Nutrition & Dietetics 2012; 69: 39–45
DOI: 10.1111/j.1747-0080.2011.01568.x
INSIGHT
Supporting healthy eating practices in a forensic psychiatry rehabilitation setting ndi_1568
39..45
Nicky FORSYTH,1 Jane ELMSLIE2 and Maria ROSS3 1
Nutrition Services, North Shore Hospital, Waitemata District Health Board, Auckland, 2National Addiction Centre, Department of Psychological Medicine, University of Otago, Christchurch, and 3Dietitians New Zealand, North Shore City, New Zealand
Abstract Aim: To evaluate the confidence and education requirements of nursing staff to provide evidence-based nutrition advice and practical assistance to patients of a healthy living programme in a forensic psychiatry rehabilitation unit. Methods: Participants completed semistructured interviews in pairs or individually to explore how their beliefs and attitudes about food and nutrition influenced their ability to support patients to plan and prepare healthy meals. Interview questions explored the nurses’ perceptions about the nutrition education needs of patients, their own nutrition knowledge, their confidence to provide nutrition advice, previous nutrition training and their current need for further training. All participants also completed a nutrition knowledge questionnaire. Data from the Nutrition Knowledge Questionnaire were summarised descriptively. Thematic analysis was used to identify the key themes that emerged from the interview transcripts. Results: Nine of eleven potential participants took part in the study. Four main themes emerged from the semistructured interviews: ‘knowledge and experience’, ‘barriers to change’, ‘realistic expectations’ and ‘reducing barriers’. Nine questionnaires were completed and returned (100% response rate). The average score was 50% (11/22). Scores ranged between 9 (41%) and 15 (68%). Three respondents scored less than 50%. Conclusion: This study highlights a need for dietitians in mental health settings to be involved not only with patient care but with staff education, to ensure that nursing staff receive the training and ongoing support necessary to protect and enhance the nutritional health of patients.
Key words: forensic psychiatry, healthy eating, mental health, nurse, nutrition.
Introduction People with serious mental illness have poorer physical health than the general population and a correspondingly reduced life expectancy.1 This is due partly to the higher prevalence of overweight and obesity among psychiatric patients compared to the general population,2 reduced access to health services,3–5 and lifestyle factors such as poor diet, low levels of physical activity and smoking.6,7 In addition, both the genetic factors associated with a predisN. Forsyth, PGDipDiet, NZRD, Clinical Dietitian J. Elmslie, PhD, NZRD, Research Fellow M. Ross, PGDipDiet, NZRD, former Team Leader Correspondence: N. Forsyth, North Shore Hospital, Private Bag 93 503, Takapuna, North Shore City 0740, New Zealand. Email:
[email protected] Research conducted at the Mason Clinic Regional Forensic Psychiatry Services, Private Bag 19986, Avondale, Auckland 1746, New Zealand. The study was completed in partial fulfilment of the requirements for the Postgraduate Diploma in Dietetics at the University of Otago, New Zealand. Accepted June 2011
© 2012 The Authors Nutrition & Dietetics © 2012 Dietitians Association of Australia
position to mental illness, and the medications used to treat it, may predispose patients to type 2 diabetes and cardiovascular disease.8 In New Zealand, dietetic services in mental health are insufficient to meet demand9 and this demand will increase with the need to address the physical as well as the mental health needs of patients with mental illness.3 Mental health nurses are in a key role to promote healthy lifestyle change in patients at risk of developing chronic disease.10,11 Nurse-led interventions have been found to be an effective model for patient education and improved health outcomes in patients with coronary heart disease,12 diabetes13 and obesity.14 Nurses are widely regarded as a highly credible source of health information; many provide nutrition education as a regular part of their work10,15 and are increasingly taking on a chronic disease prevention role.16 However, nurses may be poorly equipped for this role.11 Some studies have found their nutritional knowledge to be no better than that of the general public,17,18 scoring an average of 62% (a low-to-moderate score)19 in nutrition knowledge questionnaires.19–24 Many nurses also under-16,18,25 or overestimate15–18,23,25–27 their ability to provide 39
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dietary advice. In addition, nurse participants in several studies report seeking nutrition information from unreliable media sources.18–20 Nutrition information from these sources may mislead or harm those without sufficient knowledge to interpret it critically.28 Nonetheless, with specialist training, nurses can contribute effectively to the management of lifestyle factors involved in the aetiology and progression of chronic disease.12,13 Nurse-led interventions have been shown to be effective in promoting weight loss and healthy lifestyle behaviours in patients with and without psychiatric illness29,30 and weight loss interventions delivered by nurses in collaboration with dietitians31,32 have yielded promising results. The study aimed to evaluate the confidence and education requirements of nursing staff to provide evidence-based nutrition advice and practical assistance to patients participating in a healthy living programme in a forensic psychiatry rehabilitation unit.
