Changing the culture around hospital-based nutrition

Sheffield Teaching Hospitals NHS Foundation Trust (STH) is a large trust that provides more than two million inpatient and outpatient care contacts annually across five hospital sites and various community settings. It employs more than 5000 nursing, midwifery and health visiting staff with over 2000 inpatient beds across the sites and around 37 000 meals served each week (Sheffield Teaching Hospitals NHS Foundation Trust, 2022). The Trust is one of only a handful that produce their own food for patients, staff and visitors, and it is recognised as an exemplar by the Hospital Caterers Association (Hospital Caterers Association, 2023).

The Report of the Independent Review of NHS Hospital Food (Department of Health and Social Care (DHSC), 2020) stated that, when a patient is in hospital, food is as essential as medicine and therapies. Malnutrition in hospital settings has negative effects on recovery, morbidity and mortality; Schuetz et al (2021) discussed the development of nutritional interventions that reverse the effect of disease-related malnutrition. There is a direct correlation between good nutritional care and physical and mental wellbeing – and, for food to be therapeutic, it has to be nutritious, tasty and appropriate for the patient (DHSC, 2020). Consequently, it is crucial that healthcare settings ensure the availability of a range of therapeutic diets, including texture-modified diets. Patients in acute healthcare settings have complex requirements and hospital food should reflect this (DHSC, 2020).

Texture modification of nutrition and hydration is used when there is a risk of choking and aspiration on ordinary food. The International Dysphagia Diet Standardisation Initiative (IDDSI) (2023) devised a Framework that provides common descriptors for food textures and drink thicknesses to improve safety for patients with swallowing difficulties across eight levels (Figure 1).

At STH, around 76% of patient meals are freshly made on-site, which means that the responsiveness and visibility of catering teams impacts positively on the patient experience (see feedback from patients and families below). The catering team implements a 2-week ward-based menu cycle, providing 13 alternative menus, which include catering for a variety of special diets, as well as all modified and allergy-aware diets. Work has been ongoing to improve the patients' meal choices, making food more nutritious and varied. The Trust is very proud of the close working between ward teams and the catering department to provide patients with better food choices.

Deaths due to practices around nutrition and hydration have been recorded at hospital trusts (BBC News, 2022a; 2022b). In 2019, a serious incident occurred at STH, resulting in a patient's death following a swallowing incident. This led to a serious incident investigation, and there was also a coroner's inquest — there was learning to be addressed, particularly around communication about patients' swallowing needs. As a result, a working group was established within the Trust, consisting of catering staff, nurses, medical staff, speech and language therapists, information technology and dietetics, overseen by the Trust's nutrition steering group. This led to the development of key actions, designed to improve inpatient safety and support staff within their roles. These actions were:

• Implementation of a standard operating procedure for mealtimes that includes the need for a pre-meal safety ‘pause’
• Development of an electronic communication icon (‘knife and fork’) to be used from the emergency department (ED) onward for use on the Trust's electronic whiteboard
• Creation of job-specific mealtime safety training for those involved in providing and delivering meals
• Use of bedside posters outlining specific dietary requirements in line with the IDDSI Framework (2023).

In addition, a method of monitoring dysphagia incidents was established, and the role of Lead Educator for Nutrition was introduced on a fixed-term basis. The focus of the role has been to underpin the proposed actions, provide ward-level training and support for staff, ensure the objectives of the project were reviewed and that quality improvement changes were implemented. The Lead Educator has supported not only the implementation, monitoring and audit of the actions, but also developed and led on other opportunities to engage staff. These have included the development of Nutrition Champions across every single inpatient ward and the creation of a newsletter providing key nutrition information, as well as bespoke work with individual areas following incident feedback.

This article explains the changes implemented across the Trust and how the changes have been embedded.

Purpose

The aim was to develop a wide, multifactorial collaborative approach to reduce the risk of such incidents recurring following a serious event.

