AU3S058 Research Paper Critique: Nutritional Care Study Analysis

This document presents a critique of the research article by Sjögren Forss et al. (2018) published in BMC Nursing, which explores the experiences of registered nurses (RNs) and older people regarding participation in nutritional care within nursing homes. The study employed a qualitative, descriptive design using semi-structured interviews with RNs and older adults in Sweden. The analysis revealed three key themes: 'participation in nutritional care equals information,' 'nutritional care out of remit and competence,' and 'nutritional care more than just choosing a flavor.' The findings highlight the challenges of paternalistic attitudes and asymmetrical nurse-patient relationships, despite RNs' awareness of the importance of patient involvement. The paper emphasizes the need for strategies to enhance older people's participation in their nutritional care within nursing homes. This analysis likely examines the study's methodology, findings, limitations, and implications for nursing practice, providing a comprehensive evaluation of the research's strengths and weaknesses, and its contribution to the field of geriatric nursing and patient-centered care. This analysis likely also includes a discussion of the study's relevance to current healthcare practices and potential areas for future research.

R E S E A R C H A R T I C L E Open Access
Registered nurses’and older people’s
experiences of participation in nutritional
care in nursing homes:a descriptive
qualitative study
Katarina Sjögren Forss1* , Jane Nilsson2 and Gunilla Borglin1
Abstract
Background:The evaluation and treatment of older people’s nutritionalcare is generally viewed as a low priority
by nurses.However,given that eating and drinking are fundamental human activities,the support and enhancement
of an optimal nutritional status should be regarded as a vital part of nursing.Registered nurses must therefore be
viewed as having an important role in assessing and evaluating the nutritional needs of older people as we
ability to intervene in cases of malnutrition.This study aimed to illuminate the experience of participating in nutritio
care from the perspectives of older people and registered nurses.A further aim is to illuminate the latter’s experience
of nutritional care per se.
Methods: A qualitative,descriptive design was adopted.Data were collected through semi-structured interviews (n = 1
with eight registered nurses and four older persons (mean age 85.7 years) in a city in the southern part ofThe
subsequent analysis was conducted by content analysis.
Result: The analysis reflected three themes:‘participation in nutritional care equals information’,‘nutritional care out of
remit and competence’and ‘nutritional care more than just choosing a flavour’.They were interpreted to illuminate the
experience of participation in nutritional care from the perspective of older people and RNs,and the latter’s experience of
nutritional care in particular per se.
Conclusions: Our findings indicate that a paternalistic attitude in care as well as asymmetry in the nurse-p
relationship are still common characteristics of modern clinical nursing practice for older people.Considering that
participation should be central to nursing care,and despite the RN’s awareness of the importance of involving the
older persons in their nutritional care this was not reflected in reality.Strategies to involve older persons in their
nutritional care in a nursing home context need to take into account that for this population participation m
always be experienced as an important part of nursing care.
Keywords: Care,Content analysis,Interviews,Malnutrition,Nursing interventions,Older people,Patient involvement,
Registered nurse
* Correspondence:[e-mail]
1Department of Care Science,Faculty of Health and Society,Malmö
University,SE-205 06 Malmö,Sweden
Fulllist of author information is available at the end of the article
© The Author(s).2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
InternationalLicense (http://creativecommons.org/licenses/by/4.0/),which permits unrestricted use,distribution,and
reproduction in any medium,provided you give appropriate credit to the originalauthor(s) and the source,provide a link to
the Creative Commons license,and indicate if changes were made.The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article,unless otherwise stated.
Sjögren Forss et al.BMC Nursing (2018) 17:19
https://doi.org/10.1186/s12912-018-0289-8

Background
Registered Nurses (henceforth abbreviated ‘RN’)mustbe
seen as an importantplayer in assessing,evaluating and
intervening in cases ofmalnutrition among older people.
However,research shows that malnutrition in older people
often goes unrecognised by RNs regardless of care context,
for example,in nursing homesand/orhospitals[1, 2].
Although the prevalence of malnutrition is known to range
from 15 to 40% in nursing homes [3–6],in terms of evalu-
ation and treatment [7,8],nutritional care in general is not
a highly prioritised issue.This is noteworthy,as food and
drink are essentialhuman needs hence,a vitalpart ofthe
fundamentalsof care [9]and consequently a mandatory
competency practice skillwithin the remit of the RNs role
in care.Thus,the supportand promotion ofthe optimal
nutritional status of older people should be a prioritised area
in nursing. A plausible explanation may be that RN’s respon-
sibility within nutritionalnursing care is unclear [10,11].
Another explanation may be that RNs need further in-depth
knowledge about nutritionalnursing care issues [1],as this
has been shown to increase their awareness ofnutritional
nursing care [12],and the nutritional status of older people
living in nursing homes [13, 14].
Maintaining an optimal nutritional status is important for
the wellbeing of older people and for promoting independ-
ent living [15].However,despite this knowledge,malnutri-
tion is a common and serious problem thatcontributes
significantly to morbidity and mortality in this population
group [16].Malnutrition is associated with a decline in,for
example,overallfunctionalstatusas well as impaired
muscle function and reduced cognitive function; in addition,
malnutrition causes decreased bone mass, immune dysfunc-
tion,and anaemia [17].The cause of malnutrition is often
multifactorialand includes medical,physiological,psycho-
logical and social as well as environmental factors [16,18].
Whereas the ageing process can often explain physiological
and psychological factors, environmental factors in terms of
mealambiance can be easily modulated.It appears that
environmentalstimuliare notchanged during the ageing
process;therefore,environmentalfactors should always be
considered as part ofa nutritionalnursing plan for older
people living in nursing homes [19].Given that the popula-
tion of older people is increasing worldwide, it is crucial that
healthcare professionals and RNs in particular actively work
to prevent malnutrition and identify ways to meet the diet
and nutrition needs of this vulnerable population.
It is reasonable to suggestthatif RNs highlightand
promote the importance ofolder people’s participation
(‘participation’and ‘involvement’will be used synonym-
ously in this paper) in their own nutritional nursing care,
then the risk of malnutrition may decrease.Internation-
ally and nationally there have been an obvious shift from
the earlier hierarchicalsystems at the hospitals [20,21]
towards patients rights,which also encompass nursing.