Methods A mixed methods study design was used. Ethical approval for the study was obtained from Waitemata District Health Board Knowledge Centre. All participants provided written informed consent. All nursing staff currently working with patients participating in a healthy living programme were eligible to participate. The healthy living programme teaches life skills to patients in a forensic psychiatry rehabilitation unit who are preparing for independent living in the community. Eligible nursing staff were made aware of the study by the Healthy Living Programme coordinator. Initial contact was by email to organise convenient dates for the interviews. A follow-up telephone call was made to discuss logistics, including dates and times. Participants completed a 30-minute semistructured interview in pairs (n = 6) or individually (n = 3), depend-
ing on staff availability at the time. The purpose of the interview was to explore how staff’s beliefs and attitudes about food and nutrition, and their self-confidence in giving nutrition advice, influenced their ability to support patients to plan and prepare healthy meals. To maximise opportunities for participation, interview times were organised around rostered shifts. Interview questions explored the nurses’ perceptions about the nutrition education needs of patients, their own nutrition knowledge, their confidence to provide nutrition advice, previous nutrition training and their current need for further training (Table 1). The interviews were audiotaped and transcribed verbatim by one author (NS). At the end of the interview, participants completed a nutrition knowledge questionnaire, adapted from a questionnaire previously validated in an Australian population.19 Questions not relevant to the target audience, such as those relating to pregnancy and children, or highly technical questions, were omitted. Other questions were reworded to include words and foods that were more applicable to the New Zealand context. Additional questions relating to the Ministry of Health Food and Nutrition Guidelines for Healthy Adults33 were added by the researchers. To avoid a priming effect, questionnaires were distributed to participants by the researcher at the end of the interview. This method also ensured that factual knowledge was realistically assessed by simulating the situation in which patients would ask for advice when nurses had no other sources of information to-hand. Data from the nutrition knowledge questionnaire were summarised descriptively. The interview transcripts were coded and independently analysed by two of the authors (NS and MR), to reduce observer bias. Thematic analysis was undertaken to identify key themes. The long-table approach,34 in which statements expressing similar concepts are grouped together, allowed the themes to emerge naturally from the data.
Table 1 Interview questions Question number 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 40
Question What are the kinds of food and nutrition questions you are asked by service users? Have you noticed whether your service users have particular nutrition/healthy eating-related knowledge or skill shortages? How confident do you feel when giving service users food and nutrition advice? Have you received any formal training or education in food and nutrition? (e.g. study days, training courses) Who or what do you feel is your major source of food and nutrition information? (e.g. basic training, professional journals, colleagues, media) Do you think you would benefit from further training or information on food and nutrition? How would this benefit you? What food and nutrition information or training would you find helpful in your role supporting service users to plan and prepare healthy meals? What would be the best way of communicating food and nutrition information or training to you to support service users to plan and prepare healthy meals? In terms of a written resource, how would this information or training best be presented? (e.g. written information, pictures/visual, style/format, book, pamphlet, wall chart) Any other ideas? © 2012 The Authors Nutrition & Dietetics © 2012 Dietitians Association of Australia
Supporting healthy eating in a forensic psychiatry setting
Results Nine of eleven (82%) potential participants took part in the study (Table 2). One staff member was unavailable due to illness, and another working night shift, was unable to attend an interview during the day. The majority were female, and aged over 30 years. For most of the staff interviewed (n = 6), the dietitian was the main source of nutrition information, but more than half (n = 5) stated that they used the Internet to answer patients’ nutrition questions. All staff referred to the existing nutrition protocols, which had been developed by longer serving staff members based on information gained from reading about healthy eating and from personal experiences with commercial weight loss programmes such as Sure Slim and Body for Life. Other sources of nutrition information were television shows, Healthy Food Guide magazine and their own ideas and experiences. Only one staff member stated that nursing experience was a source of nutrition knowledge. Interview discussions focused on ways of improving the nutrition knowledge of staff and patients and ways of providing them with relevant, evidence-based nutrition information; the barriers to engaging patients in dialogue about healthy eating; and their reluctance to take responsibility for their food choices. Four main themes emerged: ‘knowledge and experience’, ‘barriers to change’, ‘realistic expectations’ and ‘reducing barriers’. Knowledge and experience: Knowledge and experience was reflected in the nurses’ perceptions of their patients and themselves. The staff saw patients as having a lack of basic knowledge about food and nutrition owing to upbringing, socioeconomic status, culture, education, mental illness and being institutionalised.
