Knowledge, Perception and Challenges of Implementing Nutrition Screening: A Survey of Healthcare Professionals

Background: Preoperative malnutrition is common in hospital settings; however, one major problem is the short practices to screen surgical patients as a part of nutrition care management to address the issue of malnutrition. Objectives: The aim of this study is to assess the knowledge, perceptions, and challenges of Healthcare Professionals (HCPs) to implement NS in pre-operative patients. Methods: A cross-sectional survey was undertaken between April and May 2023. Results: A total of 103 respondents participated in this survey. Almost 75% of HCPs acknowledged the importance of managing malnutrition in preoperative patients; however, there is a lack of implementation of NS (32.4%) and a need for training for HCPs (74.5%), which relates to fewer patients being referred to a dietitian for better nutrition care. All HCPs have a positive perception (85.4%) of the importance of preoperative NS and concur that challenges faced to execute NS accordingly beforehand are the barrier (52.3%). Conclusions: The present study suggests that HCPs are aware of early identification of malnutrition but lack implementation of NS. There is a remarkable need for the establishment of a standardised nutrition care pathway for better nutrition intervention in pre-operative patients.


Introduction
Malnutrition is a common problem, affecting a high percentage of surgical patients; it is frequently observed in 60-85% of surgical patients undergoing common medical procedures [1] .Malnutrition in the pre-operative period is associated with increased morbidity, mortality, length-of-stay, and healthcare costs [2] .These patients are at particular risk due to inadequate oral intake, cancer cachexia, muscle protein depletion, and gastrointestinal inflammation [3][4] [5] .Optimising nutrition pre-operatively has been shown to improve outcomes after surgery [6] and may impact long-term health outcomes [7] .
Nutrition screening (NS) has been defined as a process used to identify those who may be at risk of malnutrition or who are malnourished so that a full nutrition assessment is indicated, and appropriate nutrition intervention can be provided [8] .
It is the key first step in identifying those who may need additional support and is essential to avoid missing those who are malnourished without displaying overt symptoms [9] .A recent study among medical patients comparing Nutrition Risk Screening 2002 (NRS 2002), Subjective Global Assessment (SGA), Short Nutritional Assessment Questionnaire (SNAQ), Mini Nutritional Assessment (MNA), and MUST showed that all screening and assessment instruments have a higher nutritional risk associated with a higher risk for mortality and adverse clinical outcomes but not with treatment response from nutritional support [10] .
A recent review suggested that two-thirds of patients scheduled for gastrointestinal surgery are malnourished during the first day of hospital admission and these patients have a three-fold increase in the risk of developing post-operative complications and a five-fold greater risk of mortality than well-nourished patients [11] .Even with this situation, this review found that only one in five hospitals in Western countries had applied nutritional screening processes and only one in five patients received any type of preoperative nutrition therapy [12] .Therefore, as a basic requirement, a systematic nutritional risk screening had been suggested and should be considered in all surgical patients on hospital admission [13] .
NS should take place on initial registration at general practice surgeries and when there is clinical concern [14] .
Considering NS is vital for identifying patients' nutritional risk, this assessment was made mandatory and systematically integrated for all patients admitted to Portugal national hospitals in 2019 and resulted in an increased proportion of patients screened for malnutrition risk [15] .It is suggested that screening for malnutrition should be done within the first 24-48 hours of hospital admission or during the first visit in an outpatient setting.This will give the clinical team enough time to perform further nutritional assessment and refer patients to the related team for nutritional intervention as needed [13] .Study Instruments The study is a self-administered questionnaire.The questions are self-developed and adapted from previous similar studies' questionnaires, which were combined into one thorough questionnaire.The questionnaire was divided into 3 parts: A -Sociodemographic, B -Knowledge, Perceptions and Challenges on Malnutrition among Preoperative Patients, C -Knowledge, Perceptions and Challenges on Nutrition Screening Implementation.All the adapted questions were extracted from [17][18] [19] .As for Part C of the questionnaire, it contains open-ended questions [15] .
Data collected was primary data, whereby all HCPs were given a questionnaire sheet consisting of 4 parts.Their participation is voluntary, as a convenient sampling method was used.Upon completion of the questionnaire, the data collected were then transferred into softcopy documentation and analysed for the findings.

Study approval
Ethical approval for this study was obtained from the Ethics Committee for Research Involving Human Subjects UPM (JKEUPM) with a reference number of JKEUPM-2023-163.The research approval from HSAAS was obtained from the Clinical Research Unit (CRU), HSAAS.Verbal and written informed consent were sought from all participants prior to assessment.

Statistical analysis
Statistical analysis was done using the IBM SPSS Statistics version 26.This study involves univariate analysis of descriptive statistics only.The categorical variables from the answers for each question in the questionnaires were in frequencies and percentages.

Results
A total of 103 HCPs were involved in the survey.The characteristics of the participants are shown in  Table 3 summarises the descriptive results of the NS implementation part on the questionnaire.In this part, the five-point Likert scale was used to assess ranges from "1 = strongly disagree" to "5 = strongly agree".The majority of participants indicated agreement with all of the questions pertaining to knowledge of the NS implementation; however, the responses varied for the challenges faced in applying the NS tool prior to any surgical procedures.These high percentage values indicate that the participants had a high level of knowledge and positive perceptions.

