So ARE Nurses the “Nurse Police” When it Comes to Inpatient Hospital Stays?
Submitted by Elaine S. Puricelli RN, BSN
This essay addresses whether or not nurses working with hospitalized patients are acting, in part, as the “nurse police” for their patients’ eating habits while hospitalized. I read a 2013 article mentioning the low compliance rates for heart-healthy diets, once the patient returned home. We are 9 years beyond the printing of this article but I wonder about more recent statistics and I will endeavor to seek out newer articles.
My background as a nurse was working with an older patient population: Late middle-age to senior populations in an inpatient setting, a cardiac telemetry unit. My unit worked with patients during and after an outpatient cardiac procedure, cardiac catheterizations, ablations, stent placement and often, device placement such as pacemakers and defibrillators. It was commonplace to discharge a patient with the instruction to either begin or continue a cardiac prudent, or heart-healthy diet. The parameters of the diet were spelled out usually in just a few sentences, but patients always had an option, while inpatient, to speak with a dietician, receive printed material addressing their cardiac diet, or be directed to various nutritional sights online if the patient was computer proficient. The provider had to order a dietary consultation in the hospital setting. Home care by the patient and sometimes a spouse or caregiver was not something I worked with: I did not work in home health nor was I in a position to follow a patient telephonically, once at home. My essay points specifically to the inpatient time, the meals served while the patient is hospitalized, and, surprisingly, the “food gifts” brought to a patient by a visiting friend or relative.
This subject was fascinating to me while working in cardiac nursing. The number of visitors, in my experience, who brought in inappropriate food or snack choices was staggering! I saw very little effort by visitors to bring in healthy snacks or treats. Oddly enough, some patients would themselves, order pizza delivery while hospitalized or have a visitor bring in food from an outside source – almost ALWAYS from a fast-food restaurant favored by the patient!
I was constantly amazed at how many visitors fell in line with the patient’s request to bring in fast-food bagged food! I was usually calmly enraged to be honest. I would explain to the visitor, while present with the patient, that the patient must observe the diet ordered by the physician, and in some instances, I would say to the visitor (with the patient present), “If the patient’s physician approves of these fast- food requested items, the patient may eat the food. However, it is expected that the patient will eat the prescribed diet while hospitalized.” No kidding, I WAS the nurse police in that moment! I did not wish to embarrass a patient by causing a scene with the visitor present, so I maintained a calm, professional voice, but upon the visitor’s departure from the room, I would explain to the patient that his or her inpatient time was a great time to learn about the cardiac prudent or heart-healthy diet and that I didn’t mind being the conduit for the patient’s journey with a new, more restrictive diet. I would never loudly complain about a visitor’s entry into the patient’s room with bagged fast- food – I would never want to come across as punitive! It was often the case that a family member or visitor would be unaware of the harm caused by continued eating of fat-laden, overly salted food such as fast- food affords.
Interestingly, visitors were often unaware that a candy bar, even if a basic chocolate bar contained astronomical amounts of saturated fat usually in the form of palm oil, coconut oil, or “sat fat” contents by virtue of the chocolate bar’s highly processed manufacture. Yes, a simple chocolate bar. I sometimes found that ice cream was a favorite request of hospitalized patients on my cardiac unit and THAT moment was a perfect teaching moment. I could offer fat-free pudding, or sherbet if there was no restriction on sugar in the product. I could advise the patient that gelato and sorbets (usually not found in a hospital setting) were great alternatives to ice cream (if sugar was not limited) and advise that ice cream is merely a frozen saturated fat mixture.
Label reading was ALWAYS advised by me in this process, but quick access and delivery of printed dietary guidelines were my go-to instructional products as well as a dietary consultation if provider approved, and if the patient’s stay was not simply overnight (time limitations).
