
2008). Studies have shown that the prevalence of malnutri-
tion in Australian hospitals is between 35–63% of patients
(Naylor et al. 1996, Adams et al. 2008). These rates are
consistent with international studies, which show the prev-
alence of hospital malnutrition at between 19–60% in the
United Kingdom and in Germany (Bavelaar et al. 2008).
While many patients are malnourished on admission to
hospital, studies also show that patients’ nutritional status
frequently declines during the course of their admission
(McWhirter & Pennington 1994, Coxall et al. 2008).
Although the issue of patients being admitted to hospital
malnourished demonstrates that malnutrition is prevalent in
the community, the focus of this study is on changes in
nutrition for patients throughout their hospital.
Other studies have discussed the implications of under-
nourishment and malnutrition for the patient on a physical
and an emotional level. First, the physical effects are
devastating and lead to complications such as poor wound
healing, immune dysfunction, sepsis, hypothermia, bone
demineralisation and subsequent fractures and impaired drug
metabolism (Teo & Wynne 2001, Jordan et al. 2003).
Malnutrition causes unnecessary and avoidable suffering to
patients leading to a reduced rate of rehabilitation, longer
hospital stays, greater morbidity and mortality and an
increased readmission rate (Kowanko 1997, Bavelaar et al.
2008, Persenius et al. 2008). All these factors contribute to
the ever increasing cost of health care (Archibald 2006,
Wilson 2007, Dickinson et al. 2008).
Second, the provision of food also has implications for the
emotional well-being of the patient, and nurses must consider
the role that food plays in the lives of their patients (Endacott
1993, Pearson et al. 2003). Food is integral to the individual’s
sense of self (Fischler 1988) and has strong psychological
connotations associated with nurturing (Lupton 1996). When
a person is admitted to hospital, frequently the only familiar
thing and one of the few things the patient feels qualified to
318  2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 317–330
evaluate is the food. Familiar foods are important in highly
stressful situations because they represent comfort and
security to the individual (Bell & Valentine 1997). Patients’
perceptions of hospital food quality are strongly correlated
with their satisfaction with medical treatment and the
hospital stay overall (Maller et al. 1980).
Hospital food services are constrained by limitations such
as systems of food preparation and distribution and the
statutory requirements of providing safe food to patients.
However, health professionals have a duty of care to ensure
that patients receive the assistance they require to consume
their meals (Whitehurst 2009). Nutrition care lies at the
interface between medicine, nursing and dietetics, and the
role of each profession in the nutritional care team is not
always clearly defined (Jordan et al. 2003). A Joanna Briggs
Institute systematic review (JBI 2007) focuses on addressing
deficiencies in patient nutritional status with supplementary
sip feeds but, also acknowledges that nursing care is critical
to ensuring that patients receive the support required to
maintain their nutritional status. No study has looked
comprehensively at the role of nursing in nutrition care.
The development of nursing practices, which define the
nurse’s role in the nutritional care of patients and in
supporting patients in eating and enjoying their meals, will
help patients maintain or improve their nutritional status and
contribute to positive hospital experiences.
Given the range of roles and responsibilities relating to
patients oral nutrition that could exist for nurses, the team
initially considered local data on feeding and also consulted
senior dietetics managers and researchers to assist in narrow-
ing the focus of the role to areas of most concern. Data were
obtained from a feeding audit conducted in 2003 of 17 wards.
This audit showed that 35Æ8% (n = 114) of patients required
some level of assistance with meals, 54Æ4% of those patients
who were identified as requiring assistance prior to their meal,
did not receive assistance; 21% (n = 80) had not touched
their meals within 20 minutes of the tray being delivered; and
finally 18% (n = 70) had not consumed their meals prior to
the meal trays being removed (O’Loughlin 2003).
Following review of these audit results and in conjunction
with nurses and other representatives from Nutrition and
Dietetics, the scope of this metasynthesis was confined to
three aspects of nutrition and food service where nursing staff
could potentially play a vital role. These areas of focus were
as follows: patients often have difficulty accessing their meal
(Kayser-Jones & Schell 1997, Kowanko 1997, Kowanko &
Simon 2001, Kayser-Jones 2002); patients often experience
prolonged and repeated periods of being nil-by-mouth as they
await procedures (Kowanko 1997, Kowanko & Simon 2001,
Adams et al. 2008); and patients were often distracted while
Review
eating and a ‘protected mealtime’ may reduce these distrac-
tions (Kayser-Jones & Schell 1997, Kowanko & Simon 2001,
Mathey et al. 2001, Kayser-Jones 2002, Hunt 2007). This
paper reports on a metasynthesis of existing literature used to
develop a policy describing how nurses can support their
patients’ nutritional needs and thus contribute to a reduced
incidence of inpatient malnutrition.
Aim
The aim of this study was to describe what nurses could do
to reduce the incidence of malnutrition of patients in
hospitals.
Methods
Design
A systematic review method was used to develop a set of
standards on the nurses’ role in nutritional support for
patients. Similar to the steps in guideline development noted
by Thomas (2007), the following activities were undertaken:
developing a clinical question, searching the literature, eval-
uating whether journal articles were within or outside the
scope of a clinical question, critical appraisal of journal
articles selected to be included in the study, reading and
extracting data from journal articles synthesising data into a
summary table, recoding data in the summary table to identify
major themes which shape the recommendations, drafting the
policy, undertaking broad consultation including consumers
and other health professionals and finalising the guidelines. A
team of nurses, dietitians, consumers and nurse researchers
worked together to develop the policy. A qualitative meta-
synthesis approach was used for the systematic review of the
best available and most current research evidence.
Literature search
The literature search was conducted by the librarian trained
in systematic review search approaches. All literature found
on CINAHL, MEDLINE and EMBASE from 1998–October
2008 and published in English were located. The key words
used in the search strategy were as follows: ‘Inpatients’,
‘patients and hospitals’, ‘food’, ‘food services’, ‘nurses’,
‘meal’, ‘catering service’ and ‘patient satisfaction’.
Initially, the literature search identified 73 articles as
relevant. The articles were presented to the members of the
team who were asked to decide whether or not a particular
piece of research evidence was to be included in the study.
This decision was based on an examination of the abstract
 2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 317–330
The nurses’ role in nutritional care
and title to investigate whether the article answered the
following question:
• What aspects of nursing care (access to food, supportive
mealtime environments, prolonged and repeated periods
of nil-by-mouth) ensure that patients (in acute and long-
term settings) have their oral nutritional needs met in this
health service?
This clinical question did not include a comparison group,
only the population and proposed interventions. Articles
included in the study were directly related to defining how
nurses could ensure that their patients had access to food,
were eating in a supportive mealtime environment and how
prolonged and repeated periods of being nil-by-mouth were
avoided. Reasons given for excluding research evidence in the
study were that the article was not directly related to the
specific research areas (access to food, a supportive mealtime
environment and avoiding prolonged and repeated periods of
nil-by-mouth), it was not related to nursing, that it was
focused on food rather than nursing support, or that it
described the role of professions other than nursing in the
process of providing adequate nutrition for patients. Once
this process had been completed, there were 38 articles to be
included in the study.
Critical appraisal
The literature search uncovered a wide range of research
evidence and literature about the nursing support of
patient nutrition. Each article selected to remain in the study
was appraised by two readers, of which at least one was
a researcher and familiar with the critical appraisal tools
(Table 1).
Critically appraising this evidence and literature was a
difficult task as many different tools were required. The tools
used to evaluate the literature were developed by the JBI and
were related to the design of the study including: text, expert
opinion and discourse (developed to evaluate the quality of
expert opinion articles), critical appraisal checklist for
surveys, critical appraisal for experimental studies and the
qualitative data extraction instrument. No article was
rejected from the study because it scored poorly in the
critical appraisal.
Levels of evidence
To assess the level of evidence to be used in this study,
researchers used the National Health and Medical Research
Council (NHMRC) hierarchy of evidence table (NHMRC
2008). The 38 articles were then categorised according to the
level of evidence table.
319
D Jefferies et al.