One plausible explanation forthis change offocusin
care are likely to be the strong democratic movements
during the twenty-firstcentury [22].Resulting in that
patients now,and regardless ofcontext,are viewed as
active participants in their care and healthcare decisions
[23].This shiftis not attributed to changes in profes-
sionalvaluesalone.Rather,the move towardspatient
empowermentand person-centredness,is according to
Christensen and Hewitt-Taylor [20] most likely the result
of “….changes in the dominant views of society and lack
of confidencein healthcareprofessionals,not simply
because the healthcare professionals have adapted their
thinking to be more respectful of patients’rights ([20] p.
696).” In Sweden the patient’s right to be informed and
to be made part of their own care is nowadays regulated
by the PatientAct [24] and the Health and Medical
Services Act [25].Older people’s participation in all parts
of their health care should therefore be considered as
essentialfor healthcare professionals,particularly asa
means to understand preferences and the optimisation
of care [26].Although previous research,conducted with
a quantitative design,has shown that the involvement of
older people has a positive effecton health outcomes,
for example,in terms of health status,raising the energy
intake [27] and satisfaction with care [28],older people
are less often involved in their care than younger people
[29, 30]. This despite studiesthat show olderpeople
want to be involved in their own care [31].‘Participation’
in care can mean to facilitateand encourageolder
people to share the responsibility oftheir own health
and to supportthem in the decision-making process
regarding their treatment and care [32] The involvement
of older people in their own care is central for promoting
person-centred nursing models,where RNs could play an
important role in establishing this modus operandi in the
care of older people.
Alharabiand colleagues [33]suggestthatthe lack of
both understandingand confidenceamonghealthcare
professionals about involving older people in their nutri-
tional care needs to be eliminated. The level of acceptance
healthcare professionals has in regard to olderpeople’s
participation in care,has been shown to be influenced by
the professionals’need to maintain controland lack of
time as well as the type of illnesses [34].Further,ways to
involve older people who reside in nursing homes in the
food and meal activities appear to be limited [35, 36]. This
may wellbe a factor thatinfluences nutritionalnursing
care negatively in this population group.The majority of
identified published nursing research seem to focus on the
risk of malnutrition and its consequences either in the
acute care setting or in the community alone,rather than
older people’s experiences ofparticipation in their nutri-
tionalcare at nursing homes.Thus,in-depth knowledge
about RNs,and older people’s experience of participation
Sjögren Forss et al.BMC Nursing (2018) 17:19 Page 2 of 13

in nutritional care and the RN’s experiences of this type of
care in a nursing home context is therefore still sparse. To
the best of our knowledge, very few studies exist exploring
this phenomenon in a nursing home context while includ-
ing both olderpeople and RNs.Therefore,this study
aimed to illuminate the experience ofparticipation in
nutritional care from the perspective of older people resid-
ing at nursing homes and RNs.A further aim was also to
illuminate the latter’s experience of nutritional care per se.
Methods
A qualitative,descriptive design [37] was used to under-
stand the experiences ofnurses and older people who
participate in nursing care when assessed as ‘at risk for
malnutrition’or as ‘malnourished’from the informant’s
point of view [38].Data were collected through semi-
structured interviews [37],and the subsequentanalysis
was inspired by Burnard’s [39,40] description of content
analysis.
Study setting
This study took place in a city in the southern partof
Sweden during spring 2016.In Sweden,the care of older
peopleis primarilya public responsibility,and the
provision ofcare and service for older people is mainly
financed through taxes.The countycouncilsare the
regional providers of healthcare, but the municipalities are
responsible for the care of older people living in their own
homes or in nursing homes.The care is guided by RNs;
however,the main providers ofcare and service in the
municipalities are staffnurses and healthcare assistants.
For the past 16 years in Sweden,the only way into the
nursing profession has been through a degree programme,
and since 2007,the only route has been via a bachelor’s
degree in Nursing Science, which involves 3 years of study
at university.The university education aims to equip the
Swedish nursing students with the knowledge,competen-
cies and skills needed to take the lead of care.Particularly
the competencies needed to assess,diagnose,intervene
and evaluate,in relation to the same essentialhuman
needs thatwas highlighted in care already by Florence
Nightingale in the nineteenth century. Eating and drinking
i.e.nutrition is hence part of the fundamentals of care [9],
and a required practice competency expectation for nurs-
ing care also in Sweden.
Nursing homes are homelike residentialcare facilities
for older people with mainly one-bed rooms that provide
around-the-clock care.Residents atnursing homes are
quite frail,and eightout of ten are aged 80 yearsor
older.In the nursing homes,staff nurses and healthcare
assisstants are on duty around the clock to provide regu-
lar care as well as palliative care.A RN (or,at times,two
RNs depending on the size ofthe nursing home) is on
call and accessible during officetime between Monday to
Friday.Most residentshave a primary care physician
who is employed by the county counciland who works
at the localhealthcare centre usually located nearthe
nursing home where the resident lives.
Sample and recruitment
In this study,12 informants agreed to participate:The
strategic sample [30] consisted offour older persons (65
+),of which three were female and one was male.Our
sample also consisted of eight RNs working in six different
special accommodations.Of the RNs,two were male and
six were female.
The inclusion criteria for the older persons were that
they should be age 65 or older,cognitively intact,and
able to read,speak and understand Swedish.They must
also reside in one ofthe municipality’s nursing homes
and have been assessed as ‘at risk for malnutrition’or as
‘malnourished’in accordance with the MiniNutritional
Assessmenttool [41], which meansthey will have
received a nursing diagnosis and intervention.Inclusion
criteriafor the RNs were that they should hold a
permanentposition atthe nursing home,work atleast
75% and be in charge of a ward not designated for older
people suffering from cognitive decline.
Recruitment process
In the first step ofthe recruitment process,a sample of
the city’s boroughs was made and nine out of 10 boroughs
were contacted.For obvious ethicalreasons,the borough
in which the second author (JN) was working where not
included in our study.After having received permission
from the relevant branch heads to contact the municipal-
ity services,the coordinator ofcare was contacted.The
latter contacted the patients’responsible RNs in nine of
the municipality’s nursing homes via email to inform them
about the study.They acted as recruiters alone,and were
asked to forward an invitation about participation in the
study to olderpeople and RNsmeeting the inclusion
criteria.In addition,the emailcontained an information
letter about the study for the RNs.Six of the nine nursing
homesthat were contacted agreed to take partin the
study.One reason given by the nursing homes for not
wishing to participate was a lack of time.
