Using Evidence-Based Organizational Strategies to Prevent Weight Loss in Frail Elders

Affiliations:

¹Mennonite College of Nursing, Illinois State University, Normal, IL

²Department of Family and Consumer Sciences, Illinois State University, Normal, IL

³Friedrich Nutrition Consulting, Salisbury, NC

Abstract: Evidence-based clinical interventions to prevent and treat unintentional weight loss in elderly persons are outlined in the literature, but evidence-based strategies on the organizational level are less readily available and are therefore underutilized. Yet evidence-based organizational strategies have the potential to improve resident care to a far greater extent than clinical interventions implemented by a single healthcare professional treating individual residents. In this article, the authors discuss evidence-based organizational strategies to prevent weight loss in frail elders residing in long-term care settings. The organizational strategies reviewed focus on staffing, planning, leadership/supervisory, educational, environmental, and interdisciplinary interventions. Based on their findings, the authors conclude that nurse leaders need to be more aggressive in implementing management and leadership decisions that are evidence-based and lead to organizational improvements.

Article series summary:

This is the first article in a continuing series on nutrition issues in long-term care. Subsequent articles will discuss the topics of managing obesity in elderly long-term care patients, considerations in end-of-life nutrition, and more. These articles will be published in future issues of Annals of Long-Term Care: Clinical Care and Aging^®.

Key words: Weight loss, frailty, care planning, nutrition issues.
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Unintentional weight loss is common among nursing home residents and may be caused by one or more clinical problems. Three common issues resulting in weight loss in this population include starvation (ie, wasting), cachexia, and sarcopenia.¹ A significant number of frail elders lose weight as a result of malnourishment, which is estimated to affect between 35% and 85% of nursing home patients.^2-4 Involuntary weight loss continues to be a pervasive concern in nursing homes because significant weight loss leads to higher morbidity,^5,6 higher mortality,^2,5-7 and decreased quality of life.³ Furthermore, inappropriate weight loss is considered an indicator of poor nursing care.⁸ Clinical interventions to treat these issues are commonly used in nursing homes and are documented in care plans; however, directors of nursing (DONs) need to ensure that these clinical interventions are implemented and monitored. Evidence-based organizational strategies enable them to do this.

Evidence-based clinical practices for prevention and treatment of unintentional weight loss in nursing home residents is readily available in the medical literature^1,9; however, these guidelines do not specify the role of administrative interventions. While leaders in nursing have advocated for evidence-based practice, they have been less supportive of evidence-based administrative decision-making and evidence-based strategies that support clinical practices.¹⁰ A search of the literature reveals that evidence-based organizational practices have a greater potential to affect numerous residents than clinical strategies implemented by a single nurse or clinician at patients’ bedsides. Adding organizational strategies to the current clinical strategies in nursing homes may further increase care quality for frail elders. This review discusses the use of evidence-based organizational strategies to prevent unintentional weight loss in frail nursing home residents.

Organizational Strategies

In a 2007 commentary, Newhouse¹¹ stated that nursing leadership is the cornerstone of evidence-based practice in healthcare, but to be successful, these practices need to be supported by organizational infrastructure. Implementation of organizational strategies is multifaceted. The six categories of organizational strategies to prevent weight loss that we discuss in this review were identified in a recent pilot study conducted by Dr. Dyck, one of the coauthors of this review.⁹ With the intent of developing consensus regarding administrative strategies that DONs could use to prevent weight loss in nursing home residents, the study used a modified three-round Delphi method with a 21-item mailed survey that was completed by nine nurses (three DONs and six long-term care nurse consultants) and one nurse in a PhD program. After data collection, six categories of administrative strategies were identified: staffing, planning, supervisory, educational, environmental, and interdisciplinary. What follows is a brief review of the evidence supporting these types of administrative strategies as well as the considerations and specific recommendations for putting them into practice.

Staffing Strategies

The literature shows overwhelming evidence that nursing staff play a significant role in maintaining overall quality of care in the nursing home.^12-14 Several studies that examined the relationship between staff nurses and weight loss showed that low staffing levels are associated with malnutrition.^8,13,15 Improving the quality of staff involves hiring additional nursing staff with advanced degrees, increasing the amount of direct care hours, and using trained dining assistants or trained volunteers to assist at mealtimes.