Table 1 Summary of levels of evidence

Level of
and methodological quality
evidence Critical
NHMRC appraisal Critical
Research design Article (2008)* tool appraisal

Expert opinion Archibald (2006) 3 +++

Ali (2007) +++
Aziz and Campbell-Taylor (1999) ++
Clay (2000) +++
Copeman (2000) +++
Dimant (2001) +
Hunt (2007) ++
Swagerty et al. (2002) ++
Swain et al. (1998) ++
Wilson and Lecko (2005) +++
Wilson (2007) ++
Audit Davis (2007) III-3 2 +
Hamilton et al. (2002) III-3 +++
Survey Lau and Gregoire (1998) IV 2 ++
Lassen et al. (2005) IV ++
Scott-Smith and IV ++
Greenhouse (2007)
Waters (2007) IV ++
Observational study Agnew (2005) II 2 +
Horan and Coad (2000) IV ++
Ono et al. (2003) III-2 +
Simmons and Schnelle (2006) IV +
Xia and McCutcheon (2006) IV ++
Random control trial Eneroth et al. (2005) II 1 +++
Mathey et al. (2001) II +++
Report/editorial Davis (2001) 3 +
Keller et al. (2006) +
Qualitative study Dickinson et al. (2008) 4 +++
Walsh et al. (2008) ++
Summary of evidence JBI (2007) I 1 ++
Validation study Evans and Crogan (2007) 1 +
Oakley and Hill (2000) ++

*NHMRC (2008) – levels of evidence: level I – a systematic review of level II studies; level II – a
randomised controlled trial; level III-1 – a pseudo-randomised controlled trial; level III-2 – a
comparative study with concurrent controls; level III-3 – a comparative study without concur-
rent controls; level IV – case series with either post-test or pretest/post-test outcomes.

Critical appraisal: 1 – Experimental studies criteria (for example: randomisation, blinding,
statistical methods, outcome measurement, follow-up and dropouts or withdrawals. 2 – Survey
criteria (sample selection, design, analysis and interpretation). 3 – Text, expert opinion and
discourse criteria (source of opinion, patient focus, argument, reference to literature). 4 –
Qualitative data extraction instrument (method/methodology, data analysis, setting and context,
interventions, findings/narrative description).
The methodological quality is reported by the following system: +++ when all or most of the
criteria have been fulfilled (80–100%); ++ when some of the criteria have been fulfilled (50–
80%); and + when few or none of the criteria has been fulfilled (<50%) (Goldsmith et al. 2007).

protected mealtimes) was developed (Appendix 1). Data

Data extraction from research evidence
Once the critical appraisal of research evidence was com-
pleted, a data extraction tool based on the initial three areas
(access, managing prolonged periods of nil-by-mouth,
from each article were extracted by two team members.
Once the data were extracted from the research evidence, a
summary table was devised. Data were then recoded accord-
ing to the initial three areas (Table 2).

320  2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 317–330
Review The nurses’ role in nutritional care

Table 2 Summary of evidence

Level of
Theme evidence Evidence

Access to food
Adequate nursing II–IV Adequate staffing is required to improve nutrition (Agnew 2005)
staffing and Volunteers can be trained to help at mealtimes (Hamilton et al. 2002)
support Helping patients during mealtimes is demanding and time-consuming and is compromised by
staff shortages (Horan & Coad 2000)
Nurses’ mealtimes should be organised so that there is enough staff present to assist with meals
Increased nursing I–IV Nurses have a role in planning nutrition interventions and ensuring their implementation
focus on (JBI 2007)
nutritional Nurses and dietitians should ensure that a patient’s ability to eat is observed and that appropriate
care interventions are implemented and evaluated (Keller et al. 2006)
Nurses need to focus on how they can contribute to the nutritional care of their patients
(Lassen et al. 2005)
Education for nurses should emphasise the importance of nutritional care as a clinical and quality
of life issue (Mathey et al. 2001)
Nutritional care should be given greater priority by staff (Xia & McCutcheon 2006)
Nursing assessment III–IV Nutritional assessment should be a nursing priority and acknowledged as a crucial part of nursing
of patient’s care (Horan & Coad 2000)
nutritional needs The Nutrition Assessment Score is a useful tool to assess a patient’s nutrition assessment
(Oakley & Hill 2000)
Nurses need to document food intake (Xia & McCutcheon 2006)
Designated nutrition Expert A key worker should be designated on each shift (Clay 2000)
champion in each opinion Provision of a nutrition assistant improves patient welfare and nutrition care (Copeman 2000)
clinical unit and There is a need for nurse champions at both a ward and management level
editorial
Patients requiring IV Training in nutritional care is important to staff who are delivering meals to patients
assistance to access (Lau & Gregoire 1998)
their food The meal must be positioned with easy reach (Horan & Coad 2000)
Patients should be asked if they want to eat alone or with others (Lassen et al. 2005)
Food was placed out of reach 73% of the time and nearly 50% of patients required help
to access their food, change position, reposition trays and be fed in a timely manner
(Xia & McCutcheon 2006)
Oral assessment III-2 Nurses should be aware that dental care is an important aspect of nutritional care
and care are (Ono et al. 2003)
important

