The cancer nurse–dietitian alliance in the era of COVID-19 Why the role of nurses in the nutritional care of patients must not be undervalued
Felicia Maguire and Susan Stone
For referencing Maguire F and Stone S. The cancer nurse–dietitian alliance in the era of COVID-19 Why the role of nurses in the nutritional care of patients must not be undervalued. Australian Journal of Cancer Nursing 2021; 22(3):2-3.
Few would disagree that life has changed unequivocally over the past 18 months. As the COVID‑19 pandemic has evolved, most of us have endured altered lifestyles, mental health, financial stability and social relationships. For many, the work arena has changed as well. Remote workplaces, expanded role demands, increased specialisation and an increased reliance on technology have become the new reality. In healthcare, these changed work roles have been even more pronounced. Redeployment, rapid retraining, overtime shifts, increased workplace pressures and overarching mental exhaustion have become the new norm. Healthcare workers have attracted a new level of societal respect, with constant accolades for all that they are achieving on the COVID frontlines.
Little attention, however, has been focused on the healthcare demands existing in parallel to COVID care, which do not cease to exist because of COVID’s bullishness. Services that already provide complex, specialised care are now doing so in the context of altered staffing, new service delivery models and changing levels of patient engagement1,2. This is particularly evident in the cancer arena, where the disease continues to tout its presence, worldwide pandemic or not! For many, the overwhelming fear of ‘catching COVID’, so often fuelled by relentless and alarming media reportage, has trumped the presence of any worrying symptoms, and led to delayed presentation for cancer screening, testing and diagnosis3,4. Subsequently, more cases of advanced and often terminal disease are occurring, and with them greater risk of malnutrition5; malnutrition which, in this current COVID‑19 ravaged existence, has become increasingly difficult to manage by conventional means.
Malnutrition in cancer patients is serious, with the severity reflecting the hypermetabolic nature of the disease, cancer location and impact of treatment on appetite, food intake and nutritional tolerance6. Furthermore, self-imposed dietary restrictions, as patients desperately experiment with alternative ‘cancer’ diets, can also contribute to malnutrition rates, ultimately compromising longer-term treatment success and survival outcomes7.
It is therefore imperative that malnutrition be effectively managed to optimise patient outcomes and maintain quality of life. This need is already well recognised, with dietitians occupying an important role in the multidisciplinary team. Nutritional monitoring is routinely integrated into standard care, with patients undergoing regular nutrition screening, receiving targeted nutrition education, and being provided with therapeutic diets to assist in the management of nutrition-related symptoms. Anthropometry, biochemistry and psychosocial parameters are frequently monitored, and comprehensive nutritional pathways are followed to help optimise outcomes for this highly vulnerable patient group. The physical presence of dietetic staff in the cancer setting is an invaluable part of these processes.
Since the emergence of COVID‑19, it has been more challenging to execute timely and targeted nutritional care. Dietitians, like most other health practitioners, have had to change their patient management practices as they adapt to continually evolving public health scenarios. With institutional mandates limiting direct patient contact, dietitians have had to reduce their physical presence in the cancer setting, necessitating a shift to using telephone and email for patient screening, assessment and monitoring. Inter-professional collaboration and communication is now relying primarily on technology, and patient themselves are being given greater power when it comes to the reporting of anthropometrical measures, symptom severity and food intake.
While dietitians have adapted well to this change in practice, success has been reliant on a strengthened collaboration with nursing staff. This is a challenge in itself, as dietitians, already conscious of the existing demands of cancer nursing, have attempted to afford nutritional care an appropriate degree of priority without imposing additional burden or damaging the much-valued nursing–dietetic alliance.
Within the multi-disciplinary healthcare team, nurses work collaboratively with dietitians to provide nutritional care for cancer patients with the aim of optimising patient outcomes. With nurses typically the first point of contact for patients in the cancer care setting, it is the strong, trusting relationships that patients develop with their nurses that supports them through, and often defines, their cancer journey. Being a liaison point between the patient and family during times of admission, nurses have ready access to information such as normal feeding practices, food preferences, cultural and religious avoidances, food allergies, intolerances and home nutrition histories. This information is paramount to the delivery of appropriate food service and supports the comprehensive assessment and targeted nutritional care provided by the dietitian.
As coordinators of patient care, nurses also collect and communicate clinical data that directly impacts the identification of nutritional risk and the implementation of supportive care. The meticulous reporting of patients’ height and weights, fluid intake, hydration status and bowel output form the basis of dietetic reviews. Furthermore, accurate and consistent food charting provides dietitians with the means of making meaningful assessment of calories, protein and other key nutrient intake. Nutritional screening, as well as timely reporting of cancer-related symptoms such as nausea, vomiting, dysphagia, dry mouth, mucositis or low mood, can also alert the dietitian to the need for supportive therapeutic dietary manipulations and education.
Holding responsibility for the practical administration of enteral feeding support, nurses are also in the position to ensure that prescribed dietetic feeding regimes are closely adhered to and disruptions or unnecessary alterations to feeds are minimised. Likewise, nursing staff have a valuable role when it comes to encouraging patients with the consumption of oral nutrition support. Timely provision of charted Med-Pass programs, and encouraging patients with the consumption of prescribed supplement drinks or nutritious protein/energy snacks are a powerful means of supporting nutritional health.
Over the last decade the challenges faced by many patients with the physical task of feeding has gained increased attention8. For many, navigating a bed or chair to easily access meal trays, the manipulation necessary to open packets or cut up food, or simply the task of moving food from plate to mouth can prove very difficult. While much is done at dietetic, food service and institutional levels to address such issues, nursing staff are also in a prime position to intervene. Ordering cut-up/open packet or appropriately textured diets, clearing bedside trays before meal delivery, and providing set up and feeding assistance to vulnerable patients is essential in helping optimise nutrition outcomes. Advocating for protected meal times and minimalised meal disruptions, while also monitoring and acting upon unnecessary extended periods of nil-by-mouth, can also prove a valuable consideration for nutritionally vulnerable patients9.
Thus, while the COVID‑19 pandemic is undoubtedly a health crisis, an increasing appreciation of the valuable role that nursing staff play in nutritional care of cancer patients has emerged. As the roadmap out of COVID remains unclear, and with the continuation of telehealth and strict infection control protocols remaining a reality, nurturing a strong and collaborative dietitian–nursing alliance remains imperative as we work towards managing the nutritional outcomes of this vulnerable patient group.
Senior Dietitian, Cancer Services, Concord Repatriation General Hospital, NSW, Australia
Clinical Dietitian, Malnutrition, Concord Repatriation General Hospital, NSW, Australia
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- Clinical Oncology Society of Australia. Cancer-related malnutrition and sarcopenia position statement Version 1. Clinical Oncology Society of Australia; Aug 2020, p. 1–24.
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