FACTORS FOR EFFECTIVE IDENTIFICATION OF PATIENTS  
AT NUTRITIONAL RISK IN CLINICAL PRACTICE: THEMATIC ANALYSIS  
OF QUALITATIVE RESEARCH
Denis MLAKAR-MASTNAK1*, Nada ROTOVNIK KOZJEK1,2, Brigita SKELA-SAVIČ3
1Institute of Oncology Ljubljana, Clinical Nutrition Unit, Zaloška cesta 2, 1000 Ljubljana, Slovenia
2University of Ljubljana, Faculty of Medicine, Vrazov trg 2, 1000 Ljubljana, Slovenia
3Angela Boškin Faculty of Health Care, Spodnji Plavž 3, 4270 Jesenice, Slovenija
Received: Aug 3, 2021
Accepted: May 9, 2022
Review
*Corresponding author: Tel. + 386 41 482 572; E-mail: denis.mlakarm@gmail.com
10.2478/sjph-2022-0025 Zdr Varst. 2022;61(3):191-197
191
DEJAVNIKI UČINKOVITEGA PREPOZNAVANJA PREHRANSKO 
OGROŽENIH PACIENTOV V KLINIČNI PRAKSI: TEMATSKA 
ANALIZA KVALITATIVNIH RAZISKAV
© National Institute of Public Health, Slovenia. 
Mlakar-Mastnak D, Rotovnik Kozjek N, Skela-Savič B. Factors for effective identification of patients at nutritional risk in clinical practice:  
thematic analysis of qualitative research. Zdr Varst. 2022;61(3):191-197. doi: 10.2478/sjph-2022-0025.
ABSTRACT
Keywords: 
nutritional care, 
nutritional screening, 
barriers and 
accelerators, health 
professionals, nurses
IZVLEČEK
Ključne besede: 
prehranska obravnava, 
prehransko presejanje, 
ovire in pospeševalci, 
zdravstveni delavci, 
medicinske sestre
Introduction: Despite the high prevalence of malnutrition in patients at all levels of healthcare, early prevention 
and treatment of malnourished patients are often neglected and overlooked in clinical practice. The aim of this 
systematic literature review was to identify the factors considered most important by healthcare professionals 
in the identification and treatment of malnourished patients or those at risk of malnutrition.
Methods: A systematic literature review of qualitative research was conducted. Documents published in 
scientific journals in English from 2011 to 2021 were searched in the PubMed (MEDLINE), CINAHL and ProQuest 
databases. The results were analysed with a thematic analysis of qualitative research findings.
Results: From the search set of 1010 results, 7 sources were included in the final analysis. Factors identified 
by health professionals as important in the identification and treatment of malnourished patients in clinical 
practice were grouped into five themes: unclear organizational structure; indefinite structure of nutritional 
care; poor continuity of nutritional care; lack of knowledge and skills of health professionals; lack of time and 
human resources.
Conclusions: Health policy must provide resources for nutritional care for patients at all levels of health care 
on the initiative of the highest professional bodies at the state level. To improve the nutritional care of patients 
in clinical practice, the management of health care institutions must promote and enable the professional 
and organizational establishment of clinical nutrition as a regular medical activity of the institution, develop 
clinical nutritional pathways, and promote evidence-based clinical practice and interprofessional collaboration.
Uvod: Kljub visoki razširjenosti podhranjenosti pri pacientih na vseh ravneh zdravstvenega varstva sta zgodnja 
preventiva in zdravljenje podhranjenih ali prehransko ogroženih pacientov v klinični praksi pogosto zapostavljena 
in spregledana. Za razvoj potencialno učinkovitih strategij za uvedbo prehranskega presejanja in učinkovite 
prehranske terapije za paciente s prehranskim tveganjem je pomembno poznati že raziskane dejavnike, ki ovirajo 
takšno klinično prakso. Namen sistematičnega pregleda literature je bil analizirati dejavnike in ovire učinkovitega 
prepoznavanja prehransko ogroženih pacientov, ki so jih pri svojem delu prepoznali zdravstveni delavci.