Supportive meal environment

Dedicated clinical II–IV A dedicated clinical unit focus on mealtimes is no substitute for adequate staffing (Agnew 2005)
unit focus on Nurses should prioritise mealtimes to reduce disturbances and movement around food
mealtimes (Horan & Coad 2000)
Nurses used mealtimes to deal with other matters such as documentation; interruptions during
mealtimes disrupted a patient’s ability to eat; limited social interaction at mealtimes disrupted
eating (Xia & McCutcheon 2006)
Managing the II–IV Improving the ambience of food consumption led to positive changes in mean body weight and
environment stabilised health conditions (Mathey et al. 2001)
during mealtimes Food satisfaction surveys make the food service more patient centred; dietitians should be able to
assess patients while in hospital rather than after discharge; all decisions about nutrition care should
be patient centred and considered by the multidisciplinary team; this leads to an increase in patients
selecting appropriate diets (Scott-Smith & Greenhouse 2007)

Prolonged and repeated periods of a patient being nil-by-mouth

Access to food after III-3 to IV There is a need for improved snack availability when the kitchen closes (Hamilton et al. 2002)
kitchen hours Snacks should be provided in-between meals (Lassen et al. 2005)
Dietary department hours are extended to meet the needs of patients arriving late to the wards or
units (Scott-Smith & Greenhouse 2007)
Provision is variable for the availability of food over a 24-hour period (Waters 2007)