The RN in charge of each nursing home facilitated the
recruitmentof the older persons.In total,seven older
persons were assessed as meeting the study’s inclusion
criteria and thuseligible forthe study.Of these,four
older persons with a mean age of85.7 years (age range
74-90 years),residing in four differentnursing homes,
agreed to participatein the study(Table1). Of the
remaining three,one further individualinitially agreed,
but then withdrew ata later stage.Anotherbecame
acutely ill,and the third withdrew due to feeling unin-
formed about malnutrition being the focus of the study.
Sjögren Forss et al.BMC Nursing (2018) 17:19 Page 3 of 13

The interviewer provided written and verbalinformation
aboutthe study both when arranging the time forthe
interviews and before each interview began.All older per-
sons gave written and verbal consent to their participation
in the study.
The interviewer approached 14 eligible RNs,of which
eight RNs with a mean age of44.1 years (age range 28-
67 years) accepted to participate (Table 2).Reasons given
for not wanting to participate were,once again,a lack of
time.During a face-to-face meeting,they were once again
provided with verbal and written information,and a time
and place was arranged for the interview.All informants
in this study (n = 12) were informed about confidentiality
and their right to withdraw at any point without needing
to give any explanation for doing so.
Semi-structured interviews
The semi-structured interview method was used to collect
the data [30],and they were conducted by the second
author (JN) during April 2016.The interviews began with
one overarching question (Fig.1), which became more
specificas the interviewsproceeded.The overarching
interview question was tested,by the second author (JN),
on two RNs and one older person ahead of the interviews
to assure its understandability and its relevance for the
study aim.This testdid not lead to any changes.Data
from this test were not included in our analysis. Whenever
clarification wasneeded during the interviews,general
probing was used (ibid).The interviews with the older
people were conducted in their home and at a time and
place oftheir choice,while the interviews with the RNs
took place during working hours in a separate room at the
informant’s workplace – a place familiar to the informants
and at a time thatwould maximise participation.The
interviews lasted approximately 30–40 min and were tape
recorded and transcribed before the analysis begun.
Content analysis
The transcribed texts were analysed by a method influ-
enced by content analysis, as outlined by Burnard [39, 40],
and focused on both the manifestand latentlevels,as
outlined by Graneheim and Lundman [42]The process
involved four steps.In the first step,the transcribed texts
were read to gain an overallunderstanding and parts of
the texts thatwere found to respond to the aim ofthe
study were highlighted.The highlighted parts were in the
second step condensed without losing the centralmean-
ing. In the third step, codes were created and in the fourth
and final step,the codes were once again read,compared
and contrasted with the textto ensure trustworthiness
[39,40].In the finalstep,sub-themes involving several
similar codes were also created and interpreted to repre-
sent three predominant themes relating to older people’s
experience ofbeing involved in their nutritionalcare as
wellas RN’s experience of older person participation and
their experience ofnutritionalcare per se.The second
author(JN) was the main lead in the above described
process of analysis.Additionally,the research team inde-
pendently read and analysed the textand metregularly
(approximately 1 h once every second week for about 10
weeks) to discuss and reach a consensus in all the different
steps of the analysis. To further ensure the trustworthiness
of the analysis, quotes from the informants are reported in
the results.
Results
Two of the themes, ‘participation in nutritional care equals
information’and ‘nutritional care out of remit and compe-
tence’were interpreted to solely illuminate the RNs experi-
ence of older people’s participation in nutritionalcare and
their experience of nutritional care per se.Whilst the third
and last theme, ‘nutritional care – more than just choosing
a flavour’were interpreted to mirror older peoples experi-
ence of participation in their nutritional care.
Participation in nutritional care equals information?
The theme, ‘participation in nutritionalcare equals infor-
mation’,reflected how the RNs actually experienced older
people’s participation in nutritionalcare to be equalwith
supplyingthem with information.The theme also
reflected an awareness among the RNs about that the low
level of patient participation in nutritional care.Especially
when the older persons were as at risk of malnourishment
or already diagnosed by the RNs as malnourished needed
Table 1 Characteristics – older persons
Code Gender Years in special
accommodation
Body Mass
Index [BMI]
MiniNutritional
Assessment
[MNA scores]
A Male 3 21.5 7 [malnourished]
B Female 1 20.9 10 [risk of malnutrition]
C Female 1 18.8 9 [risk of malnutrition]
D Female 2 18 7 [malnourished]
Table 2 Characteristics – Registered nurses
Code Gender Work experience
(years)
Educationallevel
E Male 11 BSc Nursing
F Female 3 BSc Nursing
G Female 2 BSc Nursing
H Female 4 BSc Nursing
I Female 12 Diploma
J Male 2 Diploma
K Female 2 BSc Nursing
L Female 43 Diploma
Sjögren Forss et al.BMC Nursing (2018) 17:19 Page 4 of 13

to be developed further as a part of their nutritional care.
Thus,the main nursing strategy used to involve the older
persons in their nutritional care was to offer some brief in-
formation to them.However,the RNs recognised that the
information they offered to the older persons could be of
better quality.This was experienced by the RNs as espe-
cially true for not only the information concerning the im-
plications of being at risk of malnutrition or diagnosed as
malnourished, actions to prevent it, and actions to remedy
it, but also the information about the anticipated develop-
ment,goals and nursing interventions targeting nutrition.
An RN expressed this sentiment in her interview:
If we would have been better in our information,and
included… yeah,particularly the different options.If
we really had taken the time to go through it and to
check,as there actually are many interventions….
trying to find the cause and then treat the actual
reason.Yeah,I do not think we do it to the extent
we should.[RN/H]
On the other hand,whether one should involve older
people in their nutritional care or not stood out as an anti-
pode. Particularly as the RN’s experiences also reflected that
involving the older persons in his/her nutritionalcare was
not at the top of the RN’s agenda.It also appeared unim-
portant to the RNs to inform the older persons about the
outcomes of assessments performed, the actions to possibly
take,and/orany interventions targeting theirnutritional
issue.The theme appeared more to mirror nursing direc-
tives and strict orders to remedy nutritional problems than
strategies to support participation in care as a tool to reach
common possible solutions in regards to the older persons
nutritional care.The directives and orders were interpreted
to be purely based on the RN’s experiences ofwhat they
thought was best for the older persons.
No, I do not do it [involve the older person] … no.