Table 2 Demographics of study participants (n = 9) n Gender: Male Female Age (years): 20–30 31–40 41–50 50+ Title/position: Staff nurse Psychiatric assistant Professional qualification: Diploma in Nursing Diploma in Mental Health Nursing Bachelor of Nursing Bachelor of Health Science Postgraduate Certificate Mental Health Certificate in Mental Health Median number years in mental health
3 6 1 3 2 3 8 1 3 2 2 1 1 1 15 (range 2–34 years)
© 2012 The Authors Nutrition & Dietetics © 2012 Dietitians Association of Australia
“A lot of the guys we get come from not very well-to-do families . . . They’ve just got no idea. They come from a family that’s poor so you eat food that you can afford, not necessarily what’s healthy for you. And that’s what they’re all brought up with so it’s just an on-going battle from the time they walk in.” In relation to their own knowledge, none of the staff had received any formal nutrition education and saw this as a barrier to helping patients make healthier food choices. Most felt they knew the basics but lacked confidence when giving even simple advice. The dietitian was stated as their preferred source for nutrition information. “. . . and you know we don’t really have enough staff education before people come in or when they come in. It’s fly by the seat of your pants for a lot of it . . . ” “To be honest I wouldn’t feel 100% confident. I mean I have certain knowledge towards it but I don’t feel very confident.” Issues raised by patients, such as portion control and macronutrient content, were often areas of confusion for staff as well. “. . . focusing on portion control . . . they [the staff] get a bit confused and I think so do the residents as well.” “What’s good and what’s bad. Food labelling sometimes can be a bit confusing. Like you’ve got that labelling with carbohydrate per serve and a lot of that stuff is misleading.” The staff who had attended education sessions run by the dietitian felt more confident about their level of nutrition knowledge, but still found it difficult to pass this knowledge on to patients. “. . . I’ve attended some of the education groups, dietitian groups, so I feel a wee bit more confident. But then again, practising and then trying to teach the guys and educate them is a different story.” Barriers to change: Barriers to change included differences in food-related beliefs and practices among staff. They recognised that differences in their nutrition knowledge contributed to a lack of consistency in supporting patients to make healthier choices. “. . . Like some people have been here when the dietitian’s come in and they’ve made recommendations, and then somebody else has come in and made some recommendations to somebody else so you don’t all have the same information. So we could do with a consistent approach that everyone could follow.” “. . . if you don’t get everybody on the same page reinforcing the same thing . . . like if I say something they go to me ‘but xxxx saw me yesterday, she didn’t say anything so how come you’re bringing it up today?’ ” Patients’ resistance to change, expressed in their reluctance to ask questions and their avoidance of responsibility for their food choices, was also seen by staff as a barrier to 41
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change. Staff found that promoting understanding and awareness of healthy eating practices and encouraging patients to apply their learning was an ongoing battle. “Well they don’t really ask us anything, they try not to because they don’t want to be told not to do things they want to do. They try to get away with stuff.” “. . . Even though it’s [nutrition information] being fed to them they’re not really taking it on board. They still haven’t grasped it . . . [they think] this is what I have to do because I’m told to.” Realistic expectations: The need for realistic expectations, both of themselves and their patients, was also clearly expressed by the staff, who were aware of their patients’ right to autonomy and not taking too much control away from them by restricting their food choices excessively.
“Label reading was also seen as important.” “And reading the back, really understanding the back of the packet. The energy, the carbohydrates, the fat content. Because is it under 10 grams of fat content or is it sugar content? Is it not allowed to have any sugar at all?” Cost-effective ways of incorporating a variety of foods into patients’ diets was an issue frequently raised by staff. “Healthy eating on a budget. That would be a good one. Healthy versions of what they currently like to eat.” Portion size information was seen as a useful tool for assisting patients to eat more healthily. “Bread, how many slices are we allowed for breakfast and lunch? And what’s the equivalent? Are two slices of bread equivalent to one pita pocket?”
“But we don’t want to take too much control from them. We don’t want to dictate, you always want to have that element of choice for them.”
Simplicity was a high priority. The staff stated that visual information was more effective than words in conveying nutrition messages.
“. . . And also that you can have little bits of things that are considered fatty and not good for you but because of moderation they’re still healthy to have. I think you need a mixture of things rather than you just have low fat, low sugar, low this, low that. It’s just getting that balance isn’t it?”
