Malnutrition has significantly increased in the ageing population resulting in a major health problem in the United Kingdom and is a cause and consequence of ill health. This essay will seek to critique three research papers based on Malnutrition in older hospitalised patient. It will include evaluation of strengths, limitations of the research and a reflection on how the researched was undertaken.

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Evidence has shown that malnutrition cost the National Health Service around thirteen billons a year resulting in one of the highest spend in health care (British Association for Parenteral and Enteral Nutrition, 2009).Dunne (2009) also states that one in five people ranging from 65 and over will be affected by malnutrition by the year 2020. Malnutrition is therefore “a state in which a deficiency of nutrients such as energy, protein, vitamins, and mineral causes measurable adverse effects on body composition function or clinical outcome” (National Institute for health and Clinical Excellence, 2006). In light of the information above, this had stimulated an interest to conduct a research to analyse what is being done and what can be done to reduce the prevalence of malnutrition in older patient.
Whilst out in placement, I witness nutrition fell low on the list of nursing priorities of care, not by choice but nurses have so many tasks to complete in a given day. I observe both nurses and health care assistant struggled to cope during meal times and expressed their frustration on the subject on few occasion. Also looking at it from a professional stand point, malnutrition can affect every system in the body leading patients to become vulnerable to illness. This can lead to complication and in the worst case death, it also increases patient’s length of stay in hospital and readmission of patients to hospital. It is vital that information that is used to address malnutrition is extracted from evidence based sources as this aims to provide care in a suitable and efficient way to patient (Craig & Smyth, 2007).
I used critical appraisal skills programme to analyse my research paper as this model helped me to ascertain the relevance and importance a particular research topic relates to practice as well as conduct a systematic review of the article .It assess whether the three research paper was worth reading and helped me to make sense of the qualitative information (Cutcliffe & Ward, 2007).
I obtained my three research paper by using search engine such as CINAHL, INTERNURSE and PUBMED. I searched CINAHL (2007 to 2013), INTERNURSE (2005 to 2013) and PUBMED (2007 to 2013) for articles published in English. The search strategy will be explained in details in the reflection section part of the essay and will be demonstrated in Table 1 and Table 2. Table three comprises of the three research which can be found in the appendix. Reflection is seen as an important aspect of nursing, as it improves the quality of care we give to patient as well as it can enhance practice and greater competence. Ghaye, Gillespie and Lillyman (2000) point out that, reflection is a central part of experiential learning and the improvement of practical knowledge. I have chosen to use Rolfe et al model over John’s model because it gave me a better understanding in comparison with John model. It consists of three simple questions which are what, so what and now what. This helped me to organise my thought process. In the next sections of the essay two tables will be shown to depict my search strategy along with the critical appraisal of the three research paper.
SEARCH STRATEGY
Table 1. Inclusion and exclusion criteria

Inclusion

Exclusion

Boolean operator
Peer Reviewed
Time period (2007 – 2013)