But if I see that they are losing weight,then I visit
them and tell them that I will order nutritional
supplement drinks and that they should eat more.
[RN/J]
Thus,this theme also reflected that,at times,the goal to
involve older persons in their nutritionalcare departed
from the common professionalperspective of“I know
what is best for you”:
It becomes a bit of an “I know best” attitude in this.
That you might feel [like], ‘But I actually have this
education and I do know this stuff,so therefore I
choose this’.[RN/D]
Yeah.Thus,I think that one only thinks about it as
any other treatment – that we think we know best
about what works for them,and then we try that.
[RN/K]
Involving olderpersonsin their nutritionalcould be
experiences as a challenge for some RNs.One particular
challenge expressed as a barrier for participation in nu-
tritional care became discernible when the older persons
no longer experienced that their life was meaningful.
We try to involve them,but when they are at the
point where they refuse [to engage] completely …
they see no future and nothing,and they have lost all
interest – then it is difficult.It is really very difficult
to motivate [them and get them to understand] why
food [eating] would make them feel fitter.[RN/L]
Experiencing a constant lack oftime was also a barrier
and meantthatsometimes other types ofnursing care
was prioritised as more important than nutritionalcare.
This, along with an underestimation ofthe olderper-
sons’ability and willingness,were cited as reasons by the
RNs to not involve olderpeople in his/hernutritional
Overarching interview questions
Older
people
I am interested to hear about your experience of
being involvedincare, inparticular,the care
regarding you having been assessed as at risk for
malnutritionor as malnourished.
Registered
Nurses
I am interested to hear about not only your
experience of nutritionalcarein generalbut also
your experience of involving older peoplein their
own care when they have been assessed as atrisk for
malnourishment or as malnourished?
Fig. 1 Overarching interview questions
Sjögren Forss et al.BMC Nursing (2018) 17:19 Page 5 of 13

care.One RN expresses this in plain terms:
Ugh,this is maybe an issue that is not a top priority,
so one,yeah … yeah,one simply doesn’t have the time
because we have other things to do here which one
thinks is more important,but this is equally
important.[RN/I]
Another experience by the RNs mirrored that the older
personsdid not alwayswant to be involved in their
nutritionalcare.Instead,the RNs experienced that they
kicked the ballrightback to the RNs corner.One RN
expressed this as:
It depends on how interested the patient is.Some
patients don’t want to know anything.If you start
to talk about certain stuff,the reply is,“Yeah,yeah.
You are handling it so well”.[RN/G]
The theme also indicated that both how well-informed
the RN is aboutthe older person’s generalhealth and
the RN’s perception of how independent and capable the
older person was,were factors in the RN’s decision to
involve the older person in their nutritional care or not.
I am not sure if they are well-informed enough to
participate,and that is of course on us to give them
that information and maybe offer some more suggestions
for action than to arrive in their room and say, “Now
we are doing like this”. I am bad at that [i.e. do the
latter a lot]. [RN/H]
‘Participation in nutritionalcare equalsinformation’
also illuminatedcertain insights concerninghaving
missed outon an opportunity to engage and involve
older personsin their own nutritionalcare.This was
particularly mentioned as a lack ofengagement in how
the olderpersonsexperienced the mealtime ambience
and the food served.One RN brought this up:
I think that this is something we are not so very
good at,I think.I think that we do not really
consider that,actually.They [the older people]
are all sitting there in the dining room.It is,yes …
No, this is something one can work on much more,
actually.[RN/E]
Furthermore,the theme reflected thatinvolving older
people in their nutritionalcare actually was viewed by
some RNs as a naturaland integralpart ofprofessional
nursing – particularly if the RNs perceived that the older
person’snutritionalstatuswere a vitalfactorfor the
older person’s general condition of health,as exemplified
in the following quotation:
I usually inform that one has no energy,one cannot
move around as much as one wishes.That the risk
of attracting infections is bigger,and that one’s pain
threshold is lower if one is malnourished.On the
whole,one can withstand much if one is normally
nourished,so to speak.[RN/F]
The theme additionally echoed a wish to allocate more
time for troubleshootingand for understandingthe
underlying cause ofthe older people’s individualnutri-
tion problems.The RNs feltthatbeing able to depart
from the root of the cause would facilitate older people’s
participation in theirnutritionalcare.This could be
expressed as:
To inform them that there is a problem,what
the alternatives could be to remedy it,and most
importantly,why it is so important to not be
malnourished – [to tell them] all the risks of
being malnourished.[RN/K]
Nutritional care out of remit and competence?
In the theme, ‘nutritionalcare out of remit and compe-
tence’,RNs experience ofnutritionalcare perse was
reflected ascontradictoryin many ways.How each
individualRN experienced nutritionalcare per se was
interpreted as not only having an impact on their per-
formance of the nutritional nursing care on offer.Their
experiences also seemed to resolve to what degree the
RNs engaged in involving the older person in her/his
nutritionalcare.The texts mirrored some RNs aware-
ness ofthe importance to work proactively with nutri-
tion in general and other RNs obliviousness,where
nutritionalcare was notgiven much thought or refec-
tion.Those RNs reflecting a greater awareness of,and
proactive engagement in nutritionalcare also tended to
indicate knowledge about the relationship between nu-
tritionalstatus,older people’s health and their function
expressed as:
One [the older person] has no strength if one doesn’t
have enough food.One risks infections and sickness,
and one has no resistance.Therefore,I put a strong
emphasis on nourishment among old people.It
should be frequent,small,calorie-dense portions
and [served at] regular [times]:Three main meals
and three in-between meals.One meal needs to be
just before bedtime to avoid a long period of starvation
at night, which will happen if one doesn’t eat just before
bedtime. [RN/F]
In contrast,the oblivious approach to nutritionalcare
was reflected upon by this RN:
Sjögren Forss et al.BMC Nursing (2018) 17:19 Page 6 of 13

One tries to ask if they have any particular likings in
regards to food.I do not ask them much more than
that.I actually do not think that much about that part
– nutrition – at all.You see… there is… nature has to
have its cause.In general,one eats… you know,one
has less appetite for food and drink when getting
older,and yes,that is how I view it in the bigger
picture.[RN/I]
The theme, ‘nutritionalcare out ofremit and compe-
tence’,also reflected experiences of insecurity and certain
challenges,especially when itconcerned whatnursing
actions and/or interventions to take when the older per-
son was at risk for malnutrition.Some self-critical voices
were apparent:
It’s most likely ignorance amongst the professionals,
that is,by the nurse,um,yes.[RN/I]
Experiencing nutritionalcare as challenging could add-
itionally mean thatnutritionalsupplementdrinks were
the informants’first and main choice ofnursing inter-
vention.It was also here where more self-criticalvoices
were illuminated,and one informant expressed that the
task of giving nutritionalsupplement drinks meant a job
done and ticked off the list:
When we have given complete nutritional supplement
drinks,we believe we have done it all.One can tick it
off and record it … then one has done something.Is
that not strange? [RN/K]
Anotherresponse which reflected thiswasmade by
another RN:
My initial thought is always complete nutritional
supplement drinks … We met with the dietician
yesterday and talked about this,and then he said
that these [nutritional supplement drinks] are
actually the last way out/option.One should focus
more on adjusting the meal environment or use
simpler methods to find out what is causing the
person in question to not eat.[RN/H]
Despite interpreting the above statement to mean that
teaming up with otherhealthcare professionalscould
resultin differentperspectives on nutritionalcare,the
text reflected a rather cooland distanced relationship to
for example the dieticians:
At times,I contact them [the dieticians],yes.…Yes,
it can happen when there are problems with choking.