“. . . in our staff room we have [a poster] of one big cookie is 80 minutes running. Now that’s really quite effective because it puts you off having a biscuit because you think ‘nah, it’s not worth 80 minutes of running’. It’s a quick reference. So pictures, I think . . . you can comprehend it too a lot better than just reading.”
The appreciation of realistic expectations was also evident in the staff’s recognition that breaking old habits and familiar practices was difficult, especially when this was combined with medication-induced alterations in food intake and behaviours learned from being institutionalised.
Nine nutrition knowledge questionnaires were completed and returned by staff (100% response rate). One questionnaire was omitted from the analysis as the respondent stated having used the Internet to find answers to some of the questions. The average score was 50% (11/22). Scores ranged between 9 (41%) and 15 (68%). Three respondents scored less than 50%. Respondents scored well in questions related to the nutrient value of foods (Table 3). The lowest scores were in the areas of major food groups, determining adequacy of individual intakes, the effect of mental illness on appetite, labelling, cost-saving strategies, fibre and risk factors for metabolic disease. Many of these topics were covered by the staff in education sessions with patients and, as stated during the interviews, were areas where they either felt confident in their knowledge (food groups, mental illness and appetite) or felt they would benefit from having further information (food labelling, meal planning on a budget).
“What they eat is all based on their drives, their medications. They get so hungry and crave carbohydrates and comfort food. But they do have a general lack of knowledge about food and eating. And that comes from upbringing and lack of education . . . and because of the standards of food that we had [with the previous foodservice provider] was really bad . . . that’s what they’ve become accustomed to . . . because they’ve been in the system for such a long time. So that’s another reason we’ve had such difficulties with them making healthier food choices . . . ” Reducing barriers to change: The staff viewed simple, practical information as the key to reducing barriers to healthier food choices for patients and creating an environment in which the staff and patients could learn together. Healthy meal and snack ideas, healthy takeaway options, meal ideas tailored to other cultures, healthy food on a budget, healthy versions of patients’ familiar or preferred foods and healthier ‘treats’ were all seen as important topics to be addressed. “. . . so that it looks tastier and similar to what they’re used to and interesting. Instead of saying ‘right, you’re in here now, it’s all healthy living, here’s your crispy salad.’ ” “And meal ideas. What to make. That would be a great help.” 42
Discussion The nursing staff in this forensic psychiatry rehabilitation unit had poor nutrition knowledge owing to a lack of formal nutrition education. They struggled to understand and apply basic nutrition principles, and their advice to patients was based on information from a mixture of reliable and unreliable sources, often resulting in inaccurate and inconsistent nutrition messages. The study participants felt that formal nutrition education would increase their knowledge and confidence and ensure that their patients received accurate and consistent nutrition information. © 2012 The Authors Nutrition & Dietetics © 2012 Dietitians Association of Australia
Supporting healthy eating in a forensic psychiatry setting
Table 3 Nutrition knowledge questionnaire results by question and average score Test item
% Correct
Maintenance of desirable weight best guide for determining adequacy of energy intake Milk powder is the best buy on a cost per nutrient basis Requirement for food calories increases when physical activity increases Centrally distributed excess fat carries a greater risk of metabolic disease HDL cholesterol not a risk factor for cardiovascular disease Of the following foods, one slice of wholemeal bread has the highest fibre content Four major food groups correctly identified Ingredients must be listed in descending order of proportion of the packaged product Per 100 g column on nutrition information panel used to compare different brands of food B vitamin deficiency may occur with habitual high alcohol intake Recommended daily intake of fibre for adults is 30 g Correct identification of the formula for calculating BMI Peanuts have a high saturated fat content Reaction to stress affects appetite Beef sandwich, cottage cheese, baked custard and skim milk not a balanced meal Saturated fat is more likely to raise cholesterol levels in the blood Correct identification of menu appropriate for prevention of heart disease Of the following cereals, toasted muesli has highest proportion of calories from fat Dried beans are a meal alternative Many women in low-income families tend to be overweight Brown rice has the highest nutrient value of all types of rice Frying increases intake of fat in the diet Average score