Discussion
The current study assessed HCPs' knowledge, perceptions and challenges towards malnutrition and implementation of NS in pre-operative patients.The majority of HCPs are aware of malnutrition and the importance of NS in the clinical setting.This aligns with the study in New Brunswick, Canada, which indicated that the majority of dietitians and nurses were informed that NS is important (98.5% and 94.7%, respectively) [20] .Additionally, HCPs claimed to have challenges in addressing the malnutrition status of the patients.Obviously, general practitioners (GPs) reported inadequate knowledge, skills, training, time and resources to manage and treat malnutrition [21] .In a study, it was ascertained that only 60.4% of GPs can appropriately select patients to screen, while 19.5% reported a lack of NS knowledge [22] .GPs' knowledge deficit on malnutrition and malnutrition screening was obvious in the primary care and hospital settings, as screening was often done by nurses before referring to dietitians [23] .
Study in a public hospital in Malaysia revealed that approximately 22.0% of surgical patients were found to be at risk of developing malnutrition.Only 14.9% of them have been referred for nutrition intervention [24] .Early prevention and intervention strategies are important since the usage of the NS tool is valid and reliable, and the most important factor is the action taken as a result of the screening, to improve the nutritional status of individuals undergoing surgery to improve postoperative recovery [25] .Therefore, it is worth noting that patients undergoing any surgical procedures are generally nutrition-depleted and prone to develop postoperative complications if they are not screened.Only a few of them routinely screened the patients using the NS tool before any surgical procedures.Our findings are in accordance with a recent European multicentric study that reported an overall routine NS rate of 52% in the participating countries [26] .A remarkably high screening rate of 93% was reported from the United Kingdom, whereas only 33% of the partner hospitals in Germany and Austria performed NS [27] .In addition, routine NS was performed by only 20% of the responding hospitals, whereas another 50% performed a selective assessment of patients with a potential nutritional risk.Up to 30% of centres rarely or never assessed patients' nutritional status preoperatively, which has to be considered as an important shortcoming in modern GI surgery [4][28][29] [30] .Furthermore, 48% evaluated their patients' nutritional status only at admission or even postoperatively, which is too late for an effective nutritional intervention [27] .
According to Shafiee et al. (2016), of both two hospitals where their study was conducted, only a small number of HCPs have employed screening tools like the Malnutrition Universal Screening Tool (MUST) and Subjective Global Assessment (SGA) to identify whether or not patients are at high risk of malnutrition [31] .Previous findings declared that less than one in six patients who are at risk of undernutrition were adequately monitored, which could be due to a lack of training, resources, and time [32] .It is crucial to empower regular monitoring of the patients' nutritional status to ensure patients' optimal preoperative condition in an attempt to reduce postoperative complications associated with malnutrition [33] .These findings explained why the majority of HCPs in this study would also like to receive more assistance regarding implementing the NS in patients.Incorporating NS as part of the nutrition education for HCPs is important to introduce and train HCPs in enhancing the implementation of screening malnourished patients using NS prior to prescribing nutrition intervention properly and in monitoring patients effectively [31] .
Another important and commonly reported challenge faced is due to a lack of training in nutrition skills.Based on the study in Italy, about 46% of surgeons and residents claimed to not have the knowledge of the nutrition therapy multidisciplinary team [34] .This is in line with the current study, as 28.2% claimed that the main reason for not implementing NS tool is not perceived orders from general practitioners to conduct a thorough NS.This relates to a study carried out, as 60.4% of general practitioners choose their patients wisely for NS, and 39.6% of them claimed to have no understanding about NS [22] .
On top of that, a major number of the HCPs believe in the importance of nutrition screening for all surgical patients, though only 47.0% of HCPs are able to ascertain when patients are at risk of malnutrition or malnourished.It has been stated that the preoperative nutritional care of surgical patients includes screening for malnutrition with a 100% consensus stating that the nutritional status of patients should be assessed before and after the operation, and patients who are not meeting their energy adequacy orally should be provided with ONS perioperatively [35] .Therefore, to improve their competency in providing better nutrition care to patients preoperatively, 80.4% feel that training is necessary.This is in line with the suggestions from various previous studies that nutritional care practice can be further improved by developing the HCPs' knowledge and skills through education and training [36][37][38][39][40] [41] .If this were implemented, HCPs might report more confidence in their ability to screen patients, therefore being better able to identify those most in need of dietetic intervention.

Strengths and Limitations
These new findings add remarkable information on the positive clinical and nutrition care outcome of implementing the NS in managing malnutrition issues in surgical patients prior to any surgical procedures, specifically in the Malaysian context.
Hence, this study can serve as a foundation for future research and development of feeding protocols in HSAAS as this marks the establishment of proper nutrition care management and intervention in the field of nutrition and surgery.
Nevertheless, it is important to acknowledge certain limitations in this study.The limitations of this study were relatively small and conducted in only one institution, which potentially affects the generalizability of the findings.

Conclusion
The knowledge about the importance of managing malnutrition in pre-operative patients in HCPs was adequate.However, there is a lack of implementation of NS tool, which relates to the smaller number of patients being referred to a dietitian for better nutrition care.All HCPs have a positive perception of the importance of preoperative nutrition screening.Basically, HCPs are not sure how to execute the NS tool among the pre-operative patients and there is a need for training for HCPs.
Establishing a standardised nutrition care pathway and feeding protocol in HSAAS presents an opportunity to improve the challenges and barriers in the pre-operative patients.