Clinical Inservice Learning

Hannah Bodenhamer

School of Kinesiology and Nutrition, University of Southern Mississippi

NFS 780: Advanced Practice in Nutrition and Food Systems

Professor Roxanne Kingston, MS, RD, LD

November 30, 2021

 LESSON PLAN FOR

“Malnutrition and Weight Loss

Name of Intern: Hannah Bodenhamer

Setting: Palm Terrace Healthcare and Rehabilitation

Time Allotment: 10 minutes

Estimated Number of Learners: 30

I. Goals and Rationale

# Goal Rationale for Goal

1. CNA’s will be able to identify the As weights continue to drop at the facility, the

causes and risk factors for staff needs to be aware of causes and risk

malnutrition-related weight loss. factors so early intervention may occur.

2. CNA’s will be able to report meal Accurate meal reporting is essential for the early

intakes and meal alternatives detection of weight loss and malnutrition trends.

accurately.

3. CNA’s will be able to identify the ONS have the potential to decrease malnutrition

importance of oral nutrition and weight loss in elderly patients (MNI, 2009).

supplements (ONS) and when they When ONS are not appropriately distributed it

should be given. can cost the facility a large amount of money and

decrease availability to patients who need it.

4. CNA’s will be able to identify the It is essential to take every measure possible to

importance of offering meal encourage patients to eat. Chronic refusal of

alternatives to residents who refuse to food, or poor intake, is a leading cause of weight

eat. loss and malnutrition.

 II. Objectives

# Objective

1. By the end of the presentation, CNA’s will be able to identify causes of

malnutrition-related weight loss in residents.

2. By the end of the presentation, CNA’s will be able to report meal intakes accurately.

3. By the end of the presentation, CNA’s will be able to distribute ONS without waste

properly.

4. By the end of the presentation, CNA’s will know when to offer a meal alternative item.

5. By the end of the presentation, CNA’s will know how to report meal alternatives

accurately.

6. By the end of the presentation, CNA’s will know the impact of weight loss and malnutrition

on patient wellbeing and the healthcare system.

III. Teaching/Learning Procedures

Motivation/Intro

duction

“Hello all, my name is Hannah and I am the dietetic intern working with the

Registered Dietitian. I am here today to talk to you all about malnutrition

and weight loss! I would like to begin with our quiz so everyone please take

a handout and fill our these questions as best you can. These are not

graded and will not hurt you in any way! Hang on to your handouts for now

because you will have a chance to update your answers at the end before

you turn it in.

Teaching/Learni

ng Activities

Malnutrition is an imbalance of nutrition. Typically, when you hear the word

“malnutrition,” the person using it refers to undernutrition; or lack of

calories, protein, and other nutrients. To reduce confusion, in this

presentation, I will refer to the lack of nutrition as malnutrition. Weight loss

is an indication of malnutrition. When a resident is not eating enough, they

may lose fat, muscle, or fluid, reducing body weight. Accurate identification

of malnutrition is essential so patients can get the care they need from the

resources we offer.
Between 20 and 50% of hospitalized adults are at risk for malnutrition

(ANHI, n.d.). That’s as little as one in five and as much as one in two. That

is significant. Malnutrition has several negative impacts on patient health

and facility success, including higher costs, more extended hospital stays,

increased risk for complications, poor wound healing, increased risk for

fractures and falls, weak immune function, decreased mental function,

decreased general function, accelerated loss of body mass, and increased

death. So I think we can all agree, that we need to do everything we can to

prevent malnutrition from happening, right?

 As dietitians, our job is to complete malnutrition screenings for

every patient that comes through the door. Your part, which is essential, is

to accurately report meal intakes and distribute oral nutrition supplements.

Not too long ago at skills day, we talked about the percentages of

meals and how to report. But we are going to review that one more time to

solidify that learning. The protein counts for 30%, the carbohydrate food

counts for 15%, and vegetable counts for 10%. If the tray comes with soup,
salad, or bread that is not on the plate, that would be 20% of the meal. The

dessert would be 15%, and the juice or milk would be 10%. So in total, the

food on the plate counts for 55% of the meal, and the rest of the food on

the tray counts for 45% of the meal. Let’s walk through an example: Say

your patient eats their vegetables, their protein, their soup, and milk- but

not the carbohydrate food or dessert. That would be 10% for veggies, 30%

for protein, 20% for soup, and 10% for milk. So the total eaten would be

70%. You would report that in the 51-75% range!