 2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 317–330 321
D Jefferies et al.
Table 3 Summary of standards identified in the literature review
that formed the basis of the policy
No. Standard
1. All patients are required to have a nutritional screening
completed on admission
2. All patients are required to have an individualised
nutritional care plan as required
3. Nurses are required to assess each patient’s ability to eat
within 24 hours of admission
4. Nurses are required to ensure there is a focus on the
patient’s mealtime in every clinical setting
5. Adequate nursing or other support, such as volunteers,
relatives and carers, should be available to ensure that
assistance required by patients at mealtime is provided
6. Nurses are required to encourage and assist patients to
maintain their oral care
7. There is to be a dedicated nutritional care resource nurse in
every clinical setting
8. Nurses, in conjunction with medical and allied health staff,
are required to manage periods of prolonged and/or
repeated fasting effectively
The process used to extract data involved two researchers
reading and re-reading research material to identify which
major themes consistently appeared in the literature (Price
2009). Once these themes were identified the data were coded
and recoded until eight major strategies were uncovered.
After these strategies were identified, the data could be
recoded again under headings to pinpoint specific tasks to
integrate these strategies into the clinical setting (Sandelowski
et al. 1997, Thomas 2007). The eight strategies of nutritional
care, which became known as the eight standards, mapped
out a specific programme to assist in reducing the prevalence
of hospital malnutrition. A policy was drafted with the eight
standards as its central focus (Table 3).
Results
Each standard was based on the major themes identified from
the data extracted from the literature review. The presenta-
tion that follows connects the literature to the emerging
standards and provides some interpretation where required.
Each standard is identified with an explanation:
Standard 1: All patients are required to have a nutritional
screening completed on admission (Horan & Coad 2000,
Oakley & Hill 2000, Lassen et al. 2005).
The introduction of an admission and discharge tool
included the Malnutrition Screening Tool, a validated
screening tool (Ferguson et al. 1999). Any patient with a
score of 2 or more on the malnutrition screening tool is to be
referred to the dietitian.
322  2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 317–330
Standard 2: All patients are required to have an individ-
ualised nutritional care plan (Lassen et al. 2005, Keller et al.
2006, JBI 2007, Scott-Smith & Greenhouse 2007).
If a patient is found to be either malnourished or at risk of
becoming malnourished, a care plan is to be devised and
implemented to either correct or prevent the onset of
malnutrition. If a patient is referred to the dietitian for a
nutrition assessment, an appropriate plan will be instituted
and documented in the clinical record to ensure that the
patient’s nutritional needs are met. The dietitian will liaise
with nursing staff to discuss the implementation of measures
relevant to nursing care, such as the recording of the patient’s
food and fluid intake on a specific chart. The plan will be
discussed at all nursing handovers so that its success can be
evaluated.
Standard 3: Nurses are required to assess each patient’s
ability to eat within 24 hours of admission (Horan & Coad
2000, Dimant 2001, Xia & McCutcheon 2006, Hunt 2007,
JBI 2007, Dickinson et al. 2008).
When a patient is admitted, the nurse is required to
investigate whether a patient has any disability that could
affect their ability to eat. They should consider factors such as
the patient’s emotional state (depression leading to a loss of
appetite), limitations on mobility (for example medical
conditions such as rheumatoid arthritis or interventions such
as plaster casts) or cognitive impairment. If a patient has such
a disability the nurse is required to devise an appropriate plan
and document it in the health care record. Measures that
assist patients to eat may include repositioning patients
before meals, assisting them with feeding, or ordering a diet
that will assist them to self-feed (e.g. ‘Open All Packs’ or ‘Cut
Up’ diets). Again, any plan devised to enable a patient to eat
should be discussed and evaluated at all nursing handovers. If
the patient has any complex issue that makes it difficult for
them to eat, a referral to an appropriate member of the
multidisciplinary team, such as an occupational therapist or
speech pathologist, may be required.
Standard 4: Nurses are required to ensure there is a focus
on the patient’s mealtime in every clinical setting (Horan &
Coad 2000, Mathey et al. 2001, Lassen et al. 2005, Wilson
& Lecko 2005, Xia & McCutcheon 2006).
Initially this focus, known as ‘focus on patient mealtime’
(FOPM), will occur at the midday mealtime. Once a routine
is established for the FOPM, it can be extended to breakfast
and the evening meal as necessary. Nurses focus on the
patient’s nutritional care for 20 minutes before and for
30 minutes after meals are delivered. It is an opportunity for
nurses to provide an optimal environment for the patient to
eat and enjoy their meal, thus providing for their nutritional
care.
Review
Nurses need to consider both the patient and the ward
environment when meals are due to be served; prepare the
patient make them comfortable (positioning, toileting,
refreshment of face and hands), the bed unit (appropriate
food utensils, open all packages that a patient cannot
manage, consult their patients about food issues or prefer-
ences) and the ward area. Nurses should also make sure that
the ward environment is conducive to eating (Kayser-Jones &
Schell 1997, Agnew 2005, Wilson & Lecko 2005, Hunt
2007, Scott-Smith & Greenhouse 2007, Dickinson et al.
2008). This may involve removing objects, such as urinals
and bed pans, from the patient’s immediate vicinity and
clearing their bed tables.
If a patient has undergone a formal swallowing assessment
by a speech pathologist, nurses must ensure that they are
familiar with any plan devised by the speech pathologist prior
to a patient receiving a meal. The plan must be addressed at
all clinical handovers.
As nurses’ focus is on the patient’s nutritional needs during
mealtimes, all non-essential clinical activity is required to
stop during meals. This includes nursing procedures, such as
observations, dressings or other tasks that are not required to
be completed immediately, ward rounds should not be
conducted during this time and patients’ visitors should be
restricted to relatives who will help the patient eat. Visitors
should be made aware of the importance of mealtime and
encouraged to maintain a calm environment. It is the
responsibility of all nurses to create a mealtime atmosphere
that is pleasant and enjoyable for patients.
Standard 5: Adequate nursing or other support, such as
volunteers, relatives and carers, should be available to ensure