It can happen when we do not [succeed with them]
gaining weight despite us trying everything.…They
might view it in a different way.… You get clever tips,
but it is absolutely not always – it is [rather] seldom.
[RN/E]
Another distanced relationship in nutritionalcare was
also experienced in regard to the GeneralPractitioner
(GP). The informants’overallexperience was thatnot
many “medical” actions could be done by the GP when
an older person stops eating and drinking.Such issues
had to be dealtwith by the RNs,as this problem was
situated within the domain ofnursing.Here,another
contradiction was reflected,as the texts mirrored both
insecurity and challenges as wellas experiences such as
the RNs being much better equipped to handle nutrition
involving older people and possessing more insight into
how to dealwith it despite being self-criticalaboutthe
main nursing intervention i.e.nutritionalsupplement
drinks.
I don’t deal with the GP as much.If I would have
some bigger issues with a patient,[then] I would
contact the dietician,but not the GP.I don’t really
think they are much into this issue.[RN/F]
The theme ‘nutritionalcare outof remitand compe-
tence’also reflected thatthe mealtimeenvironment,
mealtime ambiance and choice of what food served was
not within the informant’s remit in nutritionalcare.The
main controland responsibility forthesefactorshad
instead been handed down to the healthcare assistants,
and this handingdown of actualresponsibilitywas
expressed by two of the informants:
I think it is mainly [that] one has put it on the
healthcare assistants [because] they are there all the
time.It is them handling it,so it has been put down
to them.[RN/J]
I am trying to engage,but it is mainly the enrolled
nurse.It is their environment in the kitchen and so
[on].But if I think something is wrong,I do try to
point it out – that they need to think about this or
maybe that.[RN/G].
Nutritional care more than just choosing a flavour?
In the final theme, ‘nutritional care more than just choosing
a flavour’, the older persons’experiences of participation in
their nutritionalcare reflected thatno easy standard ap-
proach exists to achieve a satisfactory level of involvement
in their care.Some of the experiences reflected by the RNs
in the theme ‘participation in nutritional care equals infor-
mation’also mirrored the older persons’experiences.This
was especially reflected amongstthose older people who
Sjögren Forss et al.BMC Nursing (2018) 17:19 Page 7 of 13

experienced being uninformed about what could be done
or which care could remedy their nutritionalstatus.One
older person states this plainly:
No one tells you anything here.They do what
they want … that is how it is.[OP/D]
Additionally,the older persons’experience of not being
involved or having the possibility to discuss things with
the RNs about how the nutritional care was to be planned
indicated frustration,and this came through in one plain-
speaking older person’s interview could be expressed as:
One is not allowed to decide anything.[OP/C]
Other experiences were also recounted,as some of the
older personsperceived thatthey had been informed
about what malnutrition could mean when being older.
They could describehow being malnourished affects
their energy levelsand is detrimentalfor their health.
One informant expressed it in the following admission:
It was okay.Yeah,one could say it was good
[the information about being malnourished].…
I needed to eat more.[OP/A]
In these cases, despite having been informed by the RN, the
older persons perceived that they not had been involved in
planning the treatment meant to target their malnourish-
mentor risk ofmalnutrition.These older people experi-
enced thatthey were passive receivers ofthe nutritional
care and the information given.
When malnourished,no,we did not [participate].
I got nutritional supplement drinks from the nurse.
I got Actimel.[OP/A]
The theme ‘nutritionalcare more than justchoosing a
flavour’also suggested that when having been assessed as
at risk of or as malnourished the only nursing action for
this was to instruct the older persons to drink supplemen-
tal nutrition drinks,and the older person’s only involve-
ment was to be allowed to “pick the flavour you like”.The
nutritionalsupplement drinks were given untilthe indi-
vidual’s weight was back up to a healthy level.
For a while,I got these … bottles.I got one three
times a day,such bottle [nutritional supplement
drinks].But now,I am told by them that I don’t
need them anymore.[OP/B]
Having been slim and slenderthroughoutlife and
consequently having a low BMI since youth meant that
some older peopleexperienced nutritionalcare and
weightgain as an upsetting ordeal.Emotions such as
nervousness and anxiety about weight gain and a chan-
ged body image were expressed.This experience was
corroborated bythe RNs, who perceived thatsome
older persons took on a highly passive role in regard to
involvement and were not particularly adherent to the
action plan purely based on anxiety aboutgaining too
much weight.
I am eating and gaining weight.Now I am scared to
gain far too much weight.[OP/B]
In stark contrastto the one nursing intervention on
offer (i.e.nutritionalsupplement drinks) was the older
persons’views reflecting the possibility to decide his/
her meals.On one hand, the older person would
experience a boost in energy by the drinks,but on the
other hand,they found them difficult,as they quickly
felt full with them.If they were given a choice,the
older people preferred normalfood over drinking more
than one nutritional supplement drink a day.
