Multidisciplinary Provision of Food and Nutritional Care to Hospitalized Adult In-Patients: A Scoping Review

Figures & data

Figure 1 PRISMA diagram. Search strategy and study selection process.

Notes: PRISMA figure adapted from Liberati A, Altman D, Tetzlaff J, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. Journal of clinical epidemiology. 2009;62(10). Creative Commons.⁷⁷

Abbreviations: NC, nutritional care; MD, multidisciplinary; MDT, multidisciplinary teams; PEG, percutaneous endoscopic gastrostomy.

Table 1 Characteristics of Included Studies

Author Year & Country	Study Aim/Purpose	Type of Study/ Method	Setting Hospital Ward identified	Component of the Food and Nutritional care examined	Discipline involved	Multidisciplinary Interventions/ Approach and Collaborative activities	Key outcomes reported
Carson and Close (1996)^Citation29 United Kingdom	To examine the nutritional care received by patients, identify key areas, and develop an audit tool	Collaborative multidisciplinary exploratory clinical audit study	Community hospitals Ward not specified	Meal environment (meal support and eating support) Food modification Documentation Education Referral	Nursing Dietetic Catering and Patients	Collaborative practice based on expertise to examine, develop an audit tool, oversee the process and analyses result	Commitment and enthusiasm were necessary components for project success Requirements for nutritional adequacy, documentation and recording of nutritional assessments were met. Nurses’ nutritional knowledge base, patients’ perceptions of the meal service, and good nutritional practice were fair, requiring further essential training. Managers, nurses, dietitians, catering staff and clinical audit staff, are required in the provision of a collaborative nutritional care approach
Gee et al. (1998)^Citation33 United Kingdom	To provide a multidisciplinary approach to nutritional status with the objective of developing a concise assessment tool identifying the nutritionally at- risk patients	Pilot study, Nutritional Risk audit tool development	Elderly care unit	Nutritional assessment	Speech and Language therapist, Dietitian, Nursing staff	Multidisciplinary group formed to develop an assessment tool Re-educative strategy for day and night nursing staff to use the assessment tool Biweekly team meeting	Multidisciplinary team approach awareness within the unit. Re-design of a more clearly defined nutritional assessment risk score tool
Biernacki and Barratt (2001)^Citation34 United Kingdom	To establish whether self-feeding could be prolonged by using foods that could be picked up rather than a meal that required the use of utensils	Quasi‐experimental 6‐year period Patient BMI scores	Long-stay Ward	Nutritional assessment Therapeutic diet Assessment Meal environment (eating support)	Nurses, Dietitian, Speech and Language therapist Caterers, Occupational therapist Medical personnel	Qualified Nursing staff training on swallowing difficulties and management and use of assessment tool Including training in the use of fluids thickening product with varying consistency for easy swallow	Increased fluid intake with significantly less distress for patients Increased confidence of staff when assisting to feed patients and BMI scores reflected weight gain Outcomes shows undernutrition can be reversed and patients with dementia can have improved nutritional status
Robinson et al. (2002)^Citation35 United States	The purpose of the study was to determine if hospitalized elders would consume a greater proportion of their meals if they receive feeding assistance from trained volunteers	Quasi‐experimental 2-month period Meal Mates records of Patient’s percentage of the entire tray (food and fluids, consumed at each meal), and feelings regarding the experience	Medical Unit	Mealtime assistance and Food intake	Meal volunteers, nurses, Dietitian, speech therapist, and occupational therapist	Knowledge transfer and training In-service training taught by an interdisciplinary team composed of 4 nurses, a dietitian, a speech therapist, and an occupational therapist Followed by assessment of food chart recording	Improved patient intake. Job satisfaction from volunteers and general assistance to the nursing staff. Patients fed by the volunteers nearly doubled their intake over those fed by nursing staff
Hayward (2003)^Citation36 United Kingdom	To evaluate the effectiveness of new nutrition coordinator role to both patients and staff	Pilot study Six months Questionnaire, Audit report Patient charts	Medical Ward	Nutrition monitoring, Malnutrition risk screening Meal environment (food ordering, meal service, food waste)	Catering Dietetics Speech and language therapy Nursing Manage-ment Ward manager	Collaborative effort by the team to create a new role to address the nutritional needs of patients Introduction of the new coordinator’s role designed with ongoing support from the clinical team and nutrition nurse Enhanced communication between Ward and catering department	Key success factor was the role of the nutritional coordinator in assisting in facilitating the administration of the patient’s nutritional needs specialist The role demonstrated a significant impact on nutritional screening, nutritional service, patients’ perceptions of their nutritional care and staff satisfaction
