Assessment and documentation of patients' nutritional status:: perceptions of registered nurses and their chief nurses

Aims. To study, within municipal care and county council care, (1) chief nurses' and registered nurses' perceptions of patient nutritional status assessment and nutritional assessment/screening tools, (2) registered nurses' perceptions of documentation in relation to nutrition and advantages and disadvantages with a documentation model. Background. Chief nurses and registered nurses have a responsibility to identify malnourished patients and those at risk of malnutrition. Design and methods. In this descriptive study, 15 chief nurses in municipal care and 27 chief nurses in county council care were interviewed by telephone via a semi-structured interview guide. One hundred and thirty-one registered nurses (response rate 72%) from 14 municipalities and 28 hospital wards responded to the questionnaire, all in one county. Results. According to the majority of chief nurses and registered nurses, only certain patients were assessed, on admission and/or during the stay. Nutritional assessment/screening tools and nutritional guidelines were seldom used. Most of the registered nurses documented nausea/vomiting, ability to eat and drink, diarrhoea and difficulties in chewing and swallowing, while energy intake and body mass index were rarely documented. However, the majority documented their judgement about the patient's nutritional condition. The registered nurses perceived the VIPS model (Swedish nursing documentation model) as a guideline as well as a model obstructing the information exchange. Differences were found between nurses (chief nurses/registered nurses) in municipal care and county council care, but not between registered nurses and their chief nurses. Conclusions. All patients are not nutritionally assessed and important nutritional parameters are not documented. Nutritionally compromised patients may remain unidentified and not properly cared for. Relevance to clinical practice. Assessment and documentation of the patients' nutritional status should be routinely performed in a more structured way in both municipal care and county council care. There is a need for increased nutritional nursing knowledge.