that assistance required by patients at mealtime is provided
(Horan & Coad 2000, Agnew 2005, Xia & McCutcheon
2006).
In some clinical units, reorganisation of meal breaks may
need to occur so that there are adequate numbers of nurses
available. Other measures that can be considered include the
recruitment and training of volunteers and family members to
assist with patient feeding. Volunteers and family members
can assist in feeding patients if there are no complicating
factors such as dysphagia or any other related disorder that
could compromise the patient’s safety. To ensure that
patients remain safe during feeding further, nurses should
initially supervise volunteers and family members to assess
their competence and confidence in this task.
Patients who would benefit from assistance with feeding can
be identified in a variety of ways, such as an entry on their care
plan or signage at the bedside. But to ensure that all nurses are
aware of their patients’ need for assistance at mealtime, this
should be identified during the nursing handover.
 2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 317–330
The nurses’ role in nutritional care
Standard 6: Nurses are required to encourage and assist
patients to maintain their oral care.
Good oral hygiene is an important aspect of nutritional
care. It aids in the enjoyment of a meal. Furthermore, good
oral hygiene has many health benefits such as reducing the
risk of heart disease from the build up of plaque on teeth
(General Practice Network Fact Sheet 2008) and a reduction
in the incidence of pneumonia in the older persons (Azar-
pazhooh & Leake 2006). Nurses should encourage their
patients to maintain good oral hygiene by educating their
patients about the importance of brushing their teeth at least
every morning and every evening (Oral Health Working
Group 2004). If patients have difficulties chewing their food,
nurses should refer them to a dietitian for appropriate diet
modification. Patients should also be referred for diet
modification if they have loose or ill fitting dentures. All
signs and symptoms of dental problems should be docu-
mented and reported to the medical officer, so that a referral
to dental services can be made if necessary. Such signs and
symptoms include pain, swelling, discharge or a dry mouth
resistant to good hydration and oral lubrication solutions.
Standard 7: There is to be a dedicated nutritional care
resource nurse in every clinical setting (Clay 2000, Copeman
2000, Mathey et al. 2001, Hunt 2007).
A new role in each clinical setting was created to ensure
that patients receive the nursing support they require to meet
their nutritional needs by providing leadership in implement-
ing and evaluating this policy.
This role will be offered to a nurse (registered nurse,
enrolled nurse or assistant-in-nursing) who has a particular
interest in the process of continuous improvement of the
nutritional care of patients. The major priority of this role
will be to ensure that these standards for the nursing support
of patient nutrition are implemented and evaluated in each
clinical setting.
Suggested aspects of the new role includes the following:
undertaking regular assessment of the ward patients’ need for
assistance with meals; ensuring that the FOPM is instituted
and incorporated into the routine of the clinical setting and
supporting volunteers and family members who are assisting
patients at mealtime; and undertaking regular audits and
reporting results to all nurses in the clinical setting and other
members of the health care team as necessary.
Standard 8: Nurses, in conjunction with medical and allied
staff, are required to manage periods of prolonged and/or
repeated fasting effectively (Clay 2000, Horan & Coad 2000,
Hamilton et al. 2002, Lassen et al. 2005, Scott-Smith &
Greenhouse 2007, Waters 2007).
Patients who experience prolonged and repeated periods
of fasting rapidly become malnourished. The nurse is
323
D Jefferies et al.
required to identify patients who have been fasted and
ensure that the patient is given a meal as soon as they are
able to eat. Meals can be accessed by nurses if they are
ordered for the patient while the kitchen is open or, if
possible, tucker boxes can be provided for patients out of
hours. If a patient is nil-by-mouth for three days or more,
they must be referred to the dietitian. Tests and other
procedures should be scheduled to minimise the number of
fasts and/or period of fasting for the patient.
Stakeholder consultation, implementation and evaluation
Once the standards were developed they were considered by
many stakeholders including: all clinical directors, medical
directors, general managers and directors of nursing and
midwifery throughout the health service. As feedback was
received, it was considered by researchers and incorporated
into the policy as necessary. After the policy was ratified by
the nursing Clinical Practice Advisory Committee, it was sent
to the multidisciplinary Clinical Quality Council and Direc-
tors of Nursing and Midwifery Service for final endorsement
and sign-off.
An implementation and evaluation plan for the standards
are evolving and will involve an extensive education
programme, a supportive team for the ward-based nutrition
resource person and the evaluation of change through a
follow-up feeding audit. Patient satisfaction with meals data
(General Hospital Meal Service Survey) is obtained through
the continuous surveying undertaken by the dietetics depart-
ment. Ethics approval was gained from the health service’s
Human Research and Ethics Committee to evaluate the
effectiveness of the policy in changing practice.
Discussion
The nursing support of patient nutrition has been an area of
concern for the past decade and represents a problem of
international significance (Tierney 1996, Murray 2006, Keith
2008, Hassan et al. 2009). Research evidence identifies the
important role nurses play in ensuring adequate nutrition of
their patients (Agnew 2005, Copeman, Davis 2007, Simmons
& Schnelle 2006) and the urgent need for nursing care and
support of patient meals to become a priority for all nurses
worldwide (Dickinson et al. 2008).
Metasynthesis as a method
A methodology known as qualitative metasynthesis was used
to identify these strategies in the research evidence and
literature. This methodology was chosen because it focuses on
324  2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 317–330
the findings in literature rather than on the method, thereby
allowing the researchers and clinicians the freedom to
investigate a wide range of literature and research evidence
unconstrained by specific study types (Sandelowski et al.
1997). All literature selected, irrespective of design, was
assessed by various tools developed by the Joanna Briggs
Institute. The quality appraisal was an important step but did
not result in articles being discarded on the basis of quality
(Popay et al. 1998), rather it provides the reader with an
understanding of the quality of the literature on which the
standards are based. The next stage involved the extraction of