Metode: Uporabljen je bil sistematični pregled literature, izveden v podatkovnih bazah PubMed (MEDLINE), 
CINAHL in ProQuest. Iskalni pojmi so bili: medicinske sestre, zdravstveno osebje, prehransko presejanje, 
prehranska ocena, podhranjenost, odnos, ovire in posredniki. Vključili smo raziskave objavljene v znanstvenih 
revijah, v angleškem jeziku, od leta 2011 do 2021. Rezultati so bili analizirani s tematsko analizo ugotovitev 
kvalitativnih raziskav.
Rezultati: Iz iskalnega nabora 1.010 zadetkov smo v končno analizo vključili 7 virov. Dejavnike, ki so jih zdravstveni 
delavci opredelili kot ključne pri prepoznavanju in obravnavi prehransko ogroženih pacientov v klinični praksi, 
smo združili v petih temah: klinična prehrana ni organizacijsko strukturirana kot del zdravstvene dejavnosti; 
struktura prehranske podpore je nedorečena; prehranska podpora ni kontinuirana; pomanjkljivo znanje in 
usposobljenost zdravstvenih delavcev na področju klinične prehrane; pomanjkanje časa in kadrovskih virov.
Zaključki: Zdravstvena politika, na pobudo najvišjih strokovnih organov na ravni države, mora zagotoviti resurse 
za prehransko obravnavo pacientov na vseh ravneh zdravstva. Za izboljšanje prehranske obravnave pacientov 
v klinični praksi morajo vodstva zdravstvenih ustanov spodbujati in omogočati strokovno ter organizacijsko 
umeščanje klinične prehrane kot redno zdravstveno dejavnost zavoda, razvijati klinične poti za prehransko 
podporo pacientov, spodbujati na dokazih temelječo klinično prakso in medpoklicno sodelovanje strokovnjakov.
1 INTRODUCTION
Despite the high prevalence of malnutrition in patients at 
all levels of healthcare and clinical guidelines emphasizing 
that early identification of patients at nutritional risk is 
critical for early prevention and treatment of malnutrition, 
its importance is often neglected and overlooked in 
clinical practice. Malnutrition is defined as a condition 
resulting from inadequate intake or absorption of 
nutrients, leading to altered body composition, cell mass 
and consequently decreased physical and mental function, 
as well as impaired clinical outcome due to disease (1). 
The recent definition of malnutrition developed by the 
European Society of Parenteral and Enteral Nutrition 
(ESPEN) is based on three aetiologies: starvation-related 
malnutrition without inflammation, chronic disease-
related malnutrition with mild to moderate inflammation, 
and acute disease- or injury-related malnutrition with 
pronounced inflammation (2).
The prevalence of malnutrition in patients at all levels of 
healthcare is confirmed by several studies. Most studies 
have focused on acutely ill patients in hospitals, nursing 
home residents and elderly patients. A multicentre 
NutritionDay (nDay) study involving 25 European countries 
and a total of 10,863 patients found that 30% of patients 
in hospitals were at risk of malnutrition, while 12.9% of 
patients were malnourished (3). In a systematic review by 
Bell et al. (4), the prevalence of malnutrition in nursing 
home residents ranged from 20% to 39% in most studies, 
and 47% to 62% of residents were at risk of malnutrition. 
The pooled prevalence of malnutrition in community-
dwelling older people in the European countries included 
in the systematic review by Crichton et al. (5) ranged from 
0.8% to 11.0%.
Malnutrition can exacerbate the effects of chronic disease 
management and lead to an increased risk of complications 
during treatment, increased mortality and poorer quality 
of life for patients during and after treatment (6). All 
these negative consequences of malnutrition also have 
a negative financial impact on the healthcare system, 
as the treatment of malnourished patients increases the 
number of visits to the primary care physician or home 
visits and directly correlates with longer hospital stays 
and increased hospital readmissions due to complications 
(7). Scientific evidence and clinical practice show that 
the nutritional management of patients, which includes 
clinically oriented nutritional interventions to prevent, 
detect and treat malnutrition, significantly reduces 
morbidity and short- and long-term mortality in patients 
and saves many healthcare costs (7-12).
Nutritional care of patients in clinical practice must be 
scientifically based, standardized, planned and systematic. 