Hire more nurses with advanced degrees. Nurses with Masters degrees, including nurse practitioners (NPs), clinical nurse specialists, and gerontological advanced practice nurses (GAPNs) improve the quality of care by providing ongoing clinical consultation in nursing homes. Krichbaum and colleagues¹⁶ described a set of strategies used by GAPNs to implement protocols into the daily care of residents, who were grouped according to four major concerns: pressure ulcers, incontinence, depression, and aggressive behavior. The results showed that residents whose care was planned by GAPNs using these protocols had better outcomes than residents in facilities without such protocols. In a follow-up study, Krichbaum and colleagues¹⁷ noted quality of care improvement, especially with regard to depression scores, when GAPNs added a set of organizational-level interventions, including membership to the facility’s quality assurance committee and collaboration with staff on problem-solving teams. Furthermore, the Quality Improvement Program for Missouri (QIPMO) demonstrated clinical efficacy of onsite clinical consultation by gerontological expert nurses with graduate nursing education.¹⁸ The QIPMO provides clinical consultation to nursing homes in the state of Missouri, especially “at risk” homes, which were identified by quality indicators according to the Minimum Data Set (MDS). The “at risk” group who accepted at least one visit from a QIPMO nurse found improvement in five MDS quality indicators: high risk of pressure ulcers, overall risk of pressure ulcers, weight loss, bedfast residents, and falls. The improvements ranged from 4% to 41%. Weight loss improved by 4% with an estimated cost savings of $2050 ($597 for treatment + $1453 for labor) in fiscal year 2006.¹⁸

Increase the amount of direct care time. More direct care time is associated with fewer adverse patient outcomes in the hospital setting, but this relationship is not as clear in the long-term care setting because detailed time studies have not been conducted in this setting.^19,20 A secondary analysis of MDS data and other data showed a 17% decrease in weight loss and dehydration in residents who received 3 hours or more of care time with a nursing assistant (NA) compared with residents who received fewer than 3 hours per resident day.¹⁵

In a study by Horn and associates,¹⁹ direct care time of 30 to 40 minutes provided by registered nurses (RNs) per resident day was associated with reduced weight loss and other improvements in resident outcomes, such as fewer pressure ulcers, fewer hospitalizations, and fewer urinary tract infections. The fewest number of complications were found with 30 to 40 minutes of direct RN care per resident day as compared with care of less than 10 to 30 minutes. The RN staffing hours per resident day had a stronger association with residents’ outcomes than those times for licensed practical nurses (LPNs) and certified nurse assistants (CNAs).

Increasing direct care time may require administrators to hire additional support staff. Schnelle and associates¹⁴ compared the staffing level, resident care loads, and quality of care measures of 30 nursing homes in California (15 were high-staffed and 15 were low-staffed, as defined by staffing data reported to the state). They found that nursing homes with the highest number of NAs on staff had fewer residents per care assignment on day and evening shifts, and that the highest-staffed homes performed significantly better on 13 of 16 care processes implemented by the NAs compared with the low-staffed homes.

Hire dining assistants. The federal Nursing Home Reform Act requires minimum staffing levels and other requirements regarding training and hours. However, the Act does not provide specific nurse-to-resident staffing ratios for RNs, LPNs, or NAs, and does not require any minimum level of staffing for NAs at all.²¹ Some studies have put forth recommendations going above and beyond these requirements. For example, Harrington and colleagues²⁰ assert that in order to provide adequate feeding assistance by NAs, a staffing ratio of two NAs to four residents is needed.