Table 2. Identifying and selecting relevant articles

Database used

Keywords / Search
terms used

Hits

Boolean
Operators

Advanced search

Titles read

Abstracts read

Studies read

Studies of relevance

Cinahl

malnutrition, hospital, food , nutrition , patient

6461

And

11

11

11

Internurse

Malnutrition , Nutrition, patient , hospital, food

1

And

PubMed

Malnutrition

112389

10

10

10

The first research paper was written by Angela Dickinson, Carol Welch, Laurie Ager, entitled No longer hungry in hospital: Improving the hospital mealtime experience for older people through action research, published in the year 2007. The title reflected the content of the research and was clear, specific and concise. It seeks to draw the reader attention to the exact area of study conducted. Marshall (2005) states that a research article should accurately and succinctly reflect the content of the work allowing the reader to be stimulated by the content. This is important as a title that is long and ambiguous can lead to misunderstanding and somewhat misleading.
The abstract was excellent, in that it was succinct, containing no jargon and clearly written in a coherent manner that gave a satisfactory overview of the study. It was able to stand on its own as it includes brief summary of the Aims and objectives of the research, the background surrounding the study, the methods used, results collated, the conclusion and the relevance to clinical practice. Paratoo, (2006) points out that the information provided in an abstracts should aids readers to decide whether to obtain the entire article or not.
Although evidence shown that ethical approval was granted, no mention of consent of the subjects taken part in the research as in accordance with the Nursing and midwifery council code of professional conduct (2008) which states that consent should be obtained before undertaking any task. Also the authors stipulated that they were unaware of other studies available that addresses meal time care in the way they have carried out the research. A more thorough search could have been conducted to rule out this assumption as this research paper might just be adding to knowledge and understanding already available or it could have been compared and contrasted to better understand the issue or to establish new truths
The second research paper was written by Heaven, B, Bamford, C, May, C and Moynihan P entitled Food work and feeding assistance on hospital ward and published in the year 2012. The Authors gave a timely overview into the prevalence of malnutrition in the introduction extracted from reputable sources and demonstrate a good critiquing ability by identifying a gap in a previous related study of which they concluded that little is recounted on the practicalities of the provision of food in hospital and how feeding assistance is seen alongside other nursing priorities which lead them to justified their rationale for undertaking the research. Wigen (2003) states that an introduction should illuminate the rational for the research and highlight any previous research that was conducted on the similar topic.
The Authors used a qualitative paradigm research that made it straight forward to follow and was applicable for the intended research. Methods such as interview and focus group was utilised to investigate malnutrition in older hospitalised patient. They provide evidences illustrating that interviews, allowed them to get close to their subject to glean information and to clarify questions that were not fully understand. The focus group they find helped them create an atmosphere where discussion and brain storming can occur to establish the problems surrounding malnutrition in older hospitalised patient and finding measures that can help to resolve the problem. Ellis (2010) suggests that the relationship between the researcher and the researched is part of the research process and is essential to gain the insider perspective that qualitative research seeks to pursue. In addition qualitative research is more suited for nursing as it can focus more on the care a patient receive as well as their experiences (Jolley , 2010).
The author took ethical issues into consideration as appropriate measures were put in place to obtain consent and prevent physical harm, hunger, discomfort or psychological suffering by not carrying out observation on feeding assistance. Ellis, 2010 highlights that ethics should saturate all that nurses do in the delivery of health and social care.
However the implication of using method such as interviews can sometimes be hard to replicate as people tend to give their views, attitude, ideals ,pre-existing ideas and their beliefs which does not necessary explains the point to why malnutrition does occur (Ellis, 2010). In addition, they can be take up vast amount of time and can be expensive (Jolley, 2010).
The third research paper was written by Vanderwee, K, Clays, E, Bocquaert, I, Verhaeghe, S, Lardennois, M, Gobert, M and Defloor, T, entitled Malnutrition and Nutrition care practices in hospital wards for older people, published in the year 2010. This research was conducted in a hospital ward for older people in Belgium. Although the research was not conducted in the UK, this paper gave insights that suggest that malnutrition in older hospitalised patient is not only a reoccurring problem in the UK but a wide spread problem.
The sample selection process was adequately described, stating the intended process of the research by using precision in information provided such as, the time period the research was carried out, the age restriction of patient involved in the research process. Consent was also obtained and adhered as specified by the Department of health (2009) which states that consent must be given unless stated or proven otherwise that they do not have the mental capacity to do so.
The authors did an exceptional job in the discussion by highlighting information that was already known about the topic extracted from a wide range of credible evidence based sources that support the importance of nutrition. It contains the findings of the research which identify a balance argument into the meaning of the result and provide recommendation that was developed from the finding. Lastly, it highlights some thought-provoking lines of enquiry for future studies to be undertaken to tackle the problem and to extend knowledge of malnutrition in older hospitalised patient. .
The limitation of this study indicates that the authors use a cross sectional study where all information of nutrition status and nutritional care practices of the ward was collated at the same time. Hence, no casual connection could be identified and patients and health care professionals could not express their views on malnutrition, leading to results that could not be quantified. (ref give reason as to why quantitative study)The author or researcher could have carried out a longitudinal study to research and analyse the impact that malnutrition has on older hospitalised patient .Ref (back up the benefits of longitudinal study) .