Yes, in the moment, while working with a patient as his or her nurse I tried to draw a parallel with the food delivered on food trays – especially with portion sizes – and have the patient notice the type of food delivered. Skinless chicken versus fried chicken, and oven-baked pork chop versus a fried or battered pork chop were typically my examples with hospital food, though my instruction did NOT speak to diabetic food. I was quick to defer to our wonderful hospital dietitians and if time did not permit an in-person visit I would ask for as much printed material as I could arrange. Many times I was advised by older male patients, that his wife or girlfriend cooked or prepared the food he ate at home and this mention did not fall on deaf ears: Engage BOTH the patient and the spouse or partner of the dietary changes as the discharge instructions will be read aloud at the time of discharge. I have seen times when engaging with the spouse, partner or caregiver will reveal the patient’s dietary “secrets,” “He always has a dish of ice cream in the evening, I know it’s not good for him but he has done this routine his entire life.” Now THAT’s a teaching moment! One particular patient comes to mind, a patient who consistently had his wife bring into his room his salt substitute whenever hospitalized!
This patient was convinced that his type, his preferred brand of salt substitute was indeed approved for his heart-healthy diet because “My primary care doctor knows about my salt substitute.” This patient fiercely guarded his brand of salt substitute, at bedside. THIS example was a quick mention to the patient’s inpatient provider so that a timely visit by the dietician was sought. Discharge instructions regarding heart-healthy diets will usually address the use of salt substitutes, but this particular patient was a “hard sell.” Dieticians’ advising inpatients is a gold standard in my opinion. I would be interested to hear my peers’ feedback on this topic. Nurses have plenty to do while working with inpatients; but remember that the inpatient is not at home, but in your care.
I have watched as several of my peers over the decades have ignored moments for dietary teaching such as meal tray times and surveillance of visitors’ food gifts, but whole body-encompassed (some may say “holistic”) care IS our responsibility as the patient’s nurse in my opinion.
Granted, nurses are NOT dieticians. However, nurses should not be blind to their patients’ habits, learning needs and learning needs of well-meaning visitors. I once observed a physician in on rounds tossing items from a patient’s newly-delivered food tray stating that she didn’t approve of a fruit juice that was only 10% fruit juice and laden with high fructose corn syrup! Hooray for this young physician! Long may she teach !!! And we, as nurses should be no less aware of the teaching needs of our patients when they are informed of the need to begin a drastic new diet. Discussions of food and “treat” items can be initiated by the staff nurse as I have done, “Now Mr. Jones, this nursing unit is a cardiac floor. We deliberately do not stock ice cream as a treat because ice cream is high in saturated fat which is against what your new diet will instruct.” O.K., perhaps nicer ways exist to advise Mr. Jones’ life-long habit of evening ice cream is inappropriate in light of his new dietary restrictions following his cardiac procedure. But that does not excuse the nurse from EXPLAINING why Mr. Jones can’t enjoy his nightly sat-fat treat while hospitalized.
The opportunities arise during inpatient stays to enlighten and educate the patient while hospitalized. Perhaps one of the hospital-provided t.v. channels addresses heart-healthy diets. Certainly a nurse can source dietary information from the inpatient dietician or possibly acquire a consultation from the provider, for a visit from the dietician if hospital policy exists in that manner. But opportunities for instruction do arise and I think nurses should embrace those teaching moments. Changing dietary habits, for any of us, has to be life-changing as well. As our health and fitness needs change over our lifetime we will all face changes in the types of foods we eat, unless we started life under the instruction of parents who knew that fat and sugar-laden foods were never a good dietary choice. Adult food choices are usually easier to navigate, and information on healthy eating, healthy foods abounds in all types of media. The hospitalized patient is taking in many new pieces of information and should never be obviously overwhelmed. But appropriate teaching moments are nurses’ gems, and should be treated as such. Nurses can be the change for a hospitalized patient by successfully learning a patients’ dietary needs in the immediate future, once discharged and left with dietary challenges at home. It can never be too early to engage with this type of patient about his new learning needs.