data so that researchers could identify major themes. Two
members of the review team read and re-read the research
material to identify themes consistently appearing in the
literature (Price 2009). Identified themes were presented to the
team for review and their inclusion in the policy was agreed by
consensus. The data extracted from the literature were coded
and recoded until eight major strategies were developed that
could be implemented in clinical areas. This method was
appropriate and allowed for the policy to emerge with key
themes. It is a method that is particularly suitable for nursing
topics that are likely to examine several interventions which
are less amenable or less likely to have randomised control
trials evidence available. These researchers have used the
method for another systematic review of nursing documenta-
tion (Jefferies et al. 2010a,b).
Consensus in the selection of themes in the team of a
majority of nursing and dietetics staff does result in some
more difficult aspects of potential policy being omitted or
some tempering of the recommendation. For example, the
suggestion that protected mealtimes should occur at all meals
immediately was much less palatable than seeking a gradual
introduction of the initiative starting with the midday meal
only.
A multidisciplinary team with consumers
Working collaboratively with the health service’s Department
of Nutrition and Dietetics and Food Services Department
ensured that all measures contained in the eight standards
were feasible and achievable. Professional boundaries were
identified and explored. In particular, the malnutrition
screening and the development of the nutritional care plan
were areas for clarification of roles and responsibilities.
Dietitians are responsible for the development of the nutri-
tional care plan, while nurses implement the plan. Dietitians
explained to nurses about the various roles and the processes
of the dietetics department and this experience was most
enlightening to most of the participants in the team. It
demonstrated the genesis of the confusion about the roles of
Review
dietitians, dietetics staff, food services staff and nurses in
supporting patient meals. Similarly, former patients engaged
as volunteers in feeding support programmes on wards
confirmed the feasibility of such concepts, but also confirmed
the experience of patients in our hospitals.
Barriers to implementation
Although many of the standards may reflect existing practices
in many national and international health services, several
aspects of this policy were contentious. First, team members
were concerned about how clinical routines would require
reorganisation to meet the eight standards. They also
recognised that this reorganisation would require the coop-
eration of the multidisciplinary team. If this cooperation was
not forthcoming it would be difficult to ensure that a patient’s
focus is on their meal if ward rounds, blood taking, cleaning
and other disturbances continued to distract the patient from
eating. The team was at pains to stress that it should not be
the nurse on the ward who is left to implement this section
of the policy. The solution to this issue was to involve the
multidisciplinary team in the consultation process. Consul-
tation with all disciplines was required if the policy was to be
implemented successfully.
Aspects of the policy, such as the focused mealtime,
reorganisation of mealtimes to assist with feeds, were felt by
some team members to be too impractical to implement
successfully. Fortuitously, it was discovered that many aspects
of the policy had been successfully implemented in various
clinical settings in the health service. Representatives from
these clinical settings were invited to speak to the team and
explain how they managed the various barriers to implemen-
tation. Many barriers were overcome when evidence was
produced to show that patients’ nutritional needs were greatly
improved when measures to assist them to eat were instituted.
New roles for nurses in the ward staff
Several writers identified the need for a dedicated nutritional
care resource nurse (Clay 2000, Copeman 2000, Mathey
et al. 2001, Hunt 2007). This provided an opportunity for a
new role for a registered, enrolled or assistant nurse in the
ward team. This new leadership role is pivotal to the success
of the policy implementation and could be considered by
managers in performance reviews of staff.
Future directions
The policy has been officially endorsed as a health service
policy and an implementation strategy has been devised.
 2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 317–330
The nurses’ role in nutritional care
Currently, three pilot sites have been selected and nutritional
care resource nurses from each clinical setting are being
identified. Once this process has been completed they will
conduct a baseline audit and will be supported by regular
forums to implement the policy. An online education
programme has been developed by the health service’s
education unit. The success of the policy will be evaluated
by audits and a patient satisfaction meal survey.
Limitations
There were several limitations to this metasynthesis of the
literature. First, although the population and interventions
were defined in the clinical question, no comparison group
was included. This was, in part, because of the lack of
randomised control trials available on this broad topic. It is
also unlikely that studies withholding nursing support for
patients’ nutrition will be undertaken, although studies using
quasi-experimental designs comparing current practice could
be conducted. Nonetheless, the level of evidence relating to
specific standards or recommendations, is generally low,
varying from I–IV level according to the NHMRC guidelines
(NHMRC 2008).
Conclusion
This policy has a wide ranging scope and the eight standards
could be implemented in any health care setting. While other
interventions such as nutrition supplements and changes to
the food service, for example, are also important components
of nutrition care, the eight standards represent an opportu-
nity to define the role of the nurse in this important area of
practice. In other contexts, such as education, the policy
provides valuable information and related research materials
for teaching registered nurses, enrolled nurses or nursing
assistants about hospital malnutrition and measures that can
be introduced in the clinical setting to reduce its incidence.
The policy also provides a starting point for managers to
consider how they should address the issue of hospital
malnutrition in their own health services. Again researchers
reiterate that mangers should adapt any recommendation or
standard from this policy to their own local condition and
suggest that this may be best achieved by instituting a wide
ranging and multidisciplinary consultation process.
Relevance to clinical practice
We have developed a comprehensive programme for the
implementation of the nurses’ role in supporting patient oral
nutrition and have described a rigorous method for developing
325
D Jefferies et al.