They tellyou that you can drink more in one day,
but one can’t.It is that much … one cannot drink
four or as much as possible.So, so that is how itis
… for me,there is a limitof one bottle [nutritional
supplement drink] a day.And that is not enough
to go up….[in weight].[OP/C]
The theme ‘nutritionalcare more than just choosing
a flavour’also entailed the olderperson’s experiences
of involvementin the mealtime environmentand the
setting ofthe daily food menu.They expressed a wish
to be involved in both theshaping ofthe environ-
mentand the menu.One older person expressed her
frustration:
And I thought, ‘It is only this time [that] itis
a catastrophe.It is only this time … and not
tomorrow’.Oh, yes,I am put at the same place
by the table every time [next to a residentshe
does notwant to be near].[They think,] ‘She is
so kind,and she is so tiny,so it doesn’t matter,
[so] we place her here’.[OP/C]
The food on offer at the nursing home was not experi-
enced as highly rated,and when asked the direct ques-
tion of whetherthe older personsexperiencedany
possibilityto becomeinvolved in thefood that was
served,two of the informants gave a reply indicating that
the menu was not able to be changed:
I get the menu,and then [I] have to eat [what’s on it].
[OP/A]
Sjögren Forss et al.BMC Nursing (2018) 17:19 Page 8 of 13

Nothing [involving participation with food].They only
serve it.On the table in front of me.[OP/D]
The theme reflected that breakfast was the only meal
where the older persons experienced that they could be
involved.Breakfast food was presented on the table,and
one could choose whatever they liked.The older persons
perceived thatthey could ask forsomething else (i.e.
extra outside ordinary mealtimes and the set menu),but
otherwise their involvementwas also limited here.The
theme reflects the wish to be involved in the menu as
well as the insightthatif the food tasted a bitbetter,
then they would automatically eat more.However,des-
pite not experiencing anymeaningfulinvolvementin
their nutrition,the food served or mealtime ambience,
the older persons stillfelt that the stafftried to accom-
modate as many of their wishes as possible.
I would like to decide my food and [choose] food that
is good.Good gravy.That the food is … when you get
pork shops or pork shoulder.Then you get no gravy.
They remove the best part.I would like to have my
mum’s great steaks [giggles].I know I cannot get it.
[OP/C]
Coffee and tea – one can have at any time you go
down and say,“Now I fancy a cup of coffee” [then
they say,] “I will arrange that for you”.They are good
in that sense:“Have all of you got [coffee or tea]?”
[OP/C]
All meals were served at set times,but they could be
slightly moved for the unique individual.This was per-
ceived as some degree of being involved as well as being
in control in some way.One older person explains:
We have our set mealtimes here:Breakfast at 8
o’clock,dinner at 12 o’clock,coffee at 2 o’clock,
and supper at 5 o’clock.This is how it is every day.
But if you are doing something,then they save your
food and reheat it for you when you arrive.[OP/B]
Lastly,the theme reflects that the older persons would
experience the need to accept what was laid out on the
table,as they perceived thatit would notbe rightto
complain about the food being served.One of the older
people explains:
If I don’t want it,they can arrange something else.
But I never do that.I am ashamed of doing that.They
do all they can to prepare good food,and then how it
comes out – that’s another matter – but one has to
try to eat it.[OP/A]
Discussion
The analysis indicate that RN’s experience ofolder peo-
ple’s participation in nutritional care and their experiences
of nutritional care per se could be understood in the light
of two predominantthemes:‘participation in nutritional
care equals information’‘nutritional care out of remit and
competence’.While the older peoples experience of their
participation in their nutritional care could be understood
in the light of the theme, ‘nutritionalcare more than just
choosing a flavour.’
The lack of engagement from the RNs regarding involv-
ing the older persons in their nutritional care stood out as
noteworthy in the theme, ‘participation in nutritional care
equals information’,particularly as the concept of person-
centred care is cited as one of healthcare’s main priorities
today,but the concept is also one of the six core compe-
tencies[43] RNs are suggested to basecare on.Our
findings putforward thatthe RNs saw participation as
analogous to simply informing the older persons about
their nutritionalstatus.When taking the time to reflect,
the RNs experienced that the information they gave could
have been better;however,a lack oftime was cited one
barrier for giving information.Our findings also revealed
thatRNs seemed to prefer to give directives and strict
orders rather than engage the older person in a discussion
aboutwhat could be the bestwaysto improvetheir
nutritional status. However, our findings may not be unex-
pected,given that Longtin and colleagues [34] found that
the staff ’s acceptance ofpatients’participation in care is
affected by their need to preserve control and by a lack of
time.Factors entrenched in the context of care such as a
task-oriented practice (e.g. giving directives) is also known
to obstruct participation [44].Others [35,36] have shown
that the participation ofolder persons,particularly those
residing in nursing homes like those ofthis study,are
rarely, if at all, involved in activities relating to nutrition or
nutritional care.
To involve older people in their own care and inform
them adequately requires effective communication.How-
ever,research into participation in clinicalpractice found
that although RNs speak about the importance of commu-
nication, they were only observed to have contact with the
persons they cared for when they had a task to complete
[44,45].This knowledge has implications,particularly in
the Swedish context of nursing homes,as the daily care is
delivered by healthcare assistants and not by the RNs. The
latter are mainly called upon in unexpected care events;
thus,this does not leave many naturalinteraction points
between theRNs and the older persons.It is clearly
important to acknowledge that adequate information [46]
is vitalin supporting people to participate in decision-
making about their own care,especially as information is
centralfor the patient’s ability to make decisions about
theircare.In particular,when the information given is
Sjögren Forss et al.BMC Nursing (2018) 17:19 Page 9 of 13

used as a toolto supportthe RN’s agenda,it becomes
ostensible rather than a factor that leads to true participa-
tion.We recommend that participation in care has to be
more than simplyinformingthe older person about
directives and already planned actions.Collaboration and
the sharing of power between the RN and the older per-
sons appear just as important as offering them relevant in-
formation.Thus,our findings imply,despite that patient
participation in care is regulated by law in Sweden,that
nutritional care for older people residing in nursing homes
may yethave some way to go before participation be-
comes a naturalpartof nutritionalcare in this context.
There are no easy solutions to remedy this;however,a
person-centred care approach should be centralin the
nutritional care of older people.
Involving older persons in their care appears to occur
when RNspossessknowledge and awarenessaboutthe
components ofnutritionalcare as reflected in the theme
‘nutritionalcare out of remit and competence’This stood
out in stark contrast to some RNs views which suggested
nature needs to have its place in old age.It also contrasts
with certain RNs feelings of insecurity and frustration about
nutritionalnursing care and strategiesfor involvement.
