Attitudes, Knowledge, Self-efficacy, and Behaviors of Nurses in NUTRItional CARE for Older People: an Observational Study (the NUTRICARE Project)

Background and rationale

Malnutrition in older people is still an unsolved issue, affecting from 3.1% among outpatients to 29.4% in rehabilitation/sub-acute settings. To date, empirical evidence shows that malnutrition in older people cause a higher risk of disability and loss of autonomy and increase morbidity and mortality. For this reason, prevention of malnutrition should be a priority of health professionals in the care and cure of older patients, and nurses are in a strategic position to prevent malnutrition in older people because they are the only health professionals who look after the patients 24/24 and 7/7. However, several studies report that the quality of nutritional care is often under the standard in clinical settings, underlining that the major barriers to nutritional care, from the nurses' point of view, were: loneliness in nutritional care, a need for competence in nutritional care, low flexibility in foodservice practices, system failure in nutritional care and the neglect of nutritional care.

In this regard, it is possible to hypothesize several key factors underpinning the nursing nutritional competencies that could influence the quality of nutritional care delivery, such as knowledge, attitudes, and self-efficacy. Indeed, numerous authors have described that a lack of knowledge about the key elements of good nutritional care is fundamental to delivering care with high quality, as lead them to underestimate the consequences of its inadequacy. Literature explained that a lack of knowledge of the important concepts of malnutrition could lead to an underestimation of the phenomenon and to behaviors that do not prevent the onset of malnutrition. Therefore, it is crucial to measure the level of the health professional's knowledge on these matters to implement targeted training, although recent literature reported an improvement in this regard. A further factor that could influence the quality of care is the attitude of nurses toward nutritional care. Indeed, previous evidence identified that the proper screening for malnourished patients and implementing corrective strategies with the multidisciplinary team are essential aspects of the nursing competencies . Unfortunately, literature reports that nurses often have a negative attitude toward nutritional care because they often perceive nutritional care as a secondary responsibility. These negative attitudes can cause underestimating malnutrition, which can remain undetected, increasing the risk of negative health-related outcomes in older adults.

Finally, self-efficacy, defined as the beliefs that people have in their ability to successfully complete complex tasks, can be considered a proxy for nursing job performance, and its perceived level by nurses could influence the quality of nutritional care. In fact, according to Bandura, self-efficacy is a predictor of performance, which can be modified through appropriate educational and motivational interventions, mediating between the level of both knowledge and attitudes with action. In this regard, Dellafiore et al. developed a self-efficacy scale for nurses to assess the nutritional care of older adults to make it possible to measure nurses' self-efficacy in nutritional care (as a proxy assessment of nursing competencies in nutritional care) and, consequently, evaluate its improvement by specific interventions.

Data collection and sample size