The effects of nutrition education on professionals' practice ... - Nature

European Journal of Clinical Nutrition (2007) 61, 1226–1232

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ORIGINAL ARTICLE

The effects of nutrition education on professionals’ practice and on the nutrition of aged residents in dementia wards MH Suominen1, SM Kivisto1 and KH Pitkala1,2 1 The Central Union for the Welfare of the Aged, Helsinki, Finland and 2Department of General Practice and Primary Health Care; University of Helsinki, Helsinki University Hospital, Unit of General Practice, Helsinki, Finland

Objective: (1) To develop nutrition education for professionals in dementia wards. (2) To evaluate the effects of education and determine the outcome of the education on the nutrition of aged residents. Design: Educational intervention with before and after measurements. Both the learning outcomes of the professionals and the effect on the aged residents were assessed. Setting: Nursing home residents in dementia wards and professionals. Subjects and methods: Twenty-eight professionals completed half-structured feedback questionnaires that were analysed quantitatively and qualitatively. Assessments of 21 residents’ energy and nutrient intake and 19 residents’ nutritional status with the MNA before and after the education. Results: The learning process included six half-day training sessions. The professionals learned to use and interpret the MNA and detailed food diaries. Keeping the food diaries and analysing them in multi-professional teams was experienced as the main source for learning insights. After calculating the diets and discussing with others, professionals felt easier about responding to the nutritional problems of the residents. After 1 year, the residents’ mean energy intake had increased 21% from 1230 to 1487 kcal. Before the education none but after 1 year 16% had a good nutritional status according to the MNA. Conclusions: We used the constructive learning theory to educate professionals. Keeping and analysing food diaries and reflecting on nutritional issues in small group discussions were effective training methods for professionals. The education had positive effects on the nutrition of the residents in dementia wards.

European Journal of Clinical Nutrition (2007) 61, 1226–1232; doi:10.1038/sj.ejcn.1602639; published online 24 January 2007 Keywords: nursing home resident; dementia ward; malnutrition; nutrition care; MNA; food diary; education; constructive learning theory

Introduction Malnutrition, low body mass index and unintentional weight loss are common problems among the elderly and nursing home residents (Mattila et al., 1986; Beck and Ovesen 1998; Saletti et al., 2000; Suominen et al., 2005), who typically have many illnesses and clinical problems associated with malnu-

Correspondence: MH Suominen, The Central Union for the Welfare of the Aged, Malmin kauppatie 26, FIN-00700 Helsinki, Finland. E-mail: [email protected] Guarantor: MH Suominen. Contributors: MHS, SMK and KHP have all participated in planning and organizing the study and writing the article. Received 26 July 2006; revised 30 November 2006; accepted 30 November 2006; published online 24 January 2007

trition, for example, dementia, depression, stroke, falls and hip factures (Morley and Kraenzle, 1994; Compan et al., 1999). Good nutritional status is essential for aged residents because of its importance in maintaining a functional status (Crogan and Pasvogel, 2003) and preventing illnesses such as infections and pressure ulcers (Lesourd, 1997; Frias Soriano et al., 2004). Malnutrition seems to be widely underdiagnosed and undertreated among nursing home residents (Abbasi and Rudman, 1993). Nutrition treatment seems to reduce mortality and have an effect on preserving the functional capacity of elderly persons with multiple disorders (Akner and Cederholm, 2001; Milne et al., 2006). Some studies with enriched food have positive outcomes in terms of energy intake (Barton et al., 2000; Lorefa¨lt et al., 2005) and weight gain as well as physical activity (Olin et al., 1996).

Effects of nutrition education in dementia wards MH Suominen et al

1227 Low energy intake is common among aged nursing home residents, and nurses often significantly overestimate residents’ actual food intake (Pokrywka et al., 1997; Simmons and Reuben, 2000; Westergren et al., 2002; Suominen et al., 2004). Professionals – both nurses and food service personnel – need more education about the nutritional problems of older people in order to be better able to understand and respond to the individual nutritional needs of aged residents (Pokrywka et al., 1997; Barton et al., 2000; Crogan et al., 2001; Suominen et al., 2004). Some nutritional education program studies have shown promising results in increasing the nutritional knowledge among professionals and in preventing weight loss and cognitive decline in Alzheimer’s disease among residents (Faxen-Irving et al., 1999; Riviere et al., 2001). We developed an educational program for professionals (nurses and food service personnel) in dementia wards to improve their skills of assessing the nutrition of aged residents and of responding to the problems in their nutrition. The aims of this study were to evaluate the effectiveness of the educational program on the learning of the professionals, to clarify its impact on the nutrition of aged residents.

