Nursing students' attitudes towards nutritional care of older people: A multicentre cross-sectional survey incorporating a pre post design
Introduction
Malnutrition is a debilitating and highly prevalent condition in acute hospital settings; in older people, it is the most frequent complication of underlying diseases (Bonetti et al., 2017). The most common type detected in older patients is protein-energy malnutrition, described by Destrebecq and Lodini (2008), as an insufficient intake and/or excessive protein-energy consumption, which leads to a state of malnutrition if protracted.
Recently, the European Society for Clinical Nutrition and Metabolism (ESPEN) has defined diagnostic criteria for malnutrition, in order to unify international terminology; in individuals at risk of malnutrition, the diagnosis should be based on low BMI (<18.5 kg/m2) or weight loss associated with either low BMI (age-specific) or low FFMI using gender-specific cut-offs (Cederholm et al., 2015).
Malnutrition is related to adverse clinical outcomes including quality of life worsening, pressure ulcers development, decrease in wound healing (for example in surgical patients), increased infections and mortality rates (Chen et al., 2007; Charlton et al., 2012). Literature reports also the negative effects of malnutrition on length of stay in hospital, consumption of resources and overall costs (Kyle et al., 2005; Abizanda et al., 2016; Gastalver-Martín et al., 2015).
In literature malnutrition prevalence in hospitalized older people varies from 10.3% to 75.8% (Lucchin et al., 2009; Meijers et al., 2009; Vanderwee et al., 2010; Charlton et al., 2012; Burgos et al., 2012; Huong et al., 2014; Nazemi et al., 2015; Redondo et al., 2015). A recent Italian multicentre study reported a prevalence rate of 22,4% (Bonetti et al., 2017). Overall, these findings point out the importance of prevention and early identification of malnutrition. Nurses play a role of paramount importance in both areas.
Despite the many validated tools for nutritional screening, several studies still report inadequate healthcare practises among nurses, who give low priority to nutritional care so that the assessment of nutritional status is often not performed (Adams et al., 2008; Bavelaar et al., 2008; Persenius et al., 2008; Bonetti et al., 2013a; Bonetti et al., 2017). Moreover, international studies revealed negative attitudes in providing nutritional care among nurses and health professionals(HPs), for example during mealtimes, a critical moment in in which nurses play a strategic role in monitoring food intake and optimize meal times environment (Bachrach-Lindström et al., 2007; Bonetti et al., 2013a; Bonetti et al., 2017; Fletcher and Carey, 2011). A recent Italian study conducted in Liguria, the Italian region with the highest aging index, confirmed the persistence of negative attitudes among nursing staff: 21% of the sample showed negative attitudes to nutritional care, 53% neutral attitudes and 26% positive attitudes (Casanova et al., 2015). Negative attitudes result in inappropriate healthcare practices, as explained by Fishbein & Ajzen in the Theory of the Reasoned Action, by which behavioural intentions are determined by attitudes to behaviours and subjective norms (Fishbein and Ajzen, 1975). If we apply the theory to malnutrition, we can conclude that positive attitudes among nurses to nutritional care can reflect a correct and adequate approach to patients' nutritional needs.
Given the many complications that malnutrition causes, it is very important that appropriate attention be paid to nutritional skills in the education of nurses and other HPs. Studies report that often in the educational curricula of HPs nutritional aspects are treated superficially, not allowing the development of adequate skills (Thomas et al., 2006; Adams et al., 2010; Dimaria-Ghalili et al., 2013; DiMaria-Ghalili et al., 2014; Kris-Etherton et al., 2014; Levy et al., 2014; Kris-Etherton et al., 2015).
Adams et al., in 2010, reported that doctors' training in nutritional care in the US was still inadequate (Adams et al., 2010). Even in the most recent study of Dimaria-Ghalili et al. (2013) they point out that the training curricula of physicians and other HPs, including nurses, in the US do not allow for the development of sufficient knowledge and skills in nutritional care. DiMaria-Ghalili et al. (2014) stress that this knowledge and skills are of fundamental importance to ensure that HPs are able to properly assess the caloric consumption and nutritional status of their patients.