Now lastly, oral nutrition supplements. Many research studies show that

oral nutrition supplements reduce malnutrition and contribute to weight

gain, healing, and better patient outcomes.

These oral nutrition supplements are full of calories, protein, and other

nutrients that add to a patient’s daily intake. These shakes should be used

to ADD to daily intake, not replace meals. At this facility, the oral nutrition

supplements are health shakes, dairy-free ensure, and nepro shakes. We

rely on you to make sure that these supplement orders are delivered and

encouraged! Most frequently, patients will need their shake around 10 AM

or 2 PM. These shakes can be really costly so we want to make sure if

there’s an order it’s given to the patient and encouraged. If you notice that

the patients are refusing the supplement, make sure to let the dietitian

know so we can better use these resources.

Closure Thank you for tuning in on the presentation about weight loss and

malnutrition! You can make a massive difference in the health and healing

of these patients, and I recognize your contribution to this facility! Now let’s

go through those assessment questions one more time. Please drop your

quizzes and pens right here on the table and I will take care of the rest.

Thank you so much for attending!

Informal I will conduct an informal assessment by surveying staff member’s

Assessment questions, need for clarification, eye contact, responsiveness, and overall

engagement.

Formal I will conduct a formal assessment by administering a quiz before the

Assessment presentation. At the end of the presentation, I will allow the participants to

change any answers they may have initially answered incorrectly. This will

allow me to assess level of focus and retention of knowledge.

1. What percent of hospitalized adults are at risk for malnutrition?

(ANHI)

a. 0-10%
b. 5-25%
c. 20-50%
d. 30-70%

2. Which of the following is an outcome of malnutrition in healthcare?

(ANHI)

a. Increased healthcare costs

b. Decreased wound healing
c. Increased death rates
d. Increased hospital readmission rates
e. All of these are outcomes of malnutrition

3. What is the total percentage of the meal on the plate, excluding

side dishes on the tray?

a. 75%
b. 55%
c. 100%
d. 40%
 4. What is the primary importance of oral nutrition supplements

(health shakes)?

a. They increase calorie and nutrient intake

b. They taste good
c. They make residents happy
d. They replace all foods and meals

IV. Materials/Media (attach a sample)

Figure 1. Amount eaten meal tray reporting diagram created by Palm Terrace Healthcare and

Rehabilitation.
 V. Assessment of Participants’ Learning

Table 1. Assessment of quiz questions with initially correct, initially incorrect, and

corrected answers.

Overall, employee learning successful. Shown by the quiz results, employees didn’t

know all of the information presented on the quiz. The staff had most difficulty with question

three: “What is the total percentage of the meal on the plate, excluding side dishes on the tray?”

23 staff members answered incorrectly and only 12 staff members corrected their answer. As a

representative from the dietary department, this raises concerns about accurate meal reporting

and may result in discrepancy. Further assessment on staff knowledge of meal reporting and

potentially a more detailed inservice about meal reporting is warranted. The staff had most

success with question two: “Which of the following is an outcome of malnutrition in healthcare?”

24 participants answered correctly; all six who answered incorrectly made adjustments to their

answers. Given these responses, it is clear that employees are understanding of the impact that
malnutrition has on hospitalized adults. Meal reporting could be covered in more detail during

future inservice lessons.

Figure 2. Example of quiz completed by inservice antendees

VI. Materials/Media

The director of staff development (DSD) requested that all visuals used at this inservice

be limited to a powerpoint presentation and a copy of a handout created by the facility (shown in

Media section IV). As requested by the DSD, the materials and media provided were minimal. In

the past, fewer visuals and more simplicity were found to be most conducive for successful

learning. I printed out copies of the quiz, the handout, and my lesson script. I also provided pens

for the employees to complete the quiz. I also required an overhead projector, computer, and

screen to display my powerpoint slides with a table and chairs for participants.
 To account for any employees or participants who are hearing impaired, I could provide a

transcript of my lesson script. This would allow hearing impaired participants to follow along my

verbal lesson with a visual supplementation. Additionally, I could send out an email with an

attachment to a summary of the lesson and any questions asked during the presentation. This

would allow participants to be able to refer back to the information provided during the inservice.

Cultural Competency Checklist

1. I conducted an assessment of my potential audience to determine linguistic, cultural, literacy,

and learning needs.