Collectively, these three research paper provide concrete evidence on the prevalence of Malnutrition and the dire consequent it has on the aging population and Health Service. They mention the benefits that can be derived from the prevention of malnutrition and practical steps that need to put in place to help tack malnutrition extracted from NICE guidelines (2006). A general consensus among the authors of the respective paper that for true progress to be achieve in preventing malnutrition all health professional needs to understands the pervasiveness of malnutrition in hospital and the effect patient nutrition care may have on whole clinical outcome. Lastly they conclude that nutrition intervention greatly improved clinical outcome and reduce cost of care, predominantly in patient 65 years of age and above and challenge health care professional to address the barriers and change the paradigm of nutrition care.
However, authors from one of the research paper went as far as to say that health professional have often failed to prioritise understanding the enormity of malnutrition in their respective hospital and the impact on cost and quality of care and was backed up by the Bapen ,2009 ) that states that nurses are at time removes from the task of assisting patient at meal time and has been delegated to less qualified staff which further strengthen the notion that mealtime care is unskilled and not important.
My first challenge in conducting a research was to identify a topic or area of interest. This was obtained by looking at websites such as Royal College of Nursing, talking with my lecturers, students and staffs on placement as well as reflecting on issues that I was personally interested in. After Collating all the information, I sift through interests, experiences and ideas that had been discussed eventually leading me to conduct a research on Malnutrition and consolidated by the use of the Rolfe et al reflective model.
I undertake my research by using a selection of different sources such as Cinahl, internurse, PubMed, Cochrane library but instantaneously found out using these data base on their own can produce a wide variety of information. The search strategies was very instrumental as it helped me to effectively narrow my search down to a manageable number and furthermore it was less time consuming .The search strategy includes Boolean operator, key words that encapsulate malnutrition , peer reviewed and limiters of inclusion and exclusion outline in table 1 and table 2 . For example, when I type malnutrition into Cinahl without using the search strategy I obtained an exhaustive result of 6461. I did another search this time with a more specific aim and objective of a topic and the usage of the different search strategy which includes peer reviewed article , date restrictions (2007- 2013) which eliminate old article , key words (malnutrition and nutrition, hospital and older people) this refined my search down to 11 papers.
My aim is to obtained three paper for my research ,so I read through the abstract eliminating paper that had no relevance to my chosen topic . I also found that the Abstract was a good indicator to identify relevant keywords to help with my search. I was now short of one paper so I check the Cochrane library which did not produce any relevant article followed by PubMed which produced 112389 at first. I included my search strategy using key words such as malnutrition, older people, hospital, feeding and a time period of 5 years, this further reduced my number down to 10 hits .I also examine the abstract with a critical eye and scan through literature to find the appropriate research articles. Although I did not use wild card and truncation I know the importance of their uses and I am quite positive they will come in handy in the future.
Part of the aim of this assignment was to gain information and understanding of malnutrition in older hospitalised patient by examining the evidence that is already available and seek to find new knowledge on what can be done to reduce malnutrition among the target group. This has put me in good stead as I have gain tremendous amount of insight into the evidence I found from the three research article as well information glean from books and journals that can be applied into practice. For example It was interesting to read nutrition now 2007, who took on a proactive approach in dealing with malnutrition by educating all members of the multidisplinary team to better understand the primacy of good nutritional care and the pivotal role they play in providing it and also implementing ways to work effectively as a team to eliminate the problem of malnutrition. Age concern (2006) also implemented seven steps to end the scandal of malnutrition in hospital, evidence was also shown how various hospital took on the initiative, saw a significant improvement in their quest to reduce malnutrition in their hospitals. The ultimate key is to systematically recognise patients who are malnourished or at risk and quickly intervene (Dunne, 2009)
The implication of the research papers showed that although research had been carried out and the accessibility of validated screening tools malnutrition still continues to go unnoticed and untreated in many older hospitalised patients (Bapen, 2009).
As a student nurse it is important that refection is part of my daily routine as this can enhance my effectiveness as an individual that enhances the quality of care I give to patient. I identify that malnutrition is every one responsibility and requires the collaboration of a multidisplinary team to leverage success in tackling malnutrition and that preventing malnutrition is a pivotal role in my nursing practice
Undertaking this assignment I was able to identify my shortfall and limitation and has taught me effectively ways to conduct a search and access academically evidence based resources. This illustrated to me the importance of not taking information at face value but adhering to the correct procedure to obtain articles and examining articles with a critical and analytical mind to decide the credibility of the article. As the profession Nursing, cannot agree to any research at face value and need to be able to ascertain strengths and limitations of the research when evaluating the information available on the research topic (Ryan et al 2007).
Conclusion
To above information has demonstrated
APPENDIX
Table 3 Research studies critically appraised

Authors

Year

Title

Study aim /question

Study design

Methods used

Population
Sample size

Outcomes
Results

Angela Dickinson
Carol Welch
Laurie Ager

2007

No longer hunger in hospital : Improving the hospital mealtime experience for older people through action research.

Ben Heaven, Claire Bamford, Carl May and Paula Moynihan

2012

Food work and feeding assistance on hospital wards.

Katrien Vanderwee, Els Clays, Ilse, Bocquaert, Sofie Verhaeghe, Miguel Lardennois, Miceline Gobert and Tom Defloor.

2010

Malnutrition and Nutritional care practices in hospital wards for older people.

REFERENCES