This paper proposes a nursing education intervention to address inpatient malnutrition at Mercy Medical Center Redding, a 267-bed non-profit level II trauma center in northern California. Drawing on demographic and institutional context, the paper outlines the scope of hospital malnutrition in the United States, identifies relevant community and organizational frame factors, and recommends an experiential learning-based education program for nursing staff. The intervention focuses on integrating malnutrition screening into key nursing workflow tasks — including admissions, rounds, handoffs, and discharges — under charge nurse leadership, with an estimated implementation budget of $10,620.
The paper exemplifies needs-assessment-driven proposal writing. Rather than presenting a generic intervention, the author first establishes the prevalence of the problem nationally, then narrows focus to local context through frame factor analysis, and only then proposes a targeted solution. This funnel structure — broad evidence → local context → specific intervention — is a hallmark of evidence-based nursing practice proposals.
The paper opens with a national problem statement supported by epidemiological data and introduces the Alliance to Advance Patient Nutrition. A frame factors section examines geographic, socioeconomic, political, and institutional variables relevant to Mercy Redding. The intervention section proposes an experiential learning model implemented by the charge nurse, includes a cost estimate, and references an appendix evaluation tool. A full reference list and appendix assessment instrument round out the document.
The Mercy Medical Center in Redding, California — a 267-bed non-profit level II trauma center within the Dignity Health healthcare system (Mercy Medical Center Redding, 2013) — appears to be unaware of a growing concern about the impact of inpatient malnutrition on health care outcomes. A word search on Mercy's website using the term "malnutrition" retrieved only one result, and that document discusses malnutrition in a patient resource guide ("Search," 2014). The lack of apparent concern about inpatient malnutrition among hospital clinicians and administrators is not atypical of many U.S. hospitals, but a few have begun to take this issue seriously (Vesely, 2014).
Close to one-third of all patients admitted to hospitals in the U.S. are estimated to suffer from malnutrition (Vesely, 2014, p. 32), whether due to unexplained weight loss, loss of appetite, or drug-induced dietary changes (Sheperd, 2009), yet only 3% are ever diagnosed with this condition (Corkins et al., 2014). This prevalence estimate also applies to patients currently residing in hospitals, because malnutrition often goes undetected even when it has an iatrogenic etiology (Bavelaar et al., 2008).
The Alliance to Advance Patient Nutrition (AAPN) represents the collaborative efforts of Abbott Nutrition, the Academy of Medical-Surgical Nurses, the Academy of Nutrition and Dietetics, and the Society of Hospital Medicine (AAPN, 2013). The goal of the AAPN is to improve patient nutrition practices and therefore health care outcomes. If malnutrition is left untreated, the risk of complications, delayed wound healing, infections, longer hospital stays, readmissions, and mortality increases significantly (Bavelaar et al., 2008). In the current climate of healthcare cost awareness, malnutrition cannot be ignored.
The main categories of malnutrition are kwashiorkor (ICD-9-CM 260), malnutrition of a moderate degree (ICD-9-CM 262), and marasmus (ICD-9-CM 261), with the first two representing protein intake insufficiency and the latter also involving insufficient carbohydrate ingestion (Sheperd, 2009). All are eligible for significant Medicare reimbursement (Bryant, 2012).
The City of Redding is located at the northernmost end of California's Central Valley and is home to approximately 90,000 citizens. An estimated 22.8% and 16.4% of Redding residents are under 18 years of age or 65 and older, respectively (U.S. Census Bureau, 2014). The median household income is about 30% below the California average, which is consistent with a greater proportion of the population living below the federal poverty line. In 2002, close to 18% of school children within California's Central Valley were eligible for welfare assistance and over 50% were receiving subsidized lunches, although children living in the North Valley fared slightly better (Danenberg, Jepsen, & Cerdan, 2002, p. v, vii). Redding is a solidly blue-collar town, with more residents completing high school but not attending college compared to the rest of the state (U.S. Census Bureau, 2014). The community is relatively homogenous ethnically, with over 80% of the population self-identifying as Caucasian. The next largest ethnic group is Hispanic residents, who represent only 8.7% of the population compared to 37.6% statewide.
The academic environment in Redding is limited, with only two academic institutions offering nursing degrees and none providing graduate-level coursework (Board of Registered Nursing, 2013). Accordingly, Shasta County — where Redding is located — has been designated a registered nurse (RN) shortage area by the State of California (OSHPD Healthcare Workforce Development Division, 2011). Approximately 70% of voters supported the Republican presidential candidate in the last five general elections, making it a politically conservative city (City-Data.com, 2013). In 2011, the Shasta Regional Medical Center, owned by Prime Healthcare Services, captured the attention of a watchdog group because of a surge in kwashiorkor Medicare claims (Williams, Jewett, & Doig, 2011). The allegations of Medicare fraud could make it difficult for other local hospitals to implement a malnutrition screening program if doing so results in significantly higher reported prevalence rates; however, this should not be a significant barrier — only a consideration.
The mission statement of Mercy Redding emphasizes meeting the healthcare needs of the poor and disenfranchised (Mercy Medical Center Redding, 2014). Accordingly, Mercy Redding is committed to engaging with the community and making a positive contribution. For example, during fiscal year 2013 Mercy Redding contributed over $43,000 to the Good News Rescue Mission to support heart health programs for homeless and very low income residents. Given Mercy Redding's focus on serving the poorest residents of the city, it seems reasonable to assume that a higher percentage of its patients would be suffering from malnutrition.
Of the five core values Mercy Redding identifies with, stewardship and excellence seem most relevant to identifying and treating inpatient malnutrition. Stewardship is defined as promoting healing and wholeness, while excellence means exceeding expectations through teamwork and innovation. Despite these important values, Mercy Redding does not include evidence-based practice in its vision. On the positive side, over 98% of nursing staff are RNs (California Department of Health Care Services, 2012).
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