Implementation

The standard operating procedure set out the actions that should be taken around the task of providing meals to patients and the roles of the team, and included the need for a pre-meal ‘pause’, initially named a ‘huddle’. Subsequently, the Trust implemented generic safety huddles, which are sometimes known as Nightingale huddles (Montague et al, 2019). To avoid confusion, it was decided that the pre-meal activity would be referred to as the ‘pre-meal pause’. This is a short event before every meal service involving those who will be giving out the patient meals, led by a member of staff. Based on the recommendations of the Report of the Independent Review of NHS Hospital Food (DHSC, 2020), the ‘pauses’ are used to:

• Share up-to-date information on all patients, including swallowing status and any changes, such as patients who are nil by mouth
• Inform the team about patient histories of allergic reactions
• Emphasise whole-team involvement in food and drink services
• Share information on any modified diets or fluids.

Capturing nutrition and hydration requirements

In addition to an electronic records system, STH uses an electronic whiteboard (e-whiteboard) from which data can be printed on to the patient handover sheet. Staff access and update this resource using a personal login or smartcard, to maintain confidentiality. A ‘knife and fork’ icon was developed for use on the board: this indicates whether a patient has a modified diet or feeding needs, allows for free text and includes a colour-coded level of risk (red, amber, green). It flashes when it has not been completed, thereby alerting staff.

The e-whiteboard system is checked and updated regularly throughout a patient's stay. It is vital to ensure that the information it contains is correct after pre-meal pauses, before a patient transfers and also when colleagues such as speech and language staff review and advise as part of the inpatient stay. The e-whiteboard has a built-in audit trail, so any new information and the person who added the data are recorded.

Staff education and engagement

As part of ongoing support for nutrition and hydration practices at STH, a meal safety e-learning package was developed for all ward staff within the multidisciplinary team who support patients with eating and drinking, which was designated as job-specific essential training (JSET). The 35-minute e-learning package consists of four videos: these cover the IDDSI (2023) Framework, the serious incident of choking, the ward meal service standard operating procedure (including the pre-meal pause), and instructions on how to handle hot items safely as part of the patient meal service. The package reiterates the importance of multidisciplinary working as part of teaching, training and practice around nutrition and hydration (Green, 2023).

The e-learning is held on an online Trust Personal Achievement and Learning Management System (PALMS), which records all training. It provides managers with oversight of who has completed the e-learning package: new staff are expected to complete it on arrival at STH, and existing staff to take a refresher every 3 years. Students on placement with the Trust are also encouraged to view the videos as part of their placement experience, consolidating the teaching they have received in partner universities.

Use of bedside posters

Kim et al (2022) and Anantapong et al (2022) have both highlighted that in hospitals communication about patients' nutrition and hydration needs is not always at optimal level.

Another key action was the development of bedside patient information: what had previously been a handwritten system was changed to widely available bedside posters, which reflect each IDDSI level and the type of food the patient can safely eat. The posters are located behind the bedheads, and enable information-sharing with relatives and visitors.

Role of the Lead Educator for Nutrition

A fixed-term post of Lead Educator for Nutrition was created and has since been extended. The focus of this role is to support the work already put in place following the serious incident. The remit of the postholder includes working closely with ward teams to help them understand the background to the actions implemented and to:

• Improve usage of the ‘knife and fork’ icon on the e-whiteboard
• Improve uptake and use of the new bedside signage
• Over a period of 12 months, train (face to face) 380 nurses and allied health professionals across the Trust about pre-meal pauses
• Improve the uptake of Trust-wide e-learning
• Increase awareness of knowledge/compliance around the nutrition and hydration needs of patients
• Adopt a Trust-wide approach to nutrition and hydration safety
• Improve the patient mealtime experience
• Increase communication between staff about patients' dietary and fluids needs
• Examine incident reporting (Datix) to highlight nutrition and hydration issues/events.