Richmond (2007)^Citation37 United Kingdom	To develop the role of a Ward housekeeper within a multidisciplinary team	Clinical audit and using nutrition practices as a KPI	All Wards (Not specified)	Meal environment, nutrition, and stores management	Matrons, nurses, dietitians, speech and language, catering facilities managers and service users	Multidisciplinary meetings and agreed on a six-point plan for all staff to follow	Multidisciplinary working between catering, facilities, dietetics, and nursing staff has improved the quality of service for patients The development of the housekeeper service within a corporate, multidisciplinary framework has had a beneficial effect on patients ‘nutrition and a positive impact on the patient experience in relation to the meal environment
Dickinson et al. (2005)^Citation38 United Kingdom	To improve the nursing care that older people received at mealtimes	Action Research Action learning, role modelling good practice and reflection Focus groups with staff, interviews with patients, six mealtime observations and benchmarking	Older persons’ Ward (Not specified)	Mealtime environment and mealtime nursing practice	Healthcare assistants, nursing staff and occupational therapist and physiotherapist	Educational sessions for staff engagement to prioritize patient’s mealtime Collaboration between nursing staff healthcare assistants, occupational therapy, and physiotherapy to identify problems of poor nutrition	Significant staff engagement and involvement in prioritizing mealtimes, ensuring that there were sufficient time and expertise available to assist patients with eating Ward staff made several changes to their nursing practice
Thoresen et al. (2008)^Citation39 Scandinavia	To investigate whether doctors and nurses on units with greater access to clinical dietitians had a greater interest and focus on clinical nutrition.	Quantitative Questionnaire Survey	Hospital staff focused. (Ward not specified)	Nutritional support via referral from the perspective of staff	Doctors, nurses, and clinical dietitians working in hospitals	Collaborative questions retrieved Multidisciplinary perspective retrieved on the evaluation of nutritional status, the use of enteral and parenteral nutrition, the allocation of responsibility and measures in the unit and education, knowledge, and routines	Reported findings indicate that in general, doctors and nurses do not acknowledge the expertise of the clinical dietitians Findings show that doctors and nurses on Wards with greater access to clinical dietitians had better focus on clinical nutrition
Brown and Jones (2009)^Citation40 United Kingdom	To ensure that patients in hospital receive nutritional care in a timely and comfortable manner	Pilot study Implementing the dining companion initiatives	Hospital Two Wards (Not specified)	Eating support	Volunteers speech and language therapy dietetic departments nursing staff	Interactive training workshop led by speech and language therapist and dietitians Volunteers assisted with feeding Speech and language therapists liaised with nursing staff to ensure support and advice was available for nursing staff Dietitians education for nurses on safe eating and drinking techniques	Reluctant eaters ate well and ‘appeared ‘to benefit from extra time and attention Evidence of improved patient care from the nursing staff was reported. Nurses reported feeling more supported in the aspects of mealtime Findings indicate that volunteers working as dining companions can provide valuable support in helping to maintain patients’ nutritional status
Hoekstra et al. (2011)^Citation41 Netherlands	To determine the effectiveness of a multidisciplinary intervention program on nutritional intake and of nutritional intake on nutritional status and quality of life in older patients treated for a hip fracture	Controlled prospective cohort study Food records	Trauma Ward	Malnutritional risk screening, nutritional assessment and eating support	Nurses, doctors, and dietitians Feeding assistant	Clearly defined roles for nurses, doctors, and dietitians	A multidisciplinary postoperative approach of nutritional care was associated with an increase of energy and protein intake during hospitalization Multidisciplinary nutritional care strategy reported to have increased the intake of energy, protein, vitamin D, zinc and calcium in the immediate postoperative period compared to standard nutritional care. The intervention group appeared to experience a significant beneficial effect on the quality of life and nutritional status according to the MNA after three months follow-up compared to the control group.