Methods Setting and participants The education was directed to 28 professionals in five nursing homes in various areas of Finland. Of the professionals, 23 were nurses and five were food service personnel. In wards specialized in dementia care in one of these nursing homes, 21 residents’ energy and nutrient intake was calculated from food diaries, 20 residents’ nutritional status was assessed, and 20 residents’ BMIs were calculated before the education in January and February 2003 and after the education in January and February 2004. The data of the MNA and BMI for 19 residents were available both before and after the education. All the studied residents were females and their mean age was 85 years. The assessments levels have been described in Figure 1. Education for professionals

Satisfaction with training

Learning outcomes

Changes in knowledge

The feedback from the professionals Figure 1

Educational process The aim of the nutrition education was to facilitate the professionals’ understanding of aged nursing home residents’ nutritional problems and to internalize the aims of good nutritional care. We wanted them to be able to intervene in the nutritional problems of malnourished residents and to enhance a good nutritional status for the residents. The educational process took place in five nursing homes and lasted for 6 months. The education included six training sessions (each 2–3 h) with lectures, small group discussions, homework tasks and personal feedback (Figure 2). In the beginning, the nutritionist (MHS) motivated the professionals with a lecture. She taught to the nurses and food service personnel about the facts and problems of nutrition and the nutritional assessment of aged people. She instructed the nurses to complete the Mini Nutritional Assessment test (MNA) (Guigoz et al., 2002) in a group session and also with the help of a video tape. Between the first and second sessions, the participants assessed their residents with the MNA test. In the second session, the results of the MNA tests were analysed in small groups. With the aid of the observations of the residents and the results of their MNA tests, the professionals decided whose food consumption they would measure over three consecutive days. The nutritionist showed how to weigh the foods, keep the food diaries and use the computer-based food record program AIVO (www.aivo.fi). Between the second and the third sessions, the professionals weighed all the residents’ food before and the leftovers after eating with an electronic scale. The food diaries were analysed by the food record program AIVO, after which the results of the energy and nutrient intake were available for individuals and the entire group. The energy contents of the recipes were calculated as they were prepared for meals by the food service. In the third and fourth sessions, the participants and the nutritionist discussed the results of the MNA tests and food diaries in small groups. The most important topics in the discussions were the residents’ BMIs, possible weight loss, illnesses, problems in eating, special diets, energy and protein intake on the basis of the food diaries, the selection of foods and their nutritional value. The professionals and the nutritionist discussed their observations, the residents’ favourite foods, and the mealtime schedule. After the discussion, the professionals planned adjusted individual changes to the residents’ diets. The changes in practice

The effects of the professionals’ education on residents’ nutrition

Measuring the BMI, MNA, energy and protein intake of the residents after the educational intervention

Evaluating the outcome levels of nutrition education.

European Journal of Clinical Nutrition


1228 Session 1. Lecture on problems of older people’s nutrition, assessment of the nutritional status by the MNA and measurement of food consumption and nutrient intake

Session 6. Discussing outcomes of the nutritional intervention

Homework: Follow-up with the MNA, measuring food consumption when needed

Learning methods: Teamwork

Homework: Applying the MNA to the residents

Learning by doing Session 5. Discussing problems in applying nutritional assessments and interventions

Small group discussion Personal feedback Studying literature

Session 2. Analysing the MNA results and recognising nutritional problems. Selecting the residents to be assessed with food diaries

Lectures Homework: Measuring the food consumption of the residents

Homework: Applying the planned diets to the residents Session 3-4. Analysing energy and nutrient intake and comparing them to recommendations. Planning changes in the residents’diets Figure 2

Educational process: incorporating nutrition as a part of the good care of nursing home residents.

