1. Chamblee, Tracy B. PhD, APRN, PCNS-BC, CPPS
  2. Smith, Susan DNP, APRN, ACNS-BC
  3. Shuster, Melanie Horbal PhD, CNS, CNSC, CRNP
  4. Haight, Kelly MSN, APRN, ACNS-BC, PCCN

Article Content

In developed countries, at least 1 in 3 patients is malnourished upon admission to the hospital.1,2 If left untreated, two-thirds of those patients will experience a further decline in nutrition status during a hospital stay.3 To make matters worse, among patients who are not malnourished upon admission, one-third may become malnourished during a hospital stay.4 Malnutrition and its impact on clinical outcomes are not a new issue in healthcare. In 1974, Butterworth5 referred to the issue of malnutrition in the hospital setting as the "skeleton in the closet."


In the United States, the increased focus on cost and quality of care is bringing the issue of malnutrition in hospitalized patients to the forefront. To address this issue, in 2014, the National Association of Clinical Nurse Specialists (NACNS) convened a task force to investigate malnutrition and recommend key clinical nurse specialist (CNS) practices that focus on promoting nutrition and/or preventing malnutrition among hospitalized adult patients. In addition, the task force was charged with clarifying the role of the CNS as a member of the interdisciplinary clinical team related to assessment, planning, and management of the nutrition care of malnourished hospitalized adults or those at risk for developing malnutrition.


The prevalence of malnutrition among hospitalized adults is high, with estimates ranging from 20% to 50%.6 As a result, the costs of treatment associated with malnutrition, as well as its underlying cause and sequelae, are estimated to be more than $11 billion annually.7 Malnutrition's sequelae include sarcopenia with muscle wasting and loss of function and significant hospital-acquired conditions such as falls, pressure injuries, and infections, which lead to increased morbidity and mortality, longer lengths of stay, and higher readmission rates.


Members of the task force first met in 2014 at the NACNS annual conference with the support of an unrestricted grant from Abbott Nutrition Health Institute. During the conference, the task force held a forum to assess knowledge and clinical practices related to malnutrition in the hospital setting among practicing CNSs. As a result of the forum, the NACNS task force identified 2 key issues:


Malnutrition remains a skeleton in the closet-a challenging issue that is difficult to discuss.


Clinical nurse specialists may not possess adequate knowledge about the risk for developing malnutrition, recognizing malnutrition and its comorbidities, or prevention or intervention strategies.



To further assess these key issues, the task force surveyed NACNS members regarding nutritional care in the hospital setting and found that many practicing CNSs have limited knowledge about nutrition, nutritional assessment tools, and nutritional interventions. In fact, less than half of the survey respondents reported that they received nutrition education beyond what was provided in their undergraduate nursing program. Moreover, 59% of the survey respondents indicated that they only had basic, or less than basic, knowledge of nutritional status and nutritional needs of hospitalized adults. In relation to clinical practice, no survey respondents identified that advanced practice registered nurses are responsible for initiating nutritional interventions, and only 4.1% of the survey respondents thought that advanced practice registered nurses are responsible for maintaining nutritional interventions.


The task force developed a conceptual framework for CNS practice to promote nutrition, decrease the risk of developing malnutrition, and treat malnutrition in hospitalized adult patients in response to the survey findings. On the basis of the CNS practice model, the malnutrition conceptual framework highlights the role of the CNS as it relates to nutrition care within the 3 spheres of influence-patients, nurses/nursing practice, and the system-and serves as a framework for educational development.


The task force offered a series of 3 webinars for NACNS members from 2015 to 2017 and began to disseminate information highlighting the role of the CNS in assuring nutrition care in the hospital setting at forums at the 2015 and 2016 NACNS annual conference and poster and podium presentations in 2016 and 2017. The culminating work of the task force was the publication of a white paper delineating the role of the CNS in this important area.8


Although more work is needed to continue to promote the role that CNSs can play in addressing malnutrition, CNSs, regardless of specialty, must take action to educate ourselves and others about the significant issue of malnutrition during hospitalization. The NACNS malnutrition white paper and conceptual framework are a call to action-to facilitate the provision of adequate nutrition, by educating ourselves and others about nutritional therapies and by advocating for our patients. As advanced practitioners, we must take an active role in making sure that this skeleton is taken out of the closet, once and for all.


The editorial authors would like to acknowledge our additional task force members for their contributions to this body of work:


* Karie Falder-Saeed, MSN, RN, PCNS-BC, VA-BC, pediatric clinical nurse specialist, Gastroenterology and Vascular Access, Children's Health, Children's Medical Center, Dallas, Texas;


* Mary J. Waldo, PhD, RN, GCNS-BC, CPHQ, director, Professional Practice, Quality and Research, Providence Health & Services, Oregon Region, Portland; and


* Hea Lan Yoon, RN, MSN, AOCNS, clinical nurse specialist, Med-Surg Unit, VA Greater Los Angeles Healthcare System, California.





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