Our findings are consistent with several previous studies showing that although nurses often give dietary or foodrelated advice, they frequently lack the training and confidence to provide even simple healthy eating advice. In our study, the nutrition knowledge scores of the participants were lower than those found in previous comparable studies;19–24 an average score of 50% compared with 62% in previous studies. This is unsurprising in light of the fact that none of the participants had received any formal training in nutrition and most obtained their information from a mixture of official and unofficial sources. In common with previous studies that have found nurses’ nutrition knowledge to be no better than the general public,17,18 we found that many participants were unable to distinguish their own nutrition education needs from those of their patients. Despite overestimating their nutrition knowledge in some areas, as highlighted by low scores in the nutrition knowledge questionnaire for topics in which they felt confident in their knowledge, participants in the present study lacked confidence when giving advice to patients. This is in agreement with a previous study of primary care nurses’ attitudes towards obesity management, where many participants felt ineffectual giving dietary advice.16 The nurses in our study were conscious of imposing too many restrictions that might impinge on patients’ rights. The term ‘food police’ was frequently mentioned, and the staff who faced personal challenges as a result of their own lack of nutrition knowledge, spoke of feeling ‘in the same boat’ as patients. This finding is in agreement with that of Brown and Thompson35 who found that primary care nurses with a high body mass index © 2012 The Authors Nutrition & Dietetics © 2012 Dietitians Association of Australia
11 11 11 22 22 22 33 33 33 44 44 56 56 56 67 77 78 78 89 89 100 100 50%
(n = 1) (n = 1) (n = 1) (n = 2) (n = 2) (n = 2) (n = 3) (n = 3) (n = 3) (n = 4) (n = 4) (n = 5) (n = 5) (n = 5) (n = 6) (n = 7) (n = 7) (n = 7) (n = 8) (n = 8) (n = 9) (n = 9) (11/22)
(BMI) doubted their effectiveness as role models for weight loss patients. Our study participants felt most confident in their knowledge about the aspects of diet they knew least about. This finding is in agreement with previous studies showing that nurses commonly overestimate their nutrition knowledge.15–18,22,23,25,27 Less than half the participants in the present study knew the correct formula for calculating BMI and the majority were unaware that maintenance of a healthy weight is the best indicator of the adequacy of individual energy intakes, or that an increase in physical activity increases energy requirements. Only three participants correctly named the four major food groups and some respondents thought that snack foods and desserts were necessary components of a healthy diet. Their understanding of the risk factors for metabolic disease was similarly poor. Most did not realise that increased levels of LDL cholesterol were a risk factor for cardiovascular disease. The majority believed that a BMI ⱖ 30 carried a greater risk of metabolic disease than centrally distributed excess fat. This misunderstanding is of particular concern in psychiatric populations among whom central fat distribution is associated with comorbidities, such as the metabolic syndrome, diabetes and cardiovascular disease.36 These findings clearly underline the risks in assuming a basic level of nutrition knowledge common to all health professionals and suggest that the failure to appreciate this has the potential to cause harm.37 Although the dietitian was an important source of nutrition information for most staff in the present study, many also relied on more experienced nursing staff for nutrition 43
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information. However, peers may be unreliable sources of nutrition information as evidenced by a study that found no significant correlation between years of nursing experience and overall nutrition knowledge score.21 All our participants reported accessing nutrition information from the Internet, television and magazines, sources which may promulgate nutrition misinformation.37 Similar findings concerning nurses’ knowledge and competence in acquiring evidencebased information were reported by a recent Australian study, which found that primary care nurses frequently do not use evidence-based nutrition information in their practice38 and that most, particularly older nurses rely on experiential learning, interactions with clients, peers, medical practitioners and specialist nurses as sources of knowledge. The nurses in the present study demonstrated a willingness to learn more about nutrition and felt that the dietitian was the most appropriate member of the staff to provide nutrition education. This is consistent with previous research showing that in-service training provided by a dietitian can positively affect practice nurses’ attitudes, practice and nutrition knowledge.20 Healthy living programmes delivered by nurses trained by dietitians to deliver group education sessions, produce positive results in terms of improved dietary behaviours and weight loss among psychiatric patients,8,10,30,39 and collaborative approaches to programme delivery by nurses and dietitians have been equally successful.31,32 There were several limitations in this study. The small, convenience sample of mental health nurses from one forensic psychiatry rehabilitation unit may not be representative of the nutrition-related knowledge of all mental health nurses and requires further exploration. The adapted nutrition knowledge questionnaire was not re-validated for use in the present study as this was beyond the scope of the study. It is possible that this may have influenced the participants’ responses. In addition, it would have been useful to explore patients’ perspectives concerning the barriers they face in adopting more healthy behaviours but this was beyond the scope of the present study. This study highlights a need for dietitians in mental health settings to be involved not only with patient care but with staff education, evaluating the nutrition education needs of staff to ensure that they receive the training and ongoing support necessary to protect and enhance the nutritional health of patients.
Acknowledgements The authors wish to acknowledge the staff of the Healthy Living Programme who participated in the study, and Dr Daryle Deering and Dr Ria Schroder of the National Addiction Centre, Department of Psychological Medicine, University of Otago, Christchurch, for helpful comments on the manuscript.
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