It should include several interrelated steps defined in 
nutritional pathways. Nutritional screening is the first 
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step in this process, which aims to identify patients at 
nutritional risk. It is performed with appropriate validated 
tools, within the first 24-48 hours of initial contact 
with the patient and must then be repeated at regular 
intervals. There are several nutritional screening tools 
that cover all the major areas that increase a patient’s 
risk of malnutrition, namely weight loss, decreased food 
intake and the presence of disease (1, 13). 
To develop potentially effective strategies for implementing 
nutritional screening and effective nutrition interventions 
for patients at nutritional risk, it is important to define 
the main barriers and facilitators that exist in clinical 
practice. Modifying or removing barriers and using existing 
facilitators can improve nutritional care for patients 
at all levels of healthcare. The aim of the systematic 
literature review was to identify the factors considered 
by healthcare professionals to be most important in the 
effective identification of patients at nutritional risk and 
their continued nutritional treatment.
2 METHODS
Since the importance of nutritional care has already been 
scientifically proven, but is rarely fully implemented and 
not all factors for its effective implementation are known, 
we decided to conduct a systematic literature review of 
qualitative research.  
2.1 Document identification methods
Using the model PICO (Patient/ Problem, Intervention, 
Comparison and Outcome), we created the following 
keywords: nurses, health personnel, nutrition screening, 
nutrition assessment, malnutrition or protein-energy 
malnutrition, attitude, barriers and facilitators. Key words 
and the Boolean operators AND and OR were used for the 
search strategies. Documents were searched in online 
bibliographic databases: PubMed (MEDLINE), CINAHL, and 
ProQuest. The search was limited to English-language full-
text articles published between 2011 and 2021.
2.2 Selected publications 
We identified 1010 publications and 51 duplicates 
were excluded. During a quick review of the titles and 
abstracts of the included articles, we identified and 
included 6 additional relevant publications using the 
“link to similar articles” browser in PubMed. The PRISMA 
protocol (Preferred Reporting Items for Systematic Review 
and Meta-Analysis) was used to display the results of the 
literature review (14) (Figure 1).
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2.3 Quality assessment of the review and description of 
the data processing
We included descriptive qualitative research that reached 
the seventh level of evidence in Polit & Beck’s hierarchy 
of evidence (15). The quality of the included research was 
assessed using the established COREQ tool (Consolidated 
Criteria for Reporting Qualitative Research Tool) (16). Data 
analysis was conducted through content analysis followed 
by a thematic synthesis method based on the thematic 
analysis of the qualitative research findings (17).
3 RESULTS
Table 1 shows the main findings of the included studies, 
and refers to the factors that hinder or accelerate the 
effectiveness of nutritional care for patients in clinical 
practice.
We recognised forty-eight codes and five categories, 
and the main results were grouped into five themes: 
unclear organizational structure; indefinite structure of 
nutritional care; poor continuity of nutritional care; lack 
of knowledge and skills of health professionals; lack of 
time and human resources.
3.1 Unclear organizational structure
The healthcare environment can have a significant impact 
on the implementation of nutritional care for patients in 
clinical practice. It is more likely to be carried out where the 
organization takes responsibility for its implementation, 
has clear expectations about it, and considers nutritional 
care as a priority of organizational and clinical leadership 
Figure 1. Results of the literature review based on the PRISMA 
method.
Green et al., 
2014 (18)
Chapman et 
al., 2015 (23)
Eide et al., 
2015 (19)
Study 
(author, 
year)
Results - barriers and facilitators 
to nutritional care
Health system 
setting, country
Research design Research 
sample
6 thematic categories: 
supportive organizational culture; time and 
resources for screening and intervention;
simplicity and acceptability of screening tool; 
professional judgement as good as screening; 
need for training and sharing of best practice; 
enhancing communication between care settings.
5 thematic categories: nutritional screening policy; 
knowledge and education; organizational constraints; 
multidisciplinary working; effective nutritional practice.
5 thematic categories: loneliness in nutritional 
care; need for competence in nutritional care; low 
flexibility in food service practices; system failure 
in nutritional care; neglect of nutritional care.
Primary care – 
community health 
care. United 
Kingdom.
Tertiary health. 
United Kingdom.
Tertiary care. 
Norway.
Descriptive 
qualitative 
research design.
Descriptive 
qualitative 
research design.
Descriptive 
qualitative 
research design.
20 community 
nurses.
80 healthcare 
professionals 
(nurses, 
physicians, 
dietitians).