In the absence of data to support more specific, federally-mandated staff-to-resident ratios, there is growing evidence that dining assistants can facilitate nutrition in nursing home residents.²² Mealtime assistance is shown to take 42 minutes per resident and snack assistance is shown to take 13 minutes.²³ Supervision and cueing can require as much time as actual feeding.²⁴

In a crossover controlled trial involving 76 long-stay nursing home residents at risk for unintentional weight loss, residents who received feeding assistance were shown to have an increase in estimated total daily caloric intake, and they maintained or gained weight.²³ Although this intervention can be valuable, it is also time-consuming for regular staff. To take some of the burden off regular staff, facilities can use dining assistants. Long-term care facilities can use paid feeding/dining assistants according to certain conditions set forth by the Centers for Medicare & Medicaid Services (CMS) in 2007.²⁵ These guidelines indicate that paid dining assistants take, at minimum, an 8-hour training course, which includes training in hygiene, feeding assistance techniques, and resident safety, among other topics. In addition to training, compliance requirements include proper supervision, appropriate selection of residents, and training records. Administrators should review these guidelines thoroughly if they wish to qualify for coverage of a paid feeding assistant.

Studies have shown that dining assistants spend significantly more time and higher quality time providing feeding assistance per resident meal than NAs.²⁴ In addition, compared with NAs, dining assistants have been reported to provide more social stimulation and have fewer residents who consume less than half of their meal.²⁴ Improved timeliness of tray delivery also occurred when dining assistants were in place.

If a facility does not qualify for CMS coverage of a paid dining assistant, other strategies to improve dining supervision include using trained volunteers and enabling flexible shifts for current staff.⁹ Non-nursing facility staff could assist nursing staff during mealtime with tasks such as obtaining a specific food substitute or enjoying a cup of coffee with a resident to promote social stimulation while the resident eats. By doing so, residents would become more familiar with other staff members, and non-nursing staff members might develop a better sense of the facility’s mission of caring for older adults by becoming acquainted with the residents. Greater collaboration, enhanced job satisfaction, and enhanced resident satisfaction support the organization’s objectives and purpose.²⁶ Of course, licensed nurses should supervise in the dining room as required. Flexible shifts during times of greatest need, such as mealtime, could increase the number of staff available to assist at mealtime without significantly increasing the number of hours worked.

Care Planning Strategies 

To meet individual resident needs, care planning requires critical thinking by RNs and DONs. Numerous care planning strategies are available to these healthcare professionals to prevent weight loss in frail elders, including diet modification, protocol implementation, and care conferences, all of which are discussed in the section that follows. 

Try diet modification. Modifying a resident’s diet refers to the adjustment of meals based on individualized nutritional requirements per resident.²⁷ In a 3-month intervention program conducted by Christensson and associates,²⁷ 11 residents received individualized diets to meet their calculated energy requirements. Ten residents met their calculated energy requirements over a 3-month period of time and showed increased nutritional status and improved functional capacity.²⁷ Increased nutrient intake, or diet modification, can also include enhanced or fortified foods. Castellanos and colleagues²⁸ reported that bigger eaters consumed more calories when breakfast foods were enhanced (with energy and protein fortifiers), although this increase in calorie consumption did not occur with enhanced lunch foods; smaller eaters consumed more calories when either breakfast or lunch foods were enhanced. Since smaller eaters are at greater risk of weight loss, enhancing several foods at more than one meal is recommended. Additionally, flavor enhancers have been found to increase food consumption by stimulating appetite, subsequently boosting immune system status and handgrip strength.²⁹

Nutritional supplements are often prescribed to nursing home residents for a variety of reasons, including decreased intake of food, unintentional weight loss, and wound healing.³⁰ However, while the addition of dietary supplements has shown varying degrees of success in maintaining healthy weight, there are also problems. In a randomized controlled trial that compared the effectiveness of oral liquid nutrition supplements to food snacks, Simmons and colleagues³¹ found that supplements were associated with a higher cost, higher refusal rate, decreased meal intake, and more care time. Moreover, delivery of supplements to residents is not always provided as ordered. In a descriptive study involving 132 long-stay residents of six skilled nursing homes, Simmons and Patel³² reported that staff spent minimal time promoting supplement intake either during or between meals. These findings show that evidence-based guidelines for supplement prescribing and monitoring are not well developed, thus a “food first” strategy prior to supplement use is recommended.³⁰ Clearly, diet modification with individual adjustment of meals, enhanced foods, and supplements should be implemented with the interdisciplinary strategy of working with a dietitian.