Between the third and fifth sessions, the professionals made practical changes to the residents’ diets. The main idea was to make the changes to their diets with the help of natural foodstuffs instead of nutritional supplements. For instance, the milk was changed to contain more fat. More fat was also added to porridge and sandwiches. Snacks and evening meals were added to the residents’ diets. The intake of protein was discussed, and the suggestions of ways to add protein content into the resident’s diets were implemented. In the fifth session, the problems related to applying the new diets were discussed with the nutritionist. The multi-professional team, including the nurses and food service personnel, participated in this discussion. After the fifth session, the professionals continued to apply the new diets, following up on the residents with the MNA and measuring food consumption if needed. After 6 months, the outcomes of the educational intervention were discussed in the sixth session. Small group discussion, teamwork and discussions with the nutritionist were used in learning to respond individually to the problems in the residents’ nutrition. The professionals were also able to study literature on nutrition available to them so that they could apply the information individually to the nursing home residents.

Measurements and data analysis The nurses assessed the residents’ nutritional status with the MNA test (Guigoz et al., 2002). The MNA is a simple and wellEuropean Journal of Clinical Nutrition

validated scale to estimate the nutritional status of aged individuals, and it has been used in numerous studies among aged residents living in various settings (Guigoz et al., 2002). According to the MNA, poor nutritional status has been associated with impaired functioning, increased in-hospital mortality, a higher rate of discharge to nursing homes, a longer length of stay in hospitals, and also with residents eating only a little from an offered food portion (Van Nes et al., 2001; Suominen et al., 2005). The residents’ height and weight were measured at the baseline and at one year, and body mass index (BMI) was calculated, as described on the website http://www.mna-elderly.com/clinical-practice.htm. The professionals in one nursing home determined the food consumption of the residents (N ¼ 21) in dementia wards with a precise weighing method before and after the education in January and February 2003 and in January and February 2004. The time between the measurements was 1 year. The professionals weighed all the food before eating and the leftovers after eating over 3 days. Any additional snacks during the study period were investigated by making an inventory of all the food the elderly residents had in their rooms before and after the study days. In addition, the nurses asked whether relatives had given the residents something to eat when meeting them. The food diaries were analysed by the AIVO program (www.aivo.fi). After the educational process, the professionals completed half-structured questionnaires regarding their experience of the education. The questions consisted of views on their own


1229 learning and the usefulness of the various methods that were used during the training. The professionals’ feedback questionnaire consisted both open and structured questions about which learning methods were experienced as the most helpful. The usefulness of the various learning methods was evaluated by a Likert scale (‘not at all’, ‘very little’, ‘something’, ‘quite much’, ‘very much’). The questionnaire also asked what the barriers to changes in practice were in the nutrition care of the residents. The answers to the questionnaires were analysed both quantitatively and qualitatively. The differences in categorical variables between pre- versus postintervention were tested by a w2 test and for normally distributed continuous variables by Student’s t-test. The results were considered as statistically significant at the level Pp0.05.

Results The mean age of the residents was 85 years (range 62–95), and they were all female. All residents suffered from moderate or severe dementia, and lived permanently in a dementia unit. Before the professionals’ education, the energy intake of the residents was on average 1230 kcal/day, and after the education 1487 kcal/day (Pp0.001). The mean energy intake increased 21%. Before the education 42.9% of the residents (N ¼ 9) but after the education only 9.5% of the residents (N ¼ 2) received less than 1200 kcal/day from their diets. Before the education, none of the residents but after the education 29% of them (N ¼ 6) received the minimum recommended energy intake (1570 kcal) for this age group (Table 1). The residents’ mean intake of protein

increased from 50.4 g/day to 60.9 g/day (P ¼ 0.006). The intake of nutrients also increased, for instance, the intake of calcium increased from 896 mg/day to 1099 mg/day (P ¼ 0.004) and the intake of folic acid increased from 177 mg/day to 219 mg/day (P ¼ 0.07). The residents’ mean BMI was 21.7 kg/m2 before the education and 21.4 kg/m2 after the education. Weight gain occurred in 42% of the residents, but 42% of them also lost weight. Before the education none but after the education 16% (3 of 21) of the elderly subjects had a good nutritional status according to the MNA test. However, the number of those who suffered from malnutrition increased from two to four residents (Table 2). On the feedback questionnaires concerning the learning outcomes, the professionals responded that the most helpful ways to learn the nutritional care of aged residents were filling in the food diaries (mean 4.3 on the Likert scale) and discussing these results in the learning sessions with the multi-professional team and the nutritionist (mean 4.6) (Figure 3). Learning to assess the residents with the MNA test was also found to be useful (mean 3.9). Lectures and studying alone were the least useful methods in the learning process. In the open-ended questions, the nurses and the food service personnel expressed their surprise about how little energy the residents had received before the education. It was much less than they had thought. On the other hand, the professionals had not understood before the education the connection of nutrition to the comprehensive well-being of aged residents. Starting to weigh precisely the residents’ food portions and to assess their energy and nutrient intake was considered laborious. However, after learning these

