By Annette M. Kobriger, RD, CD, MPH, MPA

Florence Nightingale, founder of the nursing profession and dietary profession, said, "Every careful observer of the sick will agree with this - that thousands of patients are starved in the midst of plenty, from want of attention to the ways which alone will make it possible for them to take food."

Whether we are certified dietary managers, registered dietitians, or registered nurses, we all have the same commitment to those in our care. Nursing and dietary share the responsibility for nutritional care. The split has always been artificial.

Nursing feeds the patients/residents and dietary provides the food. The split has not given us the results we need in terms of preventing weight loss, treating pressure sores, controlling blood sugar, or enhancing quality of life.

How do nursing and dietary connect? Let me count the ways! The first way is collecting accurate height and weight data required for accurate nutrition assessment. How many of us have seen a 90 year-old woman grow four inches after returning from the hospital after surgery? Weight changes during a span of time have important nutrition implications for dietary. Accurate weights give us important clinical information for formulating our plan of care.

Fluctuations in weights can drive us crazy when we have to account for changes that may have, in fact, been weighing errors. The ability of nursing to notice and re-weigh residents without us even asking is a positive result of the nursing-dietary connection on target.

Another important connecting point is in the dining room. Nursing staff usually are responsible for feeding residents.

Supervisory nursing staff usually are not present in the dining room or are passing medications. This means nursing assistants may not have the supervision they need to have residents arrive on time, to be positioned properly, and to receive the assistance they require to eat. Many corporations recognize the importance of having nursing supervision in the dining room. The presence of nursing only to pass medications is becoming a thing of the past with many large corporations.

The dining room is a therapeutic environment. The diet order is a physician's prescription. This includes both the therapeutic component and texture component, as well as instructions for thickening liquids. Why is it more acceptable for a resident to refuse a meal or eat only 25 percent? If this were a physician-ordered drug, this would be considered more serious; however, not eating is a very serious threat to the health of our residents.

The presence of nursing in the dining room in adequate numbers is important to resident feeding, and food and beverage intake. How many members of the nursing staff are needed in your dining room? Consider this formula for your facility:

• Make a list of all residents in your facility.
• Make a list of meal periods at your facility. (A meal period is the time when a resident first enters the dining room until the last resident leaves the dining room.)
• Make a list of where staff is at that time. Include nursing assistants, registered nurses, activity staff, office staff, etc.
• Using your complete resident list, indicate by each name the amount of food assistance needed. This includes set-up assistance, cutting meat, cueing - both oral and physical, feeding assistance, and total hand feeding.
• Analyze whether the staff available meets the feeding needs of residents.
• Meet as a team and review options if the staff available is not adequate to meet residents' needs. (This is perhaps the most important step in the process.) Be mindful of your state regulations - some states allow only licensed staff to feed. Check this out first, before other options are considered. Remember that when residents are in the dining room, employees who perform other functions with residents are usually free. This may include staff from activities, therapies, social services, the office, and others. How can they assist in feeding?

If non-licensed employees can feed, more options are available. Staff members are usually required to take the feeding section of the certified nursing assistant course prior to feeding residents. This increases staffing options for feeding. Activities staff and other employees can help feed. Some facilities hire staff just to feed and pass nourishments. Others train dietary staff for the task.

Still others train volunteers. Family members are an excellent source of additional help if they are willing and available.

Feeding is an important part of care. Failure to feed results in clinical consequences as great as failure to take medication. Residents must have adequate intake to maintain their physical health and sense of well-being.

For this important purpose, it is critical that someone be put in charge of the dining room. Think about it - residents spend 40-50 percent of their time awake in the dining room, or taking nourishment or fluids on the unit. Who should the person in charge be? It may vary by facility, and most important, there should be clear administrative approval to direct any staff in the dining room. Some facilities rotate the responsibility. Should it be nursing, dietary, administration, or other, is best left for the individual facility to decide.

Dining Room Manager Responsibilities

Some responsibilities of the dining room manager are to see that:

• Residents come to the dining room on time.
• Residents have their dentures, glasses, and adaptive equipment for eating.
• Residents are properly positioned.
• Residents have been toileted before their meal, and other hygiene needs have been met.
• Residents receive the correct tray and diet.
• Attention is given to food preferences, and substitutes are provided.
• Attention is given to residents who are not eating and the reason for not eating is determined.
• Special needs and requests are identified and routed to the correct discipline. This might include a swallowing evaluation, consideration of adaptive equipment, a physical problem referred back to the nurse. These changes must also be included in the resident care plan. this is quite a responsibility.

The most important job of the dining room manager is to see that food and fluid intake records are correctly documented within an hour of each meal. Waiting longer than an hour creates a risk of forgetting and recording inaccurate information. Putting in information just to satisfy the "powers that be" is fraud, and those providing inaccurate information should be aware that this is a serious matter. Important changes in resident health status are first noted when the "good eater" stops eating. This is an important signal to caregivers. If this information is missed, and no action is taken until weight loss or skin breakdown occurs, it is harmful to the resident.

Food and hydration records are important cues to health. If a friend or family member is ill, the first question we generally ask is, "Are you able to eat something?" The same is true of our residents. Nursing and dietary both need to review food intake records as important indicators of current health status. Weight loss, pressure sores, etc., are usually easier and less expensive to prevent than to treat.

Administrators should also look at food intake records. If residents are only eating 25 percent of their food, then 75 percent is being thrown away. And then, we are probably adding expensive supplements that may or may not be taken.

Why would residents not eat? The reasons are endless: poor quality food, not enough staff to feed, medication causing unpleasant taste, poor oral care, teeth or dentures in poor condition, or loneliness and depression. The solutions to not eating are as individual as the resident, and require evaluation from the entire team - but especially nursing and dietary. We are key to successful resident care.

Why is nutrition such a concern? Is it important, really? Karen Cope, in her publication Malnutrition - A National Crisis in the Elderly,* lists the progressive steps of malnutrition. (The diagram outlining these steps is shown at the bottom of the page.) In malnutrition, "The body cannibalizes itself in order to survive," according to Cope, a registered nurse.

Malnutrition is serious in the populations we serve, and nursing and dietary must take their responsibilities seriously. Think about some of the ideas presented in this article and discuss them with nursing and administration.

Remember again Florence Nightingale's words, "...thousands of patients are starved in the midst of plenty, from want of attention to the ways which alone will make it possible for them to take food."

*Written for Region X, U.S. Administration on Aging, Seattle, Wash., 1996, available from the U.S. Government Printing Office in Washington, DC.