I was so surprised to be nominated for the BJN Nutrition Nurse of the Year Award and absolutely delighted to have won. I have worked in the Nutrition Support Team at University Hospitals of Leicester NHS Trust since 2016. Starting as a nutrition nurse, I then became senior nutrition nurse and I am now specialty clinical lead for the team.
I have spent a large part of my career in gastroenterology nursing, first as a staff nurse on a gastro ward, working in inflammatory bowel disease nursing – I always thought that gastro nursing would have my heart. Nutrition as a specialty allows me to continue to nurse patients with gastrointestinal problems, but it has also allowed me to learn a great deal about other specialties and how nutrition can affect so many conditions.
A variable role
I am grateful that my role and the role of the nutrition nurses in the team are so variable, which reflects the variety of areas covered by the role around the UK. Some nutrition nurses focus on enteral nutrition, others solely on inpatient or home parenteral nutrition. But, in Leicester, we do it all! This has its challenges but it means that staff are kept on their toes. I am grateful that the team can adapt to working in a variety of areas. I am lucky to have three nurses and three dietitians in the team, supported by a wider team of gastroenterologists, surgeons, biochemists and microbiologists. We support patients who receive parenteral nutrition as an inpatient and have a cohort of patients in the community who require home parenteral nutrition.
In addition, the nutrition nurses also assess, review and prepare patients for using enteral feeding tubes, which may be short- or long-term. These patients are mainly in hospital. However, we also see those with long-term conditions in the community who may need enteral feeding tubes. We work closely with our gastroenterology and radiology colleagues to make sure the patient pathway for both inpatients and outpatients is seamless and patient focused.
One of the early changes made was to change the type of percutaneous endoscopic gastrostomy (PEG) tube we used for patients undergoing treatment for head and neck cancer. Working alongside dietitians, a radiographer, gastroenterologist and physician's associate, we changed to using traction-removable PEG tubes. This meant that the patients only had to have one endoscopy to place the PEG and it could be removed by the nutrition nurses post-treatment. This change has freed up approximately 60 endoscopy appointments per year, as well as ensuring the patients have at least one less procedure during their treatment. This change has been well received by patients who, although find having the PEG removed unpleasant, would much prefer that than having a further endoscopy.
Teaching
A large part of our role is staff training and teaching. We run monthly parenteral nutrition study days where qualified nurses come to learn how to care for patients receiving parenteral nutrition. When I first joined the team, these sessions were all-day events, with a theory session in the morning and a practical session in the afternoon. Nurses learnt to connect and disconnect parenteral nutrition as well as take blood cultures from central lines dedicated to feeding. We quickly realised that this seemed drawn out and staff did not engage as much as we wanted them to by the end of the day. The day was then redesigned. We put together a pre-reading pack with all the necessary information needed and this is sent out to the staff booked to attend. They then get 10 days to read and digest the information before attending a practical 4-hour session. At the beginning of the session, the attendees do a short assessment to ensure they understand the basics, then we talk around the questions to assure they understand the risks as well as the benefits of parenteral nutrition. The practical session can then begin and we can focus on ensuring staff can administer parenteral nutrition safely.
‘Some nutrition nurses focus on enteral nutrition, others solely on inpatient or home parenteral nutrition. But, in Leicester, we do it all!’
This change in practice has gone down well with attendees and feedback has improved. It has also meant we can run two sessions per day, doubling the number of staff trained. To date, this has had no impact on the Trust's catheter-related bloodstream infection rates.
The nutrition nurses also provide competency-based assessments on nasogastric tube insertion, and deliver bespoke teaching sessions to dietitians, postgraduate doctors in training and emergency department (ED) staff. Staff in clinical areas are encouraged to contact the team if they feel there is a particular area of nutrition support that the staff would benefit from so we can tailor the teaching to suit the needs of the group. This may be troubleshooting problems with PEG or radiologically inserted gastrostomy (RIG) tubes or providing support to those areas that have many patients receiving parenteral nutrition.
When I started in the senior nutrition nurse role I was tasked with reinstating the nutrition link nurse study days. Other specialties have successfully had link nurses across the Trust for many years but, unfortunately, lack of staff meant the nutrition link days were withdrawn. As teaching sessions were being reinstated during the COVID-19 recovery, it was decided it would be a good time to relaunch the programme. We launched back in 2021 and after a huge amount of planning and the odd cancellation, the days have been a big success. It provides the opportunity to not only promote our role but gives nurses, healthcare assistants and nursing associates time to focus and remember how important nutrition is to the care of patients. A focus for the day is always included to provide variety. We invite outside speakers to attend. So far we have had a learning disability nurse to discuss nutrition in people with a learning disability and how they can be supported, as well as the head of nursing, who leads on nutrition for the Trust, to promote and encourage the role of the link nurse. In the upcoming sessions we have a focus on mouth care and its impact on nutrition with talks from a speech and language therapist and the trust dental nurse.
Adapting to change
The COVID-19 pandemic did not have many positives. It was the most difficult time in the NHS and I'm sure that recovery will take many times longer than expected. The one thing that it did show, however, was how adaptable and amenable to change the NHS can be. Changes happened in days that would have taken months, if not years, if the pandemic had not happened. Although not all changes remained, I realised the focus of keeping patients away from the ‘front door’ should remain. Our patients with enteral feeding tubes and those on parenteral nutrition are often vulnerable. During the pandemic they needed to be kept away from hospital unless absolutely necessary and now, with such long waits in EDs waiting for a service that could be provided by us elsewhere, there was an obvious way of improving the patient experience.
We work alongside the home enteral nutrition service in the community that provides support to patients with enteral feeding tubes. In the past, if patients had problems with their feeding tubes that could not be resolved at home, they would be sent to the ED. Realising we could reduce these attendances and often prevent admissions and invasive procedures, we started providing home visits to those unable or deemed too vulnerable to come to hospital. For those patients who could make their own way to hospital we developed a pathway with the GP assessment unit, which allowed us to book a clinic room for us to see and treat our patients without needing to attend the ED, be admitted or need an invasive procedure. On the (thankfully rare) occasions that we are unable to resolve the issues we are able to get radiology or endoscopy staff to respond quickly so patients do not have a long wait. This has drastically reduced the number of our patients needing to come to hospital via the ED and now the pathway with the GP assessment unit has developed to include our home parenteral nutrition patients. We can now see them quickly if line problems develop or they require a review in between their usual follow-up appointments.
Future plans
So, what's next? I was asked recently how I thought I saw my role progressing now I have won the award. It was a tough question. I love my job and hope to continue in the role for a long time. Not wanting to rest on my laurels, however, I was recently invited to join the National Nutrition Nurses Group (NNNG) as part of their committee. It's been a delight to connect with a group of nurses so focused on improving the nutritional care of patients. It is a great forum in which to share ideas, ask questions and trouble shoot issues with other nutrition nurses around the UK. I look forward to being able to push the importance of good nutritional care nationally to the forefront as its impact is powerful and wide reaching.
Finally, I would not have won this award if it wasn't for the fantastic team I work with (and not just because they nominated me!). They have supported and worked alongside me to make changes to the way we do our job, to change pathways, improve teaching and training and, most importantly, provide exceptional care to our patients.