Macdonald et al. (2012)^Citation42 United Kingdom	To identify opportunities for and to develop and prototype a new food and nutritional management system able to meet individual patients’ daily requirements	Participative people-centered action research method, ethnography and workshop-based methods	Hospital Ward not specified	Meal environment. Meal support	Design researcher, food scientists, dietitians, medical sociologist, ergonomists, computer scientists, technologists, food producers, caterers, Ward staff, nurses, physicians, speech, and occupational therapists	Iterative multidisciplinary co-design process and testing of an electronic nutritional management and monitoring system	The evaluation and trialing proved that the ‘hospital foodie’ prototype could deliver effective improvements in ward-based nutritional care. The outcome of the whole team’s efforts through a structured and iterative approach to innovation was reported greater than the sum of normally separate contributions from a different discipline
McKeane (2012)^Citation43 United Kingdom	To enhance patient care and dignity while ensuring all patients are supported to have adequate nutrition and hydration	Rapid Spread clinical change methods	Across all Wards (not specified)	Nutrition assessment	Nursing staff, dietitians, radiographer, speech and language therapists and representatives from the catering and communication departments	Multidisciplinary project team was set up consisting of key stakeholders that included nurses. Staff explored solutions and solve issues as a team and communicated to the rest of the trust the changes they had brought about	Improvement in patient care as a result of more robust nutritional assessment Patient satisfaction has improved. Staff now feel empowered to make the changes required to deliver on aspects of patient nutritional care
Walton et al. (2012)^Citation44 Australia	To explore current practices of foodservice provision in Australian hospitals. To determine the key barriers to adequate dietary intakes. Prioritize the most practical interventions for ongoing improvements to foodservice provision	Qualitative Survey Focus Groups	Hospital (184 hospitals participated) Medical and rehabilitation Wards	Nutritional Support	Dietitians, nurse unit managers and food service managers	Multidisciplinary inquiry via a web-based questionnaire	Significant agreement between stakeholders regarding many key barriers and priority interventions for improvement A lack of feeding assistance, limited variety and inadequate flexibility of food service were the key barriers identified Food fortification, assistance with packaging, additional feeding assistance by nurses, non-nursing feeding assistance and further nutrition assessment were key priorities for improvement
Cooper (2013)^Citation45 United Kingdom	To investigate current practice at Ward level regarding adherence to a care plan generated from a nutrition screening tool, improve basic nutritional support actions by modifying a care plan and finally evaluates the change in practice	Qualitative study Focus groups	Hospital	Malnutrition risk screening Nutritional care plans	Staff nurse, clinical support worker, Student nurse assistant practitioner, sister, dietitians Ward staff	Multidisciplinary perspectives via Focus group discussion Focus groups allowed engagement with Ward staff to explore how care plans were used, which assisted in re-designing the care plan	Themes regarding barriers and facilitators for completion of care plans were derived from the focus groups, including: ‘duplication,’ ‘time pressures,’ ‘leadership support,’ ‘operational issues,’ ‘document style’ and ‘training.’ Nutritional support actions increased from 13 (9%) to 98 (52%) for moderate or severe malnutrition risk patients. The study showed that completion rates of an ICP could be improved by involving staff in the development of documentation
Farrer et al. (2013)^Citation46 United Kingdom	To evaluate the practice of nutritional screening using MUST in elderly care wards, and to assess whether healthcare improvement methodology can address any discrepancies in nutritional screening that may be apparent	Random pilot study MUST scores records	Hospital care of the elderly’ Wards	Malnutrition risk screening	Senior nursing leads, Ward managers, nurses and auxiliary staff catering and dietetic staff	The Steering team to examine six-month retrospective data and collectively evaluated the project team Baseline ‘MUST’ data was documented in <60% of patients within six hours of admission, of which only 70% were accurate.	All the Wards achieved an improvement and documented MUST within six hours of admission; one Ward achieved 90% accuracy in the scores. Ward teams receiving training and monthly feedback of their results created ownership, momentum and maintained enthusiasm for striving to reach stretch targets