16 nurses.
Table 1. Authors, health system setting and country, research design, research sample, barriers and facilitators to nutritional care.
194
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Håkonsen et 
al., 2019 (20)
Hestevik et 
al., 2019 (21)
Avgerinou et 
al., 2020 (22)
Verwijs et al., 
2020 (24)
Study 
(author, 
year)
Results - barriers and facilitators 
to nutritional care
Health system 
setting, country
Research design Research 
sample
6 explorative themes: lack of uniform and systematic 
communication affects nutritional care practices; 
experiential knowledge of primary workers affects daily 
clinical decisions; different attitudes towards nutritional 
care result in differences in quality of care; differences 
in organizational culture affect quality of care; lack 
of clear responsibilities for nutritional care affects 
how daily care is delivered; lack of clinical leadership 
and priorities makes nutritional care invisible.
2 explanatory themes: absent inter- and intra-professional 
collaboration and communication impedes optimal 
clinical decision-making; quality deterioration due 
to poorly established nutritional care structure.
2 main themes and 6 subthemes:
Theme 1: meeting patients with complex nutritional 
problems, with the subthemes: It’s much more complex 
than just not eating; seeing nutrition as part of the whole. 
Theme 2: the structure of nutritional care, with the 
subthemes: nutritional routines; lack of time for 
individualized nutritional care; lack of interdisciplinary 
collaboration in nutritional care; meeting challenging 
situations with limited resources in home care.
4 thematic categories: understanding 
and recognising malnutrition;
management of unintentional weight loss 
in the community; challenges in addressing 
malnutrition; possible solutions.
6 thematic categories: causes of malnutrition; 
knowledge and awareness;
recognition and diagnosis of malnutrition; communication; 
accountability; food preparation and provision.
Nursing homes, 
home care sector, 
home nursing 
sector. Denmark. 
Acute geriatric 
hospital care and 
home care. Norway. 
Primary care. 
United Kingdom.
Primary care. 
Norway.
Descriptive 
qualitative 
research design.
Descriptive 
qualitative 
research design.
Descriptive 
qualitative 
research design.
Descriptive 
qualitative 
research design.
14 healthcare 
professionals 
(nurses, 
social and 
health service 
helpers, 
social and 
health service 
assistants).
23 healthcare 
professionals 
(nurses, 
activity 
therapist).
60 healthcare 
professionals 
(physicians, 
nurses, 
dietitians). 
41 healthcare 
professionals 
(physicians, 
nurses, 
dietitians, 
social 
workers, 
cooks). 21 
malnourished 
older adults 
(≥ 65 years), 
5 caregivers.
(18-20). Although nutritional screening was implemented 
in some clinical settings as a tool to assess patients at 
nutritional risk, healthcare professionals generally 
relied on their own subjective professional judgment, 
clinical experience and “common sense.” In some cases, 
nutritional screening was performed only after the patient 
reported weight loss or decreased appetite (18, 19, 21, 
22). Existing clinical guidelines were often poorly applied 
in clinical practice, and nutritional treatment of patients 
was considered only as a form of nonmedical patient care. 
The quality of nutritional care and treatment of patients 
often depended on the individual interest of healthcare 
professionals in clinical nutrition (20).
3.2 Indefinite structure of nutritional care
Healthcare professionals expressed very different and 
also conflicting views about taking responsibility for the 
continuing nutritional care of patients at nutritional risk. 
They expressed uncertainty about the role that each 
professional group (physicians, nurses and dietitians) 
should play in the nutritional care of patients. They called 
for a multidisciplinary approach in which responsibilities 
and competencies for the nutritional care and treatment 
of patients are formally divided between the different 
professional groups, and for better communication and 
collaboration between them (19-21, 23, 24).
Dietitians defined physicians as those most able to 
identify malnourished patients and diagnose nutritional 
disorders. However, identifying patients with malnutrition 
was often of secondary importance to primary care 
physicians. Physicians recognized malnourished patients 
during primary treatment of their other clinical conditions 
or diseases rather than as a distinct clinical condition 
to be systematically diagnosed and followed up (22). 