Table 1 Nursing home residents’ energy intake before and after professionals’ the education. Compared to the reference values 1570 kcal/day for women over 75 years (National nutritional council, 1999) Energy intake (kcal)

Before the education

After the education

P-value

n

%

n

%

o1200 1200–1570 41570

9 12 0

43 57 0

2 13 6

10 57 29

Total

21

100

21

100

0.005

Table 2 The nursing home residents’ nutritional status indicated by the MNA test before and after professionals’ education Malnutrition indicator score on the MNA test

Before education

After education

P-value

n

%

n

%

Not at risk of malnutrition At risk of malnutrition Malnourished

0 17 2

0 89 11

3 12 4

16 63 21

Total

19

100

19

100

0.10



1230 Studying alone

Assessing residents by the MNA Discussing the results of diaries in multiprofessional team Filling the food diaries

Lecture 0

1

2

3

4

5

Figure 3 The professionals’ evaluation of how useful various methods were for their own learning: ‘1 ¼ not at all’, ‘2 ¼ very little’, ‘3 ¼ something’, ‘4 ¼ quite much’, ‘5 ¼ very much’.

assessment methods, the professionals found them very helpful in their work. The professionals were very motivated to respond to residents’ nutritional problems after calculating their diets and nutritional status. After learning about these issues, they felt that it was easier to respond to the nutritional problems and accordingly to make the proper changes to the residents’ diets. After the education, they found that they had the facts and proper advice to implement individual nutritional care. The professionals also responded that during the education they had learnt to evaluate how the residents’ meals correspond to the nutritional recommendations given to this age group. The work in multi-professional teams was found to be very useful. A lack of time and problems in the flow of information were the most difficult points of the project.

Discussion The nutrition education for the professionals in nursing homes had a positive impact on the mean energy and protein intake, and on the results of the MNA tests of many frail residents living in dementia wards. After the education and the assessment of the residents’ food and nutrient intake, the professionals were very surprised at their overestimation of the residents’ food intake. The professionals felt that it was easier to respond to the residents’ nutritional needs after calculating the energy content of the residents’ diets and discussing nutritional matters in their multiprofessional teams. To our knowledge, this outcome among frail and old residents living in dementia wards has rarely been examined in previous studies. Educational studies in particular are scarce. It is easier to show the effect of education on the learning outcomes of professionals than its impact on changing the practice of nutritional care or, especially, on the nutritional status and weight of elderly residents. Our small study shows that adult education may European Journal of Clinical Nutrition

also have real positive effects on the nutrition of older residents. Our study shows that it is possible to increase the energy and protein intake of frail elderly residents. In addition, their calcium intake increased significantly. However, it was contrary to our hypothesis that even the nutritional status of some elderly residents could be improved. The demented, institutionalized residents represent the frailest part of the aged population. Among them, the mean body weight usually decreases at a mean rate of 2 kg/year (Muurinen et al., 2003; Soini et al., 2004), and the mean BMI decreases at the speed of 0.52 kg/m2/year among Alzheimer’s patients (Cronin-Stubbs et al., 1997). Therefore, it was expected that our study residents’ BMIs would decrease even more than actually happened in our study. What is more, among old and frail nursing home residents, the MNA test scores were expected to decrease at the 1 year follow-up. Therefore, it is surprising that some old residents’ nutritional status improved before the 1 year follow-up. However, a proportion of residents lost weight despite our intervention. The same phenomenon has been observed in a previous study (Lauque et al., 2004). Our dementia ward residents suffered from moderate to severe dementia and were at the end stage of the disease. Therefore, it can be speculated whether at some point of the terminal stage the demented individuals no longer respond to nutritional intervention. Several studies show that nutritional treatment, particularly balanced nutritional supplements, is beneficial to frail elderly people (Akner and Cederholm, 2001; Milne et al., 2006). The effects of enriched food is more controversial. Our study is in line with previous ones showing that energy intake may be increased with enriched food (Olin et al., 1996; Barton et al., 2000; Lorefa¨lt et al., 2005). Very few studies aim at training and changing the professionals’ practice in these issues, although standardized training programs have been suggested (Pokrywka et al., 1997). The few educational studies aiming at improving frail elderly


