Using mealtime volunteers to support patients

Author

Joanne Sneddon is deputy sister/nutrition nurse, Royal Hampshire County Hospital, Winchester.

A high level of malnutrition in hospital patients continues to be an area of concern. In 2008, Lean highlighted that the number of patients being discharged from English hospitals while malnourished had increased by 85% in the past 10 years as nutritional screening tools remained under-used.

Best (2008) discussed how developments, such as increasing nurse awareness of nutritional screening and encouraging them to use protected mealtimes, are vital to maintaining patients’ nutritional care.

Despite these efforts, Care Quality Commission reports in 2011 are still highlighting issues that are a cause for concern. These issues bring into question whether national minimum standards for good nutritional practice are being met; the organisation continues to find patients with trays of food left out of reach and poor implementation of nutritional screening.

Over three million people in the UK are affected by malnutrition and associated healthcare costs exceed £13bn annually (British Association for Parenteral and Enteral Nutrition, 2010). Malnutrition, in terms of undernourishment, has clinical implications including delayed wound healing, pressure ulcer development and prolonged hospital lengths of stay. In 2003, Elia published the Malnutrition Universal Screening Tool (MUST) report, which found evidence that malnourished patients are more likely to need a longer hospital stay. The tool was developed to try and detect any adult patients at low, medium or high risk of malnutrition in both hospital and community settings; appropriate nutritional care could then be implemented.

Recent reports and campaigns have looked at how important good nutritional care is for hospital patients (Age UK, 2010; Royal College of Nursing, 2007; National Institute for Health and Clinical Excellence, 2006). They all suggested nutritional care for hospital patients could be improved by focusing nurses on ensuring nutritional screening is completed for all patients on admission.

The publication of the Still Hungry to be Heard report highlighted that nurses are still not recognising malnourished patients and continue to fail to provide appropriate assistance to older patients at mealtimes (Age UK, 2010). The report outlined seven steps to try and reduce malnutrition in hospital (Box 1); step seven suggested that, where appropriate, trained volunteers should be used to help provide additional support at mealtimes for older patients. Volunteers can help the nursing teams to ensure all patients that need help at mealtimes receive it in an appropriate, timely way.

Introducing mealtime volunteers to the trust

In April 2010, mealtime volunteers were introduced to the Royal Hampshire County Hospital to address specific concerns that had been raised during a hospital-wide nutrition audit. Patients had reported difficulties such as lack of assistance with opening lids and not receiving appropriate help to eat.

Volunteers were recruited specifically to assist patients at mealtimes. Brown and Jones (2009) found mealtime volunteers were useful in helping patients with simple tasks such as menu completion, opening packaging around food and encouraging them to eat. With these tasks in mind, the trust organised a three-hour training session for volunteers that included input from a speech and language therapist and the nutrition nurse specialist.

Both theoretical and practical issues around the best position for eating, the normal swallow and how it feels to be fed by someone else were included. The session also addressed the type of patients that may require assistance at mealtimes, as well as looking at the competencies required for the role. Training also addressed such practical issues as completing menu cards with patients and how to fill in food and fluid charts.

Before the mealtime volunteers started on the wards the trust developed guidelines and competencies. The trust volunteer service manager and nutrition nurse specialist were included in discussions about the specific duties the volunteers were being asked to do. This helped provide the basis for the guidelines and competencies.

Further information was obtained from other nutrition nurse specialists who had experience of mealtime volunteers via the National Nurses Nutrition Group. As the mealtime volunteer role was new to the trust, the volunteers were paired up to provide a buddy support system. They would work together each time they were on the ward. Before they briefed the mealtime volunteers on the role, we spoke to each ward manager who had agreed to have a volunteer. Guidelines and competencies for the mealtime volunteers were given to the ward managers. They were asked to discuss the use of the volunteers with their nursing teams, so everyone was clear about what their roles on the ward would be.

Mealtime volunteers on the wards

By August 2011, seven teaching sessions had been undertaken and 35 volunteers had had been trained.

Volunteers cover a mixture of lunch and supper times. We have found they have a better experience and settle in quicker if the ward manager is enthusiastic about patient nutrition. Nursing teams that are motivated about patient nutrition also encourage volunteers to feel supported in their role. This is important to ensure they keep coming to the wards.