Nurses frequently expressed frustration and feelings of 
loneliness at the lack of physician involvement in the 
nutritional care of patients. Dietitians were recognized by 
health professionals as useful and necessary professional 
collaborators in the nutritional treatment of malnourished 
patients, but their availability in certain healthcare 
organizations was too low (19, 21). With the implementation 
of nutritional screening, it has been shown that autonomy 
in providing comprehensive nutritional care to the patient 
allows nurses to use their clinical knowledge and skills 
more effectively in clinical practice (18, 23).
3.3. Poor continuity of nutritional care
Poor prospects for referring patients for further 
nutritional assessment and treatment emerged as one of 
the most important barriers, especially when referral was 
not possible (18, 21). On the other hand, patients were 
sometimes referred to a physician only for the physician 
to prescribe an oral nutritional supplement (18). The lack 
of a protocol for follow-up of patients at nutritional risk 
has been shown to be an important factor contributing to 
poor continuity of nutritional care (21). 
In the study by Verwijs et al. (24), the lack of exchange of 
written information about the patient’s nutritional status 
between different profiles of healthcare professionals 
was pointed out. In the study by Håkonsen et al. (20), 
the continuity and quality of nutritional care were mainly 
affected by the different use of nutritional terminology by 
different groups of healthcare professionals, and by different 
standards of nutritional care for patients in different health 
facilities within the same level of healthcare. Incorporating 
nutritional screening into clinical practice and nursing 
documentation can improve its implementation; however, 
continuity of nutritional care can be difficult when findings 
about the patient’s nutritional status are recorded in 
different documentation, reducing the transparency of the 
patient’s comprehensive nutritional care (19, 23). Nurses 
emphasized that the patient’s nutritional status was not 
adequately recorded in nursing documentation, which is 
necessary for continuity of the patient’s nutritional care 
between different levels of healthcare (18). Similar findings 
were found in a study by Verwijs et al. (24), in which 
information about the patient’s nutritional status was 
incomplete, delayed or not documented at all in discharge 
records. The quality of documentation of patients’ 
nutritional status was compromised by the lack of time 
of medical staff, and the poor quality of documentation 
proved to be a barrier to effective ongoing nutritional 
care of patients. This presented a deficit in the patient’s 
transition between different health care environments and 
levels of healthcare (21).
3.4 Lack of knowledge and skills of health professionals
Healthcare professionals frequently expressed a lack of 
knowledge and skills to identify and treat patients at 
nutritional risk. Continuing education and training were 
highlighted as important for improving the implementation 
of nutritional screening in clinical practice, and the 
importance of practical training in the use of screening 
tools when working with patients was emphasized (18, 
19, 24). Nurses and physicians emphasized that there 
is a lack of basic education in the field of nutrition in 
undergraduate education (22, 23). Håkonsen et al. 
(20) found that functional education and training to 
develop and deepen expertise in nutritional support is 
not systematic and regular, and that training is usually 
conducted as “decoding of practices from peers” when 
working with patients. In the study by Hestevik et al. (21), 
healthcare professionals highlighted that organizations do 
not provide sufficient support for nutrition training and 
they often have to attend it in their spare time as part of 
food company promotional events.
3.5 Lack of time, staff and other resources
Nurses cited lack of time and human resources as one of 
the most important barriers to effective implementation 
of nutritional care for patients, especially in relation to 
the large number of patients treated, extensive nursing 
and medical documentation, the large number of priority 
medical treatments for patients, and entering data in the 
information system (18, 20, 21, 23). The increased time to 
perform nutritional screening in clinical practice was also 
significantly affected by the availability of appropriate and 
functioning weight scales (19). Primary care physicians 
pointed out the problem of limited time to treat patients, 
which affected the quality of nutritional care provided to 
patients (22).
4 DISCUSSION
4.1 Systematic literature review results
The findings of the systematic literature review of 
qualitative research highlighted key factors that 
healthcare professionals consider important for the 
effective identification of patients at nutritional risk and 
their ongoing nutritional care in daily clinical practice. 
The systematic review included research conducted in 
different healthcare settings and at different levels of 
healthcare delivery, and we identified five main factors 
common to all. 