Heaven et al. (2013)^Citation47 United Kingdom	To understand and describe processes that promote or inhibit nutrition in hospital	Qualitative Interviews and focus groups	Hospital staff focused (not specified)	Meal support and eating support (Food work and feeding assistance)	Catering managers, catering staff, consultants senior nursing, health care assistant, housekeeper, staff nurse, occupational therapist, physiotherapist, dietitian, speech & language therapist, stakeholder representatives patients and carers	Perspectives via Interviews with health care professionals. Interpersonal engagement through feeding assistance and reassurance and the arrangement of resources that facilitate meals such as the preparation of food trolleys	Findings demonstrate how food work is overlooked by being conceptualized as common sense and as one of the most mundane and elementary tasks in hospitals Food work constituted two overlapping spheres of activity: interpersonal engagement through feeding assistance and reassurance and the arrangement of resources that facilitate meals such as the preparation of food trolleys
Young et al. (2013)^Citation48 Australia	To implement and compare three interventions designed to specifically address mealtime barriers and improve energy intakes of medical inpatients aged 65 years	Prospective study	Hospital	Meal support and eating support	Dietitian, dietetic assistant, nursing staff other Ward staff	Clearly defined roles collaborative working between dietitians, dietetic assistants, and nursing staff	Findings suggest improving mealtime assistance by enhancing the mealtime involvement of existing staff across disciplines may be as effective as introducing a dedicated feeding role
Bell et al. (2014)^Citation49 Australia	To investigate the impact of individualized versus multidisciplinary nutritional care on nutrition intake and outcomes in patients admitted to a metropolitan hospital acute hip fracture unit	A prospective, controlled before and after comparative interventional study using an action research-based approach Records of anthropometric measurements Records of nutritional assessment	Hospital Orthogeriatric unit	All aspect	Orthopaedic and geriatric consultants, surgical and medical registrars and resident medical officers, nursing staff, senior and junior physiotherapists and occupational therapists, a senior dietitian, a social worker, a pharmacist, healthcare assistant staff, and operational staff	Case-conferencing and daily board rounds (Monday Friday) attended by multidisciplinary staff to support integrated patient care and discharge processes	Multidisciplinary nutritional care reduced intake barriers and increased total 24-h energy Multidisciplinary nutritional care improves nutrition intake and outcomes in acute hip fracture inpatients
Keller et al. (2014)^Citation50 Canada	To identify enablers and challenges and, specifically, the activities, processes, and resources, from the perspective of nutrition care personnel, required to provide quality nutrition care	Qualitative study Focus group discussion	Hospital staff focused. (not specified)	All aspect of nutritional care focused on barriers	Dietitians, dietetic interns, diet technicians and menu clerks	Multidisciplinary perspectives via focus group discussion	Five themes reported regarding the nutrition care process. Developing a nutrition culture, Using effective tools Creating effective systems to support the delivery of care Being responsive to care needs Uniting the right person with the right task
Roberts et al. (2014)^Citation51 United Kingdom	To determine the feasibility and acceptability of using trained volunteers as mealtime assistants for older hospital inpatients	Qualitative study Focus group and interviews	Hospital	Mealtime support Eating support	Volunteers, patients, and nursing staff, speech and language therapist	Multidisciplinary training	Changes in practice including hospital senior nursing, therapy, and dietetics teams continue training and assessment of competency of volunteers Senior Ward nursing staff takes on role to identify suitable patients for assistance, supporting the volunteers as part of the Ward team
Schultz et al. (2014)^Citation52 South Australia	To evaluate a multifaceted nutritional intervention implemented across a metropolitan hospital	Randomized cluster trial	Hospital	Malnutrition risk screening	Nursing staff, dietitian and other staff groups not defined	Nurse-dietitian pairs as facilitators The intervention involved staff education and training on the use of MUST tool Changes to hospital policy on nutritional screening using ‘MUST’ Provided patients with nutritional supplements and feeding assistance (‘red trays’)	Implementation of a multifaceted nutritional screening was facilitated by the stepped wedge design and led to improved screening rates and patients being weighed by nurses on a weekly basis