Despite the latter and thatsupport was available both in
the form ofthe GP and dietician,nutritionalsupplement
drinks were shown to be the nurses’ gold standard for those
older peopleassessedat risk for malnutrition oras
malnourished.It is clear that knowledge and competence
supportRNs in involving olderpersonsin their care.
However,the ease at which RNs confess to lack sufficient
competence in nutritionalcare and how to involve the
older persons in this care is unexpected,although others
have also highlighted shortcomings in nutritionalnursing
care.For example,Alharabi and colleagues [33] suggest the
need to remove the lack of understanding and confidence
among healthcare professionals when it concerns how to
involve olderpeople in theirnutritionalcare.Suominen
and colleagues [1] further support this by putting forward
thatRNs need more in-depth knowledge aboutnutrition
issues to raise their awareness aboutnutritionalnursing
care.This corroborateswith our interpretation ofthe
connection between RN’sknowledgeand awarenessof
nutrition and the RN’s level of involving patients. Moreover,
interprofessionalcollaboration in addition to the collabor-
ation between RNs and older persons is required to estab-
lish appropriate and sustainable nutritional care.
Considering thatone of the core competenciesfor
RNs put forward by Cronenwett et al.[43] is that nurs-
ing care on offer should be evidence-based,it was rather
unexpected that nutritionalsupplement drinks were the
first line of nursing intervention in treating older people
assessed atrisk for malnutrition oras malnourished.
Especially,considering the weak evidence abouttheir
actualeffect on malnutrition i.e.effect in weight gain or
improved function among older people [47,48].It seems
reasonable to draw the conclusion thatnutritionalcare
in this context seemingly stillnot rests on an evidence-
based care.Taking this into account,it becomes difficult
to whitewash orgive alternative interpretationsto the
kind ofnutritionalnursing care reflected by statements
such as “a job done and ticked off”.Understanding and
applying evidence-basednutritional knowledgeare
importantways to effectively assess dietary intake and
provide appropriate guidance,counselling and treatment
to older persons.This must be vitaldespite the fact that
a recent systematic review [49] aiming to determine the
effect of nursing interventions targeting fundamentals of
care [9] such as nutritionalcare concluded that current
evidence for nutritionalnursing care interventions was
sparse,of poor quality and unfitto provide evidence-
basedguidanceto RNs in clinical practice.Conse-
quently,educationalefforts alone willnot be enough to
improve nutritional care as Richards et al.[49] highlights
that nursing research additionally need to step up when
it concerns effective nursing care interventions targeting
fundamentals of care.
Although the RNs ultimately are responsible for care,
thus expected to take on the role asthe point-of-care
leader, our findings indicated that some of the responsibil-
ities for the older persons nutritional care depended upon
the health care assistants.Leaving some of the RNs with
the experience that some ofthe generalnutritionalcare
were outof their remit.On the other hand,RNs were
quite determined that the GPs not were in a position to
support nursing care in case of nutritionalchallenges i.e.
older patients refusing to eat and drink as this belonged to
the domain ofnursing.It is not based on these findings
reasonable to predict the reasons for these contradictory
experiences.We know thatRNs providing leadership at
the point-of-care can have a positive impacton clinical
practicebut also introduceleadershipbehavioursof
importance for allroles [50].However,to be able to lead
care demands competent and safe RNs and,our findings
did at time,reflect experiences of both insecurity and lack
of competency concerning nutritionalcare.Additionally,
teamworkis known to improvepatientplanning,is
clinically more efficientand supportsa person-centred
care [51].Working in interprofessionalteams in order to
ensure continuity of care, patient safety and quality of care
is also one ofthe six core competencies suggested for
nurses to possess to meet health care standards [43] and
would be a realistic approach to improve older peoples
nutritional care in nursing homes.
Older persons’participation in their own nutritional care
appearsto be an ambiguousand tortuouspath.In the
theme, ‘nutritional care more than just choosing a flavour’, it
is clearthat,although theolder peoplewished to be
involved in both what was on the menu and in shaping the
Sjögren Forss et al.BMC Nursing (2018) 17:19 Page 10 of 13

environment,their involvement was restricted to choosing
whatthey wanted forbreakfastand whatflavourthey
wanted if they required a nutritional supplement drink.No
easy standard approach exists to achieve a satisfactory level
of involvement in their own care.The older people stated
that communication often failed,and they were not able to
be involved or have the possibility to discuss things over
with the RNs about how their nutritional care was planned.
Our findings are corroborated by others. Say and colleagues
[26],conclude in their literature review that it is important
to remember that participation may not be acceptable or
appropriate for everyone.In a qualitative study by Nyborg
and colleagues [52] the older people experienced difficulties
when participating (i.e.their involvement in decisions and
in their own care).The reason given by the older persons
in the study was theirdeteriorating capability to do so.
Additionally,an older person’s desired level of participation
in his/hercare may be influenced by theirgenerational
values.This notion falls in line with Nyborg and colleagues
[52],who state that today’s participation ideology is based
on individualism,which they suggestis likely to conflict
with the current older generation’s “commonly held values
of solidarity and community” (p.1).Consequently,research
[53] has shown that older people’s gratitude for the health-
care system and to healthcare staffat times overshadows
not being informed or involved;thatis, they rejecttheir
own needs and preferences.Another study by Penney and
Wellard [54] found that participation in care was equated
with being independent by the older persons.The later can
be extra challenging for the RNs to handle when engaging
in strategiespromoting participation,as it is likely that
older people residing in nursing homes already experience
that their independence is restricted. Nursing that strives to
involve older persons in their care and decisions about their
care would therefore gain from departing from person-
centred care models,particularly as is seems fair to assume
thatthese kindsof nursing modelsautomatically mean
acceptance ofthe RNs to offera care adapted to what
degree the older person wishes to participate.
Study limitations – Strength and weaknesses
Our study design allowed an emphasis to be placed on the
statementsand interpretationsof thosebeing studied.