Implement and enforce standardized protocols. In general, when standardized protocols are implemented into daily care routines, there are better outcomes for residents.¹⁶ Nonstandardized protocols or observations lead to subjective results and thus difficulty in replication by other independent observers and unreliable quality improvement efforts.³³ One intervention study found that when a standardized weighing procedure or protocol was used, there was better identification and assessment of residents with weight loss when compared with usual nutrition care without a protocol.³⁴ The protocol involved assessment; intervention, including weighing frequency; facilitation of communication with staff, physicians, families, and residents; and reassessment. Simmons³³ emphasized the importance of a meal rounds protocol, which would define when to observe eating, who is being observed (ie, at-risk patients), and what to observe (ie, amount of food eaten, food refusal). Meal rounds are discussed in more detail in the Leadership and Supervisory Strategies section.

Hold regular care conferences. Biweekly care conferences about residents with weight loss and/or eating problems can assist the facility in being proactive in preventing weight loss.⁹ These conferences provide an opportunity to implement both clinical and organizational strategies and provide opportunities for discussion among interdisciplinary team members. In addition, DONs need to include NAs in care planning discussions as they give direct care and can individualize care for residents.⁹

Leadership and Supervisory Strategies

Nursing leadership is important for ensuring nursing home care quality, as lack of leadership leads to poor resident outcomes.^35,36 In a comparative case study, researchers found that DONs who facilitated open communication and teamwork among their staff achieved quality improvement, whereas leaders who impeded communication and teamwork did not.³⁶ Leadership skills need to be implemented in conjunction with supervisory strategies for weight loss prevention, such as dining room rounds, medication pass scheduling, and quality improvement.

Perform meal rounds. Dining room rounds, also known as meal rounds, involve taking brief, informal observations of residents and staff in the dining environment. The purpose is to identify, document, and correct feeding and nutrition problems before significant weight change occurs.³⁷ Direct observation is important in nursing home quality improvement programs due to the minimal or inaccurate documentation often found in nursing home charts.³⁸

In a study of long-term care residents from two special care units, Keller and colleagues³⁷ observed the usefulness of two standardized measurement instruments—the Edinburgh Feeding Evaluation in Dementia Scale (EdFed) and the Eating Behavior Scale (EBS)—which were administered by dietitians during meal rounds. The EdFed and the EBS revealed 32% of residents to be at moderate nutrition risk and 40% to be at high nutrition risk. The common problems observed during meal rounds were inappropriate consistency of food for residents and difficulties with eating and swallowing.

Another benefit of administrative involvement in the dining room is that it creates an informal dining setting that encourages socialization and allows the DON and residents to become better acquainted. Leadership in the dining room may be demonstrated through observation, socialization, and role modeling of appropriate behaviors for staff. Licensed nurses, either RNs or LPNs, also need to be in the dining room during mealtime in case of choking or aspiration.

Be mindful of medication pass times. The DON can choose to schedule medication passes before, after, or during mealtimes. As Dyck⁹ found in a pilot study that outlined administrative strategies, if the medication passes occur during mealtimes, then the nurses are focused on medication administration and not on dining activities. If the medication passes occur before or after meals, the nurses are more available to assist with feeding residents who are more difficult to feed, and because they are more qualified than NAs, they can role-model feeding assistance skills.

Arrange quality improvement activities. Quality improvement activities are particularly important with the problem of weight loss. Routine audits can help the DON track processes of care related to weight loss.³⁹ Audits might include tracking residents with weight loss,⁴⁰ monitoring use of a weight loss protocol, and monitoring feeding assistance. Simmons⁴¹ developed quality indicators (QIs) for feeding assistance. These QIs include the following:

•     Identifying residents with low oral food and fluid intake during meals;

•     Providing assistance to at-risk residents;

•     Assisting residents identified during their MDS assessment as requiring staff assistance to eat;

•     Prompting residents verbally who receive physical assistance at mealtimes;

•     Interacting socially with all residents during mealtimes; and

•     Assisting residents who receive an oral liquid nutritional supplement during mealtimes.

