Around 28 per cent of patients in hospital are considered at risk of malnutrition, and the risk is most pronounced in elderly patients with declining mental function. Kathie Paling explains how a Royal College of Nursing leadership programme helped her improve the nutritional status of patients on her ward

I worked on a 22-bed ward with patients who had dementia and varying degrees of ability. Some were totally dependant on staff, others required a diabetic diet. One patient wandered around during meals and this often distracted other patients.

The ward's day room served as a dining area and lounge, and the front door led straight into the day room. Laundry men, visitors and doctors would come in and want to speak to staff. Carers would come to help their relative with their meal but would often shout across the room. Sometimes the TV would be left on. The staff nurse would be administering medication and three healthcare assistants would be with the patients at mealtimes.

Assessing the situation

One of the workshops I attended as part of a Royal College of Nursing clinical leadership programme was on observation of care. I used the skills I gained from this workshop to assess mealtimes on my ward. Colleagues from the course came to my workplace to help with the assessment. We documented everything we heard and saw during the 30-minute lunchtime and then compared notes. With the information gained, I was able to look objectively at what was really happening and found it was not what I thought was going on.

On the positive side, patients were given the right utensils to eat with and had a choice of meal. Textured modified meals were given to those with swallowing difficulties.

However, no-one knew whether all the patients had completed their meal - some got up without finishing and carers did not inform staff if they were unable to feed their relative because they were asleep. Sometimes puddings were served cold.

I met with the nursing team and shared my findings and together we worked out how we could improve mealtimes on the ward.

Improving mealtimes

We began by encouraging a quiet environment. We divided patients into three groups and allocated one staff member and one trolley to each group. One group was for independent patients, another for those who needed encouragement or prompting, and the third for those dependant on others. We ensured each trolley was loaded with the correct meals, napkins or aprons, cutlery, alcohol gel and a black bag for rubbish. We kept drinks and puddings in the kitchen until the first course was complete to keep them warm.

We placed a notice on the front door informing everyone of the times of protected mealtimes, as well as posters detailing the benefits of protected mealtimes. We also informed doctors of the protected mealtime policy during their induction.

Respecting patients' preferences

The catering staff and I also designed more patient-friendly menus based on the information collected. We made sure fruit was delivered daily and a liquidiser was used to puree it if necessary. Relatives were encouraged to bring in fruit as well as chocolate and other treats for their loved ones. Our aim was to ensure that all patients had five portions of fruit and vegetables a day as recommended by government guidelines.

The healthcare assistants on the ward also collected information on the likes and dislikes of the patients and put it in a folder, so everyone would know who prefers tea rather than coffee, for example.

These uninterrupted mealtimes enabled us to be more aware of the nutritional status of patients and to keep them nourished and hydrated. Taking a step back and involving other professionals brought fresh eyes and ears to our situation. This experience empowered me to implement change through a planned and constructive process, building a motivated and dedicated team, and thus improving patient-centred care.