My nomination for the Nutrition Nurse of the Year 2023 came as a surprise to me, but I think it reflects my work over more than 20 years to establish a network of carers, and training and supporting them to care for very vulnerable patients requiring enteral feeding in the London Borough of Bromley. I was nominated by a community dietitian colleague with whom I work closely and to be a finalist means so much to me and my dietitian colleagues. We are part of a wonderful team of dietetic clinicians.
I became a community nutrition nurse specialist 22 years ago, working with community adult dietitians for Bromley Healthcare. It was a brand-new post and I was asked to set up and implement the nutrition nurse role in the community to provide a service to care for our enteral feeding patients who needed support when discharged home from hospital. The caseload at this time was an average of 23 patients requiring enteral support; now, average numbers are around 100 plus. This increased temporarily during the COVID-19 pandemic as endoscopic procedures were not being performed and more patients were receiving care at home. The fact that this service has been achieved with a minimal increase in resources is a tribute to all the NHS and non-NHS staff engaged in enteral care in Bromley.
My role was to set up a patient pathway and guidelines and polices in nursing care to:
- Ensure that enteral equipment and feeds for patients were safe and cost-effective by working closely with enteral feed company nurses
- Provide training for community nurses, nursing home nurses and family members to support enteral patients at home or in nursing homes
- Work alongside the community dietitians to enable patients to receive their required feeding regimens without any complications and provide support through patients' planned care
- To respond to any requests for specialist assistance with feeding systems to prevent patients (many of whom are vulnerable) having to attend an accident and emergency department (A&E) for treatment.
My aim was to work in partnership with clinicians, families and nursing home staff to ensure a gold standard of care for this group of patients.
At this time, very few nutrition nurses were working in hospitals or in patients' homes, nursing homes or residential care. I managed to locate and network with other nutrition nurses to see how the service could be provided and what training had to be put in place for health professionals working in the community.
I spent time with a gastroenterologist who placed percutaneous endoscopic gastrostomy (PEG) tubes and a radiologist who placed radiologically inserted gastrostomy (RIG) tubes and replacement balloon gastrostomy tubes. I observed procedures and learnt how to place balloon gastrostomy tubes and Mic-Key button tubes for patients whose tubes had become blocked or had fallen out. I gained experience and became competent in these skills; this has enabled me to carry out these procedures in a patient's home so they do not have to attend A&E for a tube replacement. It has also allowed me to build good working relationships with hospital consultants and clinicians.
Preventing hospital admission
This service has prevented many A&E visits and admissions to hospital, so reduced time spent in A&E or acute services. Not only has this saved money for the NHS and freed up resources but, importantly, it has also protected the quality of life for our enteral patients, many of whom are immune suppressed or vulnerable.
In the event of a patient having to attend A&E. I also arranged a protocol with hospital nutrition staff to ensure they were seen and sent home promptly, much to the appreciation of them and their carers.
As a specialist nutrition nurse, I am committed to providing training and support for community nurses, community dietitians, patients and carers. This training has covered basic practical care involving looking after all types of feeding tubes, stoma care, water changes, water flushes, administering medications, troubleshooting and changing tubes.
I regularly engage with GPs and hospital consultants and attend multidisciplinary team meetings on complex cases, for example if tubes need to be replaced or urgent case reviews carried out. I have also met with our local hospital nutrition nurse to discuss best practice, for example over granulation treatments. I have joint meetings with dietitians and nutrition nurses in other areas in south-east London on good practice and any emerging issues, such as around the use of Monarch tubes and patient safety regarding the removal of these tubes at a patient's home.
I have empowered some of my independent patients to change their own balloon gastrostomy tubes and Mic-Key button tubes if required. This is especially beneficial for patients going on holiday as they then have independence, confidence and less stress. I have also taught some family carers to replace a balloon gastrostomy if a tube falls out and encouraged the use of an Enplug to keep the stoma tract open so a tube can be replaced. Some nursing-home nurses have also been trained to change a balloon gastrostomy or Mic-Key button tube, so their patients do not have to attend A&E, which reduces stress on the patient and family.
Over the past 5 years, I have also provided a training programme for the band 5 nurse induction, which I managed to support even through COVID-19. This is a worthwhile training programme, as it gives our newly joined nurses some practical experience and confidence to support enteral patients. The feedback has been complimentary from nurses and the training department and this makes me feel my work is beneficial in providing a good service and enhances the nurses' quality of care. I feel undergraduate nurses do not receive enough training on enteral feeding and enteral care.
I also carry out update training for community nurses and nursing-home nurses as well as education on request if they have a new patient and are unfamiliar with the type of feeding tube or unsure about how it should be managed, or are having problems with stoma site leakage and granulation treatment not responding. My door is always open to help nurses and to give advice and support on any issues they have to enable them to give patients the best treatment.
Spreading the skills
My training of another community nutrition nurse to cover a different community health authority in south-east London on enteral care has been very successful and been highly praised by my management and the contracted service provider. This nutrition nurse is now highly trained and works closely with me on any problems that need solving and any changes to services or treatment.
We are working together with other nutrition nurses on the south-east London procurement tender for the provision of nursing care from feed-company nurses. This is an important task of joint working and the outcome is that the patient is provided with high-quality nursing care. Working with company nurses needs to complement NHS patient care and the service needs to be cost-effective in providing this care.
During the height of the COVID-19 pandemic, I was redeployed to general community nursing duties but remained committed to ensuring enteral patients were not forgotten and managed to prioritise them when necessary.
I do feel every community service should have a nutrition nurse to support the growing number of enteral patients being cared for in the community. Community nutrition nurses are an asset and should not be overlooked when planning and providing an enteral care service.
My work in the community over the past 22 years has sometimes been stressful and I have felt overworked but it has been enjoyable knowing I have given my best to our enteral patients. My can-do attitude has always been praised by my colleagues and knowing that I am respected by management and my patients makes the work worthwhile. My nomination stated that my dedication and continual support and training were reflected in the sheer amount of positive feedback and thank-yous received from not only patients but also other health professionals.
At the end of next year, I will be looking forward to retiring fully after 42 years as a nurse. I know I will miss my work and seeing patients and families and have all the memories of times good and less good.
I was very pleased to be given the Nutrition Nurse of the Year silver award by British Journal of Nursing for my contribution to nutrition nurse nursing as it will highlight the important nature of this service within community care.