1231 people’s nutrition via increasing professionals’ knowledge of nutrition often report only outcomes on frail elderly people’s nutrition (Riviere et al., 2001; Lauque et al., 2004) or the outcomes on professionals’ learning (Crogan et al., 2001). Two studies did report both outcomes (Faxen-Irving et al., 1999, 2005). However, none of these studies have opened up in detail the contents of the educational program. Thus, they cannot be implemented into further practice. An educational intervention has several outcome levels, which should be considered when developing and studying such programs (Figure 1). This is the strength of our study. In two controlled studies, the caregivers of home-dwelling Alzheimer’s patients were trained in nutritional issues (Riviere et al., 2001; Lauque et al., 2004). According to these studies, the body weight of demented individuals could be maintained more often in the intervention than in the control group (Riviere et al., 2001; Lauque et al., 2004). In two other studies, professional working for the elderly subjects living in service flats showed positive learning outcomes but no effects on the residents’ nutritional status (Faxen-Irving et al., 1999; Faxen-Irving et al., 2005). Demented individuals residing in group-living gained weight after the education of professionals (Faxen-Irving et al., 2002). Our study confirms and extends the study results of these previous studies. It is possible to educate professionals to respond to the nutritional problems of demented elderly residents. However, evidence-based educational methods should be used. Adults learn and make changes in their practice when the problems in their everyday work motivate them (Knowles, 1990) and when they are able to test and reflect the issues learned in their everyday practice (Kolb ¨ n, 1987). Lecture-based education has been 1984; Scho shown to be ineffective in changing professionals’ practices (Davis et al., 1995). This may explain the mild results reported by Faxen-Irving et al. (1999, 2005). The basis of our education was constructive learning theory (De Corte and Weinert, 1996; von Wright, 1996) ¨ n, 1987). and the reflective learning model (Kolb, 1984; Scho We used consciously reflective learning cycles to facilitate learning: experience – feedback – reflection – forming theoretical concepts. The professionals were able to acquire personal experience in assessing nutrition, to receive feedback and reflect on it, and to test new ideas in practice in their own work. The valuable part of education was gaining different perspectives from the multi-professional team. The professionals felt that our education helped them very much in their daily work. It resulted in many insights in nutritional care. The professionals especially realized that they had overestimated the energy intake of their residents. The residents’ nutrient intake was assessed by a precise weighing method that accurate results. After the assessments and group discussions, the professionals found it easier to figure out how to change the diets of residents in a direction that better fulfilled their palatable and nutritional needs. The whole process helped the professionals in their documentation of the residents’ nutrition

and also helped them to follow the nutritional recommendations. Our study shows that it is possible to educate professionals in practice and near their daily work to pay attention to the good nutritional care of demented nursing home residents. This may be converted to better nutritional outcomes in a short period of time. Our education and further changes in nutritional care increased the mean energy intake and improved the results of the MNA tests of many of the frail residents. Before the professionals’ education, the energy intake of these very old residents was considerably less than is recommended. The limitation of this study is the small sample size (21 residents and 28 professionals), thus we cannot generalize our results to all nursing homes. However, it is laborious and difficult to carry out an educational intervention and at the same time to evaluate and follow-up outcomes on both old demented residents and professionals’ practice. As our study is not a randomized, controlled and the MNA assessments were unblinded, the true effect of intervention cannot be interpreted explicitly. In any case, our findings are consistent with other studies. We have taken some steps forward to develop a standardized training program for professionals to prevent weight loss in very old, frail residents.

Acknowledgements This study is part of a larger study which The Central Union for the Welfare of the Aged in Finland has organized in order to emphasize the nutritional aspects of good care of the elderly on the levels of research, information and practice. Finland’s Slot Machine Association supports this work. We thank to the personnel of the nursing home for their co-operation during the study.

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