such a policy. Both the policy and the methods are transfer- their hard work developing the Minimum Standard for the
able to other international health settings. Although some Nursing Support of Oral Adult Patient Nutrition. The
readers may see this policy as a return to past practices, the members are Lucy Bird, Rachel Chapman, Henilieta Ha’un-
prevalence of hospital malnutrition highlights how important ga, Angela Lucas, Linda Marov, Ann-Margaret Miller, Chris
nutrition is for the health and well-being of patients. In this Nocera, Wayne Phillips, Carolyn Wildbore, Kylie Wright.
instance, the researchers believe that it is a positive feature of
nursing to identify when changes may have inadvertently
Contributions
distracted nurses from important issues, such as patients’
nutritional well-being. In 1861, Florence Nightingale identi- Study design: MJ, DJ, JR; data collection and analysis: DJ,
fied the importance of the nurse’s role in nutrition care when MJ, JR and manuscript preparation: DJ, MJ, JR.
she wrote ‘Every careful observer of the sick will agree in this,
that thousands of patients are annually starved in the midst of
Conflict of interest
plenty, from want of attention to the ways which alone make
it possible for them to take food’ (Sketkowicz 1992). This All authors declare that there is no conflict of interest.
policy, having defined the role of nursing in nutritional care,
demonstrates how nutrition and the management of meal-
Funding statement
times can return to the forefront of patient care.
This research has received no specific grant from any funding
agency in the public, commercial or not-for-profit sectors.
Acknowledgements
The authors would like to thank all the members of the
Clinical Development Group for Patient Nutrition for all