Mudge et al. (2015)^Citation53 Australia	To engage the interdisciplinary care team to recognize the care needs of older patients, recognize care gaps, and take responsibility for local, sustainable solutions	Implementation study Promoting Action on Research Implementation in Health Services (PARIHS) framework	General medical Ward	Eating support	Physician, medical officers, physiotherapist occupational therapist, social worker, nurse unit manager, nutritionist, and speech therapist	Partnership between a treating team who met daily with the medical and Ward-based nursing staff to discuss patients’ care and discharge planning	The audit showed improved nursing documentation in targeted domains during the first 18 months and improved performance of mobilizing and cognitive strategies; length of stay for older inpatients fell by 3 days on the intervention Ward
Robison et al. (2015)^Citation54 United Kingdom	To obtain multiple perspectives on nutritional care of older inpatients, acceptability of trained volunteers and identify important elements of their assistance	A qualitative study Semi-structured interviews and focus groups	Acute Wards	Mealtime environment Meal support Eating support	Health care assistant, staff nurse, Ward Sister, matron, housekeeper, volunteers and relatives	Multidisciplinary perspectives via interviews and focus groups	The introduction of trained volunteers was perceived by staff and patients to have improved the quality of mealtime care by preparing patients for mealtimes, assisting patients who needed help, and releasing nursing time to assist dysphagic or drowsy patients Reported factor for success was if a good relationship and a sense of teamwork can develop between Ward staff and volunteers
Collins et al. (2017)^Citation55 Australia	To explore, from the perspective of hospital foodservice staff, their experiences of delivering a nutrition intervention and the barriers and enablers to its implementation	Parallel controlled qualitative pilot study Focus groups and semi-structured interviews	Hospital food service staff	Meal support/food service	Foodservice staff, foodservice assistants, and supervisors	Multi-perspectives via interviews and focus groups	Five key themes were reported. I. Environmental factors ii. Characteristics of the nutrition intervention iii. Responses of the patients, iv. Implementation process factors, v. Characteristics of the foodservice staff Aspects of the foodservice environment and patients’ resistance were barriers to implementation and perceived sustainability. Teamwork, problem solving, leadership and job satisfaction were enablers Characteristics of foodservice staff, including their knowledge, beliefs and perceptions of diet, health, and their job role, had the potential to influence their behaviors and decision making
Laur et al. (2017)^Citation56 Canada	To understand how staff members perceived and described the necessary ingredients to support change efforts required to improve nutrition care in their hospital	Qualitative study focus groups	Hospital staff focused. (not specified)	Nutritional care practice	Nurses, physicians, food service workers, dietitians, and hospital management	Multidisciplinary discussion regarding ways to improve nutrition	Five main themes identified: i. Building a reason to change ii. Involving relevant people in the change process iii. Embedding change into current practice iv. Accounting for climate and v. Building strong relationships within the hospital team Participants described key ingredients to support successful change and specifically engaging the interdisciplinary team to effect sustainable improvements in nutrition care
Eglseer et al. (2018)^Citation57 Australia	To determine the effect of the use of a valid and reliable malnutrition screening tool as part of an existing electronic documentation system in a hospital to assess the knowledge, attitudes, and perceived practices (KAP) of nurses, nurses’ aides, and physicians regarding malnutrition	A controlled qualitative study Questionnaire	Hospital staff focused. (Ward not specified)	Malnutrition risk screening	Nurses, nurses’ aides, and physicians	Multidisciplinary perspectives via interviews and focus groups	Implementation of a validated malnutrition screening tool helped improve the KAP of healthcare staff KAP reported as key components for successful nutritional care in malnourished patients.