The number of patients requiring assistance at mealtimes can vary from one day to the next, especially on the acute wards. Patient dependency can change rapidly and staffing levels will affect each mealtime. Often, wards are running on minimal staffing levels and the number of patients needing red trays (which indicate their need for assistance or supervision at mealtimes) may be much higher than the number of people available to assist them; nurses then have to decide who to feed first. Despite best attempts, it may not be possible for nurses to give each patient  requiring assistance the time they need at mealtimes.

Having mealtime volunteers on the wards means mealtime care for those who need assistance can be enhanced, which also helps boost patients’ diets. The main tasks undertaken by mealtime volunteers, and the benefits these can have, are listed in Box 2.

Mealtime volunteer experience

Little information on the experience of volunteers at mealtimes is available in the literature, but feedback from those in post at the trust indicated they found the role fulfilling. They enjoyed being involved at mealtimes as they were viewed as an important part of the patients’ day.

Nursing staff experience

Nursing teams gave positive feedback about mealtime volunteers. Several wards with more experienced volunteers have expanded their roles, for example, they now write out menu cards, including those with dietary requirements. Nurses have found they are not required to assist at all with menu selections when the volunteers are in.

A sister who uses mealtime volunteers on her orthopaedic ward, has found they are good at reporting back if any patients are missing a meal or an item of food from their tray. She has also found volunteers are good at reporting back if patients are not eating much, and at offering them a suitable alternative so they are not missing out on meals.

A senior healthcare assistant reports that volunteers have helped with the mealtime structure by supporting the nurses, clearing patients’ tables and providing hand wipes prior to meals. All this helps with the quick, efficient delivery of meals, freeing up time so the nursing team can assist those in need physical or verbal encouragement to eat.

Patient experience

Patients reported that the main benefit of mealtime volunteers was the chance to “have a chat”. The volunteer was someone who was there to help them at mealtimes but, because they were not in uniform, they were seen as being less busy than
the nurses.

Longer-stay patients looked forward to the days when the mealtime volunteers came in. One patient said she not only looked forward to them coming in, but also that their presence helped her try harder to eat more to get well.

Reviewing the impact of mealtime volunteers

Overall, the introduction of mealtime volunteers to the trust was been viewed as a success.

Green et al (2011) discussed how difficult it had been during their literature search on mealtime volunteers to find feedback on the impact of the role. It is hard to measure the effect volunteers have had on mealtimes or levels of malnutrition in patients within the trust. Audits of mealtimes using volunteers and those without, which examine the length of time taken to hand meals out and the numbers of patients assisted each time, are being considered. Having mealtime volunteers has ensured the trust is addressing issues highlighted in Age UK’s (2010) Still Hungry to be Heard report.

The mealtime volunteers all had different reasons for volunteering. They ranged from pre-university students wanting to gain insight into hospital life to people who had retired and were looking to do something useful. They all bring different life experiences and have settled well into the nursing teams with whom they work.

The buddy system has proved a useful source of support, especially when older volunteers are teamed up with younger ones, and is something they all report as enjoyable. For all the volunteers, the social interaction with patients remains an important part of their role and one that helps enhance patients’ mealtimes.

Some wards with mealtime volunteers have been more successful than others. The scheme seems to work best when ward managers are enthusiastic about patient nutrition and nursing teams have a positive approach to the nutritional care of their patients. The teams were all aware of the role of the mealtime volunteers. They were able to support them when they started and make sure they find them appropriate patients to help when they are on the ward. This, in turn, helps mealtime volunteers feel confident in their role and that any concerns they report about patients will be dealt with in an appropriate and timely manner by the nurses.

Conclusion

Nurses remain accountable for their patients’ nutritional care. Introducing mealtime volunteers to support them has helped improve the efficiency of mealtimes. The volunteer role has helped enhance mealtimes for patients by improving social interaction. This, rather than physically assisting patients at mealtimes, has proved to be a larger part of the volunteer role.

Future plans include continuing to train more mealtime volunteers, as there is a constant waiting list of volunteers wanting to join. Using more experienced volunteers as buddies to support them and help them settle into the role before allocating them to a ward will help ensure a smooth transition into the role.