Strongly Agree Agree. Neither Agree or Disagree Disagree Strongly Disagree

2. The photos and videos included in my visual materials reflect the cultures and ethnic

backgrounds of the potential audience determined by the above assessment.

Strongly Agree Agree Neither Agree or Disagree Disagree Strongly Disagree

3. The text included in any visual materials or handouts is adapted for the average literacy level

of the potential audience.

Strongly Agree Agree Neither Agree or Disagree Disagree Strongly Disagree

4. My lesson plan uses various forms of communication style (visual, verbal, hands-on, etc.) to

meet different learning needs.

Strongly Agree Agree Neither Agree or Disagree Disagree Strongly Disagree

5. I have considered my own values and cultural beliefs in relation to this topic to avoid imposing
my own personal biases on my audience.

Strongly Agree Agree Neither Agree or Disagree Disagree Strongly Disagree

6. I understand that my audience may have varying backgrounds and beliefs regarding the

selected educational topic, and I am prepared to adapt my communication style and answer

questions in a manner respectful to differing beliefs and backgrounds.

Strongly Agree Agree Neither Agree or Disagree Disagree Strongly Disagree

Adapted from: Goode, T. D. (2009). Promoting cultural and linguistic competency: Self-assessment

checklist for personnel providing primary health care services. Georgetown University National Center

for Cultural Competence. Retrieved from https://nccc.georgetown.edu/assessments/.

VII. Summary

I presented my inservice to 30 certified nursing assistants (CNAs) at Palm Terrace

Healthcare and Rehabilitation center. Malnutrition and weight loss is common in rehabilitation

facilities where the patients served are generally older. The registered dietitian (RD) at this

healthcare facility completes Mini Nutrition Assessments (MNA) for every admitted patient. This

assessment evaluates oral intake, changes in weight, oral nutrition supplements, mobility,

neuropsychological problems, BMI and appetite. Most of this documentation is reported by the

CNAs. The CNAs must receive training on standardized meal reporting to increase the accuracy

of malnutrition screening.

I administered a formal learning assessment in the form of a quiz at the beginning of the

presentation to which I requested all attendees fill out to the best of their ability. I explained that

we would be discussing the content on said quiz and that participants would have the
opportunity to update answers before completion of the inservice. Initially, only 10 answered

correctly on the first question, 24 on the second question, 7 on the third question, and 22 on the

fourth question. Most attendees answered incorrectly on question three, which addressed meal

reporting percentages. Employees who guessed incorrectly on the questions about malnutrition

(question 1 and 2) were more likely to correct their answer than participants who answered

incorrectly on the question about meal reporting (question 3). Participants aslo had high

success rates on question four, with 22 corrections and 6 corrected answers. Overall, the staff

benefitted from this inservice and improved on quiz scores.

During the presentation, I observed 5 participants who seemed to be unfocused. Their

body language and lack of eyecontact was indicative of lack in focus. Between the two groups

of CNAs I presented to, only 3 questions were brought up. As result of this informal assessment,

I would conclude that engagement was good but not as excellent as I had hoped.

Based on the informal and formal assessments, this inservice was beneficial to staff

development and learning. I would suggest additional inservice trainings and education to

increase staff knowledge on amount eaten meal reporting. CNAs are essential to the collection

of malnutrition criteria data and assessments of patient outcomes. Therefore, regular CNA

inservice trainings are vital for the success of this healthcare facility.
 References

Abbott Nutrition Health Institute. (n.d.). Role of malnutrition in increasing risk of hospital ...

Role of Malnutrition in Increasing Risk of Hospital Readmissions. Retrieved

November 29, 2021, from

https://static.abbottnutrition.com/cms-prod/anhi-2017.org/img/malnutrition-and-read

missions-pdf_tcm1423-103343.pdf.

Nutrition intervention with oral nutritional supplements. Nutrition Intervention with Oral

Nutritional Supplements. (n.d.). Retrieved November 28, 2021, from

https://abbottnutrition.com/clinical-studies/nutrition-intervention-with-ons.

Oral nutritional supplements to tackle malnutrition. Medical Nutrition International Industry

(MNI). (2009). Retrieved November 28, 2021, from

https://medicalnutritionindustry.com/files/user_upload/documents/ONS_2012/Dossi

er2012FINAL2012-09-04.pdf.