These QIs can be used for standardized assessment of feeding assistance quality, in addition to the QI on prevalence of weight loss based on the MDS. These quality improvement strategies need to be integrated into a facility-wide quality improvement program.

In a 2000 study, Feilmann⁴² outlined a model for determining whether a resident has experienced significant weight loss, which was successfully implemented in an Iowa veterans’ home. The procedural model involves weighing all residents twice per month and using a dietician to assess the occurrence of significant weight change (5% in
1 month, or 10% in 6 months). The dietician is then actively involved in making necessary alterations to the resident’s care plan and meals, and he or she is responsible for reporting changes to the resident’s physician, primary RN, and the entire care planning team. The Feilmann⁴² study also includes a sample questionnaire for ensuring accurate weight-taking procedures.

Dyck³⁹ developed an evidence-based quality improvement program for the University of Iowa Gerontological Nursing Interventions Research Center. A copy of this protocol, titled Quality Improvement in Nursing Homes With Quick Reference Guide costs $35 and can be obtained by contacting the University of Iowa College of Nursing (Hartford Center of Geriatric Nursing Excellence) at www.nursing.uiowa.eduhttps://s3.amazonaws.com/HMP/hmp_ln/imported/documents/hartford/EBP_Catalog_Nov_2012.pdf.

Educational Strategies 

Nurses typically do not receive extensive training in the nutritional issues of elders, including malnutrition and weight loss. Directing healthcare professionals to seek education focusing on signs of malnutrition and prevention of weight loss in the long-term care environment may positively impact residents.^43,44 Nutrition education that aims at teaching nursing staff to recognize and respond to nutritional problems of their residents may have a positive impact on the total energy and protein intake of the residents.⁴⁵

At a Finnish nursing home, Suominen and associates⁴⁵ completed an 18-hour educational program to help nurses improve nutritional care of residents, none of whom had good nutritional status. The intervention was divided into 2- to 3-hour classes each month for 6 months. Each session included lectures, small group discussions, homework tasks, and personal feedback. After 1 year, 16% of residents had good nutritional status. Breaking up the educational hours enabled the professionals to internalize the aims of good nutritional care and intervene to enhance the nutritional status for the residents. Furthermore, this study found that strategies with a variety of components better facilitate understanding of information. Positive results were found when educational programming included presentations, discussion groups, out-of-class assignments, and individual feedback. Motivating healthcare professionals through presentations facilitated remembrance of facts concerning nutrition problems. Homework assignments included hands-on activities, such as weighing foods, keeping food diaries, using computer-based food record programs, and observing residents at meal times. Discussion topics included specific plans for individual adjustments to the residents’ diets and meal times. The use of discussions, readings, and teamwork enabled professionals to respond individually to the nursing home residents.

The purpose of an educational program may vary from facility to facility. For education programs to be successful, it is advisable to consult the facility’s dining room guidelines to identify learning needs of professionals. This enables the intervention to target specific learning deficits at the facility. Continuous training and education is important to meet the learning needs of the staff.⁴⁶

In addition, it is important to encourage nurses to obtain gerontological nurse certification. As discussed in the Staffing Strategies section, research shows that staffing with nurses who have higher educational levels leads to lower mortality rates in patients in acute care settings.⁴⁷ While this same research has not been completed in long-term care settings, it would appear that specialized nursing skills are necessary for nursing home patients as well.

Environmental Strategies

A high-quality dining experience may help prevent weight loss in frail elders. Factors affecting the dining experience include dining location, surroundings, food quality and choice, and good service.

Dining location. Where residents eat their meals can significantly impact nutritional care quality.⁴⁸ A cross-sectional study in 34 nursing homes involving more than 700 residents found that residents who eat in a common dining room had better nutritional status than residents who ate in their rooms.⁴⁸ This was attributed to the presence of nursing home staff in the dining room, as they could give feeding assistance to residents in need and accurately document food and fluid intake for the medical records. The authors of this study concluded that residents at risk of unintentional weight loss should eat their meals in a common area, such as the dining room, as opposed to being isolated in their rooms.