However,its relatively smallsample (n = 12) has implica-
tions for the trustworthiness of the findings. Our sampling
technique ensured the possibility ofcapturing different
views and perceptions,and although the sampling was
strategically conducted [30],it was relatively homogenous
in aspects like gender when it concerned the RNs.This
impliesthat the resultcan be specific forfemale RNs
within this context and that homogeneity can affectthe
transferability of the result.However,their heterogeneous
ages,levelsof education and amountof time in their
position,in addition to including two RNs who are male,
may counterbalance this.It wasa challenge to recruit
older people,and the samplesize endedup being
restricted to four informants (three women and one man),
as three informants chose to withdraw from the study
prior to the interviews. Therefore, due to the small sample
size and the homogeneity,generalisations must be made
with caution.However,to the best of our knowledge,few
studiesregarding olderpeople’sexperiencesof involve-
ment in nutritionalcare have been conducted,and thus,
this study contributes with new knowledge to this field.
The amalgam of realities presented here may be regarde
as the views of the informants,and as such,may be trans-
ferable to similar settings.Finally,the risk of subjectivity in
the data interpretation alwaysexists,as there isalways
more than one possible way to interpret a text. Our method
of analysis – content analysis [35] – allows the possibility to
justify the texts by structuring and presenting them using
categoriesand themes.However,the risk ofsubjectivity
always remains,as data interpretation can be influenced by
the interpreter’s life experience and ability [55].To reduce
this risk and to enhance the credibility ofthis study,the
authors worked together throughout the phases of analysis
to strengthen the interpretations,not by achieving consen-
sus or arriving at identicalformulations in interpretations
but by supplementing and contesting each other’s readings
By describing the analytical procedure used and presenting
quotationsfrom the interview texts,we have hopefully
enabled the reader to consider the interpretation valid [56]
and trustworthy.A qualitative study such as this is limited
in regard to its transferability and its relevance to other
types ofsettings;consequently,this should be taken into
account when evaluating our findings.
Conclusion
Our findings are somewhatdisheartening because today
substantial existing knowledge confirms that it is important
for healthcare professionals to strive towards true participa
tion in care.However,we acknowledge that participation is
a complex processwhich requiresall factorsto work
togetherwell beforeparticipation and decision-making
become a naturalpartof essentialcare for older people.
Although our findings suggest that RNs should be aware of
the importance of involving older people in their care,they
also indicate that,despite the knowledge that participation
should be central to nursing,this has yet to become a real-
ity despite itsregulation by law.Therefore,educational
strategies that support RNs in developing the competences
needed to enable olderpeople’s participation in nursing
care should be a priority,even during the firstyears of
nurses’training.Furthermore,our findings indicate that a
paternalistic attitude in care as wellas asymmetry in the
nurse-patient relationship are stillcommon characteristics
of modern clinicalnursing practice in the care ofolder
people.However,we envisagethat this unsuccessful
Sjögren Forss et al.BMC Nursing (2018) 17:19 Page 11 of 13

approach in care willbe phased out when new cohorts of
older peoplesuch as babyboomersbecomethe new
consumers of health and social care.
Nursing care striving to involving older people in their
own care,and those making the decisions need to be
aware thatdifferentstrategies may be needed to make
participation a reality.Although our findings may need
to be interpreted with caution,they reflectthatgetting
involved in care was not always as high on the older per-
sons’agenda as one might expect.Thus,developed strat-
egies for participation need to take this into account.A
person-centred approach to care could be one modelof
care to facilitate this.To be successfulin this work,an
interdisciplinary approach including both RNs,GPs and
Health Care assistants is needed.To promote effective
collaboration,it is important to assure that the roles of
the team members is clear,but also that RNs are ready
to take on the role as the point-of-care leader.Enhance-
ment of collaboration by communicating roles and mak-
ing work agreements should therefore be continuously
on the agenda.It is also importantfind strategiesto
empowerRNs to take the point-of-care leadership for
the fundamentals ofcare and here especially for nutri-
tional care.However,before doing thisit seemsthat
there is a need to raise competence and knowledge as
our findings indicate both insecurity and lack of compe-
tence among RNs concerning nutritional care.
Finally,it appears importantto conclude by suggesting
thatdifferentstrategies are needed for researchers to be
able to explore more in-depth how participation can be
achieved or experienced among older people,particularly
those residing in nursing homes,as this is an extremely
vulnerable group.For them to participate in and be able to
decide about their care may be effective ways to support
the older person’s feelings of independence and well-being.
It is important to get a deeper understanding ofwhat
matters to patients and to RNs who are responsible for
deliver nutritional care in an often complex and challen-
ging environment,and moreresearch in thefield is
needed.Nutritionalcare must be based on evidence and
future research also need to focus on the effectiveness of
fundamentals ofcare to supportnursing knowledge in
the deliverance of an evidence-based care.
Abbreviations
GP:Generalpractitioner;RN:Registered nurses
Acknowledgements
We would like to thank the registered nurses and the older people who
participated in this study and the Language Editing Group at Malmö
University for support with language revision.
Funding
This research received no specific grant from any funding agency in the
public,commercial,or not-for-profit sector.
Availability of data and materials
The dataset from this study is available from the corresponding author upon
reasonable request.
Authors’contributions
JN and KSF were responsible for the study’s inception and design.JN was
responsible for the data acquisition and drafting the manuscript.JN,KSF and
GB performed the data analysis.KSF and GB were responsible for the critical
revision of the paper.KSF and GB added important intellectual content,while
KSF supervised the study.All authors read and approved the final manuscript.
Ethics approval and consent to participate
This study was conducted in compliance with the established ethical
guidelines of the Declaration of Helsinki.Although under the Swedish Ethical
Review Act 2003:460 this study did not require ethicalclearance,we applied
for and received ethicalguidance from the EthicalAdvisory Board in
Southern Sweden (No.HS2016/28).The researcher gave oraland written
information and obtained written informed consent from allparticipants
before the interviews.Participation was voluntary,and the participants
had the right to withdraw at any time without further explanation.The
participants gave consent for direct quotes from their interviews to be
used in this paper.To ensure confidentiality,each quotation was assigned
a pseudonym in the form of a capitalletter.Data were stored securely and
anonymously in compliance with the Data Protection Act.
Competing interests
The authors declare that they have no competing interest.
Publisher’s Note
Springer Nature remains neutralwith regard to jurisdictionalclaims in
published maps and institutionalaffiliations.
Author details
1Department of Care Science,Faculty of Health and Society,Malmö
University,SE-205 06 Malmö,Sweden.2Malmö Town,Borough
Administration West,SE-214 66 Malmö,Sweden.
Received:13 November 2017 Accepted:3 May 2018
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