Howson et al. (2018)^Citation58 United Kingdom	To evaluates the wider implementation of a mealtime assistance programme	Mixed methods prospective quasi-experimental study Questionnaire Interviews and focus group	Across 9 Medicine for Older People’ Wards	Mealtime Environment Meal support Eating support	Patients, volunteers, Ward managers, student nurse and housekeepers	Multi-perspectives via interviews and focus groups	Patients and nurses universally valued the volunteers, who were skilled at encouraging reluctant eaters Training was seen as essential by volunteers, patients, and staff. The volunteers released potential costs of clinical time equivalent to a saving of £27.04/patient/day of healthcare assistant time or £45.04 of newly qualified nurse time above their training costs during the study
Byrnes et al. (2019)^Citation59 Australia	To explore staff perceptions about barriers and enablers to practice change aligning with nutrition-related recommendations from ERAS guidelines	Qualitative study Interviews	Hospital staff focused. (Ward not specified)	Nutritional care policies	Surgical consultants, registrar, intern; anaesthetist; nurse unit managers, surgical nurse coordinator, nurses, and dietitians	Multidisciplinary perspectives via interviews	Three major themes were identified: i. Complexity of the context (unpredictable theatre times, the requirement for flexibility and large, multidisciplinary workforce) ii. Strong decision-making hierarchy, combined with lack of knowledge, confidence, or authority of junior and non-surgical staff to implement change; and iii. Poor communication and teamwork (within and between disciplines) Proposed change processes and ongoing communication to establish adequate monitoring and feedback processes
Ottrey et al. (2019)^Citation60 Australia	To explore the relationships, roles, and responsibilities of staff involved at hospital mealtimes, and their impact on nutrition care	Qualitative Study Observations and interviews	Hospital staff focused. (Ward not specified)	Mealtimes, and the influences on meal provision	Nurses, dietitians, speech pathologists, physiotherapists, occupational therapists, social workers, food and support services, and administration staff	Multidisciplinary perspectives via interviews	Three themes describing Ward culture and staff relationships reported: Defining mealtime roles and maintaining boundaries Balancing the need for teamwork and having time and space Effective communication supports role completion and problem-solving
Roberts et al. (2019)^Citation61 Australia	To develop, implement, and evaluate a multifaceted, tailored intervention to improve nutrition care, delivery, and intake among acute medical inpatients	Pre-post observational study	Acute Medical Unit	Food intakes, and the mealtime environment	Nurses, patients, doctors, and foodservice staff	Multidisciplinary co-development of intervention with key stakeholders which was a multifaceted and targeted individual, Ward, and organizational levels Multidisciplinary hospital staff training	Significantly higher patients’ mean energy and protein intakes and the number of patients eating adequately doubled Implementation alongside hospital staff and patients reported being effective in improving nutrition practices and patient nutrition intakes on an acute medical ward Increased awareness of nutrition among staff groups and a change in Ward culture regarding nutrition were reported
Sykes et al. (2019)^Citation30 Australia	To improve mealtime assistance (MTA) where needed to patients on a general medical Ward	Collaborative best practice implementation study (audit, feedback, and re-audit). Observation, combined focus groups of nursing and food service staff	Medical Ward	Meal delivery Nutritional assessment Meal environment Meal assistance	Nursing staff, food services officers, dietetics, volunteers, and representation from the centre for education and research	Staff education program Multidisciplinary teams to revise systems and processes to ensure that patients receive adequate and timely MTA	Reported significant improvements in the provision of MTA attributed to improved collaboration, communication, and cooperation between nursing and food services; clearly defined roles and responsibilities; increased patient assessment of the level of MTA system and protected mealtime period Changes in mealtimes from chaos to calm with the widespread support and buy-in from key stakeholders. The collaborative approach to barriers taken by the nursing and food services teams reported as critical to success

Figure 2 Application of input-process-outcome (IPO) framework.

Figure 3 Distribution of disciplines in the retrieved studies.

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