Dining room surroundings. Long-term care patients, especially those with dementia, may benefit from a more personalized and comfortable dining room, which may include hanging pictures on the wall and changing them occasionally, decorating the room with patterned tablecloths and curtains, and placing residents’ personal items in the room.⁴⁹ Mamhidir and associates⁴⁹ reported that personalizing the dining room was particularly effective in reducing weight loss risk in patients with Alzheimer’s disease and dementia. A study by Thomas and Smith⁵⁰ found that individuals with dementia may consume 20% more calories when familiar background music is added to the dining surroundings. Routine seating plans can be particularly helpful for individuals with dementia⁵¹ due to their decreased ability to tolerate and adapt to environmental changes.⁵²

Other common barriers in the dining room that may contribute to discomfort and distraction from eating include visual overstimulation, poor lighting, poor visual contrast, and auditory confusion.⁵³ An easy fix for poor lighting is to turn up the lights or seating patients near windows, as increased light can decrease eye fatigue during the meal and make food easier to see. Similarly, patients with nutritional risk should not be seated in high-traffic areas, such as the middle of the room or by food serving areas. A decrease in people-generated and environmental-generated noises may improve acoustics and increase the quality of the dining experience.⁵³

Food quality and choice. Food quality is often the most important predictor of patient satisfaction. Residents’ choice of foods encompasses views about menu selection to meet preferences as well as having options to choose food outside the established menus. Facilities have worked to accomplish choice and variety of foods by rotating the menu, trying new recipes,⁵⁴ and having a refrigerator close to the dining area to facilitate substitutions.⁹ A sufficient staff of experienced cooks to serve food at correct temperatures is important, not only to ensure safety but also to improve satisfaction.

Service. Courteous servers who exude a caring attitude are important to quality dining environment. Staff can provide good service through family-style or buffet dining rather than serving meals on trays, which may result in increased socialization among residents with a more pleasurable mood and subsequent weight gain.^49,55,56 In a continuing care retirement community, Hackes and colleagues⁵⁵ demonstrated that family-style service resulted in significantly less food waste compared with healthcare-provider tray service and wait-staff service; however, changing to this style of service should take into account food and supply costs and meal acceptability, they concluded.

Interdisciplinary Strategies

Optimal resident dining experiences require individualized care with multilevel interdisciplinary strategies.⁵⁷ Nutritional support teams have been shown to improve outcomes and safety, although they are not well used.⁵⁸ Dietitians, occupational therapists, physical therapists, and activity staff are all instrumental in facilitating pleasant dining and social experiences. Dining room observation by professionals from several disciplines could provide assistance in meeting the needs of individual residents. Dietitians can help monitor each resident for early detection and treatment of changes in eating patterns or behaviors, and they can suggest and oversee food and mealtime interventions. Physical and occupational therapists can consider client needs and environmental factors to help develop effective strategies to facilitate residents’ independence at mealtime. Speech therapists can monitor and observe swallowing difficulties. Activity staff, who plan social events usually involving food, can meet residents’ needs if they have knowledge of nutritional issues during the planning process. DONs need to facilitate open communication and teamwork with the interdisciplinary team to promote quality improvement and quality care for residents.³⁶

Conclusion

Unintentional weight loss is a multifactorial problem for frail elders, but it is a cardinal feature of frailty and must be addressed with urgency and individualized care. Undesirable weight loss can increase the risks of mortality and morbidity and also decrease quality of life in long-term care residents. Evidence-based clinical practices to prevent and treat unintentional weight loss in frail elders are well known, whereas organizational strategies to prevent and treat weight loss are not as well known and therefore underutilized. Nurse leaders have been less aggressive in implementing management and leadership decisions that are evidence-based and could lead to organizational improvements. The potential impact of organizational strategies is far greater than the impact of a single clinician using evidence-based clinical interventions for one resident. Residents at risk of unintentional weight loss deserve to benefit from the implementation of evidence-based organizational strategies.

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Disclosures:

The authors report no relevant financial relationships.

Address correspondence to:

Mary J. Dyck, PhD, RN, LNHA

Associate Professor

Mennonite College of Nursing

Illinois State University

Campus Box 5810

Normal, IL 61790-5810

mjdyck@ilstu.edu