The Lead Educator for Nutrition helped introduce an approach of ‘on-the-job learning/discussion’, enabling staff to learn from the incident and other real-life examples, to relate these events to their work and encourage them to consider the care they would expect for themselves or their families. In this way, the role reinforces the good nutritional care practices set out in Pownall and Taylor (2017), which centre on sharing information and reinforcing the safety implications of nutrition and hydration practices, including food consistency, the use of thickeners, staff responsibilities, and patients' risks of choking and suffocation.

Early changes

Patients and patient safety are at the heart of all the interventions/actions that have been undertaken. In addition, it was felt that the changes offered an opportunity for all staff, regardless of whether they are involved in direct or indirect patient care, to become aware of the value of good nutrition and hydration.

Within the organisation, the role of ward/unit-based Nutritional Champions has been in existence for many years. Those recruited to the role are from across all staff groups and it was felt that the Lead Educator would help further their role by examining which areas of the Trust had a champion, check that the role was still being undertaken, support them and train those new to the role.

A series of varied training days helped to inform the nutritional champions, particularly around the important safety work. The Lead Educator for Nutrition also examined ways that could support ward areas with meal ordering, serving meals, stock rotation to reduce waste, and promoting the ward meal service standard operating procedure.

As part of enhancing the visibility of the role, regular visits to clinical areas, talking to staff and updating them on new ways of working have been paramount. To complement this activity, a monthly newsletter, the Nutrition and Hydration Times, was circulated via email, keeping staff up to date with current information and showcasing good practices. Informal feedback on the newsletter has been positive.

Historically, the ED had not used the e-whiteboard system – it was felt that nutrition and hydration assessments at the start of a patient's admission could be improved by introducing this at first contact. This was a big change in practice, which required investment in resources of an appropriate e-whiteboard, staff training and collaboration, namely:

• The involvement of the ED senior leadership team in all discussions
• The Lead Educator attending handovers to promote good nutrition and hydration practices with all staff
• Recruiting new Nutrition Champions in the area to reflect other inpatient areas.

Audit findings

The changes made to practice supported by the Lead Educator for Nutrition had a positive impact on findings as the subsequent cycles of audit have revealed. There has been further work to embed the audit tool into a 6-monthly hydration and nutrition audit within an electronic clinical assurance tool used across STH.

Nutrition Champions

Prior to the appointment of the Lead Educator for Nutrition there were 28 active Nutrition Champions. Since the start of 2022, 115 new champions have been added, increasing the Trust-wide total to 143. Both new and existing Nutrition Champions have continued in post, accessing training and support to help them act as a useful resource across the clinical areas. The increase in the number of Nutrition Champions has meant that awareness of safe nutrition and hydration practices has increased across the Trust.

Audits

The clinical audits were registered with the Trust Clinical Effectiveness Unit, with four actions audited:

• Nutrition Champion in place in each ward
• Pre-meal pause compliance
• ‘Knife and fork’ e-whiteboard compliance
• Appropriate use of bedside signage.

The findings of audits undertaken between January 2022 and March 2023 are presented in Table 1.

The reduction in compliance with pre-meal pause in March 2023 reflected the work remaining to be done with ward teams on this element, particularly around clarification of the ‘pause’ in relation to the Trust-wide safety huddles that had been embedded. An audit of this standard in February 2024 demonstrated an increase in compliance to 85%.

Since the audit carried out in 2023, additional interventions have been implemented to support teams and offer assurance of compliance, including the introduction of a ‘power of 3’ approach. This involves members of staff from senior nursing, catering and dietetics being involved in the mealtime service on an identified ward each month to observe practice and share ideas for improving safety, the patient experience and reducing food wastage.

Reporting of incidents

The Trust's incident reporting system was developed so that events relating to dysphagia could be identified easily and monitored monthly, and in order that the themes and clearing could be addressed.

The results are shared with specific areas each month and also in a quarterly report prepared for senior nurses and the STH Nutritional Steering Group.

e-whiteboard activities

The use of the ‘knife and fork’ icon has improved across STH, particularly in areas that have, historically, not used the e-whiteboard. Wards that have not improved as much as others are being offered extra support and training. The ED, which previously did not use an e-whiteboard, is now also trained in its use to record patients' nutritional needs and status using the ‘knife and fork’ icon.