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328  2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 317–330
Review The nurses’ role in nutritional care

Appendix 1

Clinical development group for patient meals data extraction tool

Name/ code of reviewer________________________________________________

1. Study reference
Author_____________________________________________________________________

Title_______________________________________________________________________
Journal_____________________________________________________________________
Year_______________________________________________________________________

Vol_____________________Issue_____________Page numbers_____________________
Source_____________________________________________________________________

2. Verification of study eligibility for inclusion

• What research design is used in this study?
_____________________________________________________________________
______

• What is the stated aim of the study?

_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
________________________

• What are the inclusion criteria?

_____________________________________________________________________
_____________________________________________________________________
____________

• What are the exclusion criteria?

_____________________________________________________________________
_____________________________________________________________________
____________

• What level of evidence should be given to this study?

___________________________

3. Description of participants
• Number of participants N =
• Gender of participants

Male N= Female N=

• Age range of participants__________________________________

• Setting of study (circle most appropriate)
Acute hospital Long term hospital Residential care: Other
nursing home
4. Relationship to clinical question (circle most appropriate)
Access to food Supportive Repeated and prolonged n/a
mealtime periods of NBM
environment

 2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 317–330 329
D Jefferies et al.

5. Intervention
• Access to food
What innovation was tested to make food more accessible to patients?
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
__________________

Patient group required assistance Yes No n/a

Reason for assistance noted Yes No n/a

Who provided assistance Nurse Other n/a

• Supportive meal time

What innovation was tested to make mealtimes more conducive to increasing the
nutritional status of the patient?
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
__________________

6. Type of strategy

Environmental change Yes No n/a

Change in clinical routine Yes No n/a

Increased nursing focus on meal times Yes No n/a

• Repeated and prolonged periods of NBM

What innovation was tested to prevent undernourishment in patients who experienced
prolonged and repeated periods of Nil by Mouth?
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
__________________
• Number of patients lost to study N =
Please identify reason
_____________________________________________________________________
_____________________________________________________________________
____________

7. Outcome
What conclusions did researchers draw from the results?

330  2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 317–330
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Users should refer to the original published version of the material.