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Our findings showed that poor continuity of nutritional 
support was one of the most important factors negatively 
affecting the quality of nutritional care provided to 
patients. In particular, the following were highlighted 
as important components of this factor: poor chances of 
referring a malnourished patient for further treatment; 
lack of protocols for nutritional care; lack of exchange 
of written information about the patient’s nutritional 
status between different healthcare professionals; 
inconsistent use of nutritional terminology between 
different healthcare professionals; inconsistent standards 
of nutritional care for patients; and incomplete 
documentation of patient discharge (18, 20, 21, 24). A 
similar conclusion was reached in the study by Mersini 
et al. (25), which examined the impact and success 
of Albanian nutrition policy implementation. Lack of 
institutional/infrastructural support, lack of intersectoral 
coordination, and lack of effective collaboration between 
different sectors and institutions were obstacles to the 
implementation of their nutrition policy plan.
The implementation of clinical nutrition pathways, their 
integration at all levels of the health system and the 
establishment of a multidisciplinary team that includes a 
clinical dietitian in addition to the physician and nurse, 
must become one of the priorities of health systems. 
Implementation should be guided by clinical guidelines for 
the prevention, diagnosis and treatment of malnutrition 
and other nutritional disorders (2, 26). Nutritional 
screening, performed with a validated screening tool, 
provides the basis for further evidence-based nutritional 
treatment of the patient. Some studies have shown 
that the lack of a “key person” with specific knowledge 
in clinical nutrition (nurse) to support, promote and 
control the development of new procedures may hinder 
the effective implementation of nutritional screening in 
clinical practice (27). In addition, clinical dietitians who 
are frequently present on the wards and educate nurses 
and physicians can act as motivators and promoters of 
successful nutritional care (28). 
Our findings show that health professionals expressed 
uncertainty about their roles, responsibilities and 
competencies due to the indeterminate structure of 
nutritional care for patients, and emphasized the need 
for formal regulation in this area and the introduction 
of an effective multidisciplinary approach (19-21, 23, 
24). The multidisciplinary nutrition team is a group of 
specially trained and educated health professionals in 
clinical nutrition, including physicians, dietitians, nurses, 
pharmacists and other relevant professionals (2). When 
there is no specialized nutrition team, nutritional care 
is provided by the basic team of physicians, nurses, 
physiotherapists, pharmacists, etc. Nutritional care 
provided by multidisciplinary teams is effective when 
their work is focused on solving the patient’s individual 
problems, is based on evidence-based practice, and a 
collaborative approach is taken in clinical practice (29).
According to our findings, the lack of knowledge and skills 
among health professionals is another important barrier 
to effective nutrition-related care for patients (18-20, 
22-24). Healthcare professionals often have to rely on 
their own professional judgment and clinical experience 
when assessing patients at nutritional risk (18, 19, 21, 22). 
Therefore, health professionals emphasized the lack of 
support from the health facility management in providing 
nutrition-related care to patients and considered the 
influence of the facility management as a crucial factor in 
assuming professional responsibility (18-20).
4.2 Potential for clinical practice and further research
The results of our systematic literature review identified 
barriers that may significantly impede the implementation 
of effective nutritional care for patients at nutritional 
risk. Our findings can help healthcare providers consider 
and implement appropriate strategies to improve this 
clinical practice. According to our findings, it is important 
to examine organizational culture, multidisciplinary 
collaboration, roles and responsibilities of health 
professionals, continuity of nutritional care for patients, 
and protocols and standards currently used in clinical 
practice.
5 CONCLUSION
Health policy must provide resources for nutritional care 
for patients at all levels of healthcare on the initiative of 
the highest professional bodies at the state level. The main 
barriers to the implementation of effective nutritional 
screening and nutritional support for patients in clinical 
practice are primarily related to the poor organization of 
nutritional care in healthcare institutions and the lack of 
knowledge of health professionals about clinical nutrition. 
To improve nutritional care for patients in clinical 
practice, the management of healthcare institutions must 
promote and enable the professional and organizational 
establishment of clinical nutrition as a regular medical 
activity in the institution.
6 LIMITATIONS
Limitations in methodological quality have been noted in 
some studies, particularly in the area of the researcher’s 
relationship with study participants.
CONFLICT OF INTEREST
The authors declare that no conflicts of interest exist.
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FOUNDING
No funding has been received for the conduct of this study 
and/or preparation of this manuscript.
ETHICAL APPROVAL
The method used in this systematic literature review 
involves no ethical issues and therefore no ethical approval 
was necessary.
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