Staff training

As identified in regular Trust-wide audits, compliance with meal delivery training has been above 90% (Table 1). In addition, the number of staff trained in 1 year has surpassed 4341 nurses and allied health professionals and has added to wider organisational learning. The training is supplemented by posters, information boards and the Nutrition and Hydration Times newsletter, highlighting good practices. The training is based on real-life experiences to make it more realistic and relevant for clinical staff. Adopting a supportive, non-punitive approach has helped increase awareness and staff engagement, as well as improving outcomes for patients. This is reinforced by encouraging staff to consider nutrition and hydration as important not only for patient comfort, but also for longer term patient safety (Brennan et al, 2023; Green, 2023).

The training also highlights everyone involved in the nutrition and hydration process, and ensures that all staff are aware of the food production process from start to delivery to the wards, which has increased understanding of others' roles and collaborative working (DHSC, 2020).

The Lead Educator for Nutrition role has empowered staff to support each other and given them confidence to speak to colleagues and relatives about the importance of the nutrition and hydration safety measures currently in place.

Changes in practice

In adopting this model, STH has demonstrated its commitment to quality improvement to ensuring that actions are in place to prevent incidents recurring

Feedback from patients and families

Anecdotal feedback from patients and family members has been collated and relayed to staff to reinforce good practices, patient feedback has included:

‘I obviously worry about having to go to hospital, but the one thing I can count on is that the food is lovely.’

‘I was in hospital over Christmas, and I have to be honest, the Christmas dinner was one of the best I have had.’

Comments such as these have contributed to staff recognising the importance of good nutrition and hydration.

Conclusion

Implementing a comprehensive, collaborative approach involving teams from catering, information technology, governance, facilities, nursing and allied health professionals, has enabled STH to improve the care of patients requiring nutrition and hydration support.

Staff engagement around nutrition and hydration has improved with the introduction of the Lead Educator for Nutrition, a visible staff member who is available as a resource on nutrition and hydration issues and who has a regular physical presence across inpatient areas. In addition, information is reinforced through the use of posters, information boards and via the Nutrition and Hydration Times newsletter.

The work is fully embedded to promote and maintain patient and staff safety. It is thought that the work has contributed to an increase in staff confidence, and knowledge and skills around safer nutrition and hydration. The number of staff groups involved in helping colleagues to recognise the importance of good nutrition and hydration practices and in disseminating awareness of the issues has widened to include those working in facilities, procurement and materials management teams.

The serious incident that prompted these changes has not been forgotten – and is a key driver of the work that has been undertaken. Nutrition and hydration safety remains a priority, with momentum growing in terms of wider discussion, activities and change management.

Anecdotal feedback from patients and family members has been used in staff training. It has ensured that staff are now more aware of the huge impact that nutrition and hydration have on recovery and on the length of hospital stay, as well as how they affect mental health and wellbeing. Good nutrition and hydration also important in reducing health risks such as falls, infections and malnutrition.

At STH, nutrition and hydration safety, and patient experience, remain paramount, with collaboration across staff disciplines to ensure the delivery of optimum nutrition and hydration to all patients.

KEY POINTS

• Good nutrition and hydration are paramount in promoting healing and recovery
• Research supports the importance of good nutrition, but is limited around communication and human factors within mealtime services
• Greater emphasis on the patient experience in terms of nutrition and hydration can bring about positive clinical changes
• Using a holistic, Trust-wide approach to raise awareness of all issues related to nutrition and hydration, including food production, distribution and patient delivery, can bring about positive changes

CPD reflective questions

• What steps has your organisation taken to ensure mealtime safety?
• How much do you know about the production methods for the food that your patients receive?
• Does your workplace have similar roles to that of Nutrition Champion?
• At your organisation, is there a postholder with responsibility to lead on good nutrition and hydration practices?
• In your practice, reflect on what do you do well in terms of good nutrition and hydration