This inadequacy of training is also recognized by Kris-Etherton et al. (2014), who emphasize how important diversified strategies are to develop these skills in HPs. In another study by Kris-Etherton et al. (2015) the authors point out that in many countries there is no training on nutritional issues in the training of doctors.
Levy et al. (2014), highlighted how one of the barriers to the adoption of specific training courses on nutritional aspects is to be found in the negative attitudes of trainers, who first consider these contents to be of secondary importance and do not promote their development in the training curriculum. Although we cannot say with certainty that there is a correlation between knowledge and positive attitude, it is very likely that the lack of knowledge and skills does not develop in professionals that sensitivity that allows to consider the nutritional aspects of the treatment important, favouring or developing a negative attitude (Levy et al., 2014; Bonetti et al., 2017).
International literature also reports that nurses often have a negative attitude towards older care (Liu et al., 2013; Hanson, 2014; Rush et al., 2017). The combination of negative attitudes and lack of knowledge about nutritional care and a negative attitude towards older people greatly increases the risk that these individuals, will receive inadequate nutritional care.
It is therefore important from the early steps of education to ensure that future professionals pay due attention to nutritional aspects, especially in fragile populations such as older people.
So far, most academic studies have focused on knowledge of nutritional aspects rather than attitudes.
Based to our best knowledge, there are currently few studies aimed to assess attitudes towards nutritional care among nursing students (Thomas et al., 2006).
The goal of the present study was to measure nursing students' attitudes towards nutritional care in older hospitalized patients, by using the The Staff Attitudes To Nutritional Nursing Care Geriatric Scale (Italian version) (SANN_GITA scale) (Christensson and Bachrach-Lindström, 2009; Bonetti et al., 2013b).
Section snippets
Design and setting
A cross-sectional multicentre study was carried out, by administration of a paper questionnaire (Hallberg, 2008). Students of the degree course in Nursing at the University of Milan were involved in three sections of the course (San Paolo Hospital, Luigi Sacco Hospital, San Donato Hospital in Milan).
The degree course in Nursing is present in 16 hospital sites in the territory of Milan and the province of Milan. Students take periods of theoretical lessons followed by practical training periods,
Participants
A total of 245 students were enrolled (response rate 88.4%) from three schools of nursing. The mean age of the participants was 22.3 years (SD ± 4.1), with a range between 19 and 41 years. The majority of them were female (n = 189, 77.14%). Among them, 111 (45.31%) were in their first year of course, 68 (27.76%) were in their second year, 66 (26.94%) were in their third year; no significant differences by gender (p < .05).
193 persons (78.8%) attended basic courses, as a part of the core
Discussion
The primary aim of this study was to measure nursing students' attitudes towards nutritional care in older hospitalized individuals using the validated instrument SANN_GITA scale. The study shows a neutral global attitude, with a trend towards positive attitudes, showing the will of going in-depth with the nutritional thematic. Interestingly, it was found an increase in score to the change of the academic year, which suggests progressive positive changes in students' attitudes during their
Limitations
The main limitation of this study is the no random sample size. The study included students of the bachelor's degree in Nursing in three hospitals, who represent just a small part of students attending the nursing degree course of The University of Milan. It would be interesting continue the study including a wider and random sample, in order to support the results emerged from this study. It must be emphasized that we obtained a high response rate (88.4%), thus we can consider the data
Conclusions
The aim of this study was to assess nursing students' attitudes towards nutritional care in older people. This study revealed a progressive improvement of the attitudes during the three-year course, underling the importance of nutritional educational contents provided; however the results highlighted relevant lacks in specific aspects about nutritional care, which could be studied to understand in which areas university education should be improved, in order to train nurses able to assess and
Acknowledgements
The authors are thankful to all the tutors, students, and degree course directors involved in the study.
Conflict of interest statement
The authors declare that they have no conflict of interest.
Funding
This study has no funding sources.
Author contributions
MB, PF, LB and ST: conceived the study, trained the tutors for data collection, analysed the data and prepared the manuscript; AD, MB and PF: organised data collection; MB: conducted data collection; AD: managed the process of approval of the study by the faculty and the degree courses directors; AD and LB: supervised the manuscript; All authors revised and approved the final text of the article.
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