Awareness, perceptions and practices of UK veterinary nurses on managing the risk of malnutrition in hospitalised cats and dogs

Nutrition is important for animals recovering from illness (Corbee and Kerkhoven, 2014). According to the International Society of Feline Medicine (ISFM) consensus guidelines, inappetence is the third most common reason a cat is presented in practice (Taylor et al, 2022). Similarly, one study found 84% of hospitalised dogs consumed less than 25% of their resting energy requirement (RER) (Molina et al, 2018).

Background

Malnutrition

Malnutrition is defined as poor nutritional status due to insufficient, unbalanced or excess nutrients and can increase morbidity and mortality in critically ill patients (Chan, 2015). One study found vomiting, older age and longer hospitalisation are risk factors for malnutrition with a link between insufficient calorific intake and death (Molina et al, 2018). A patient is at a low risk of malnutrition when calorific intake is less than 80% RER for 3 days. Moderate risk factors include: a calorific intake of less than 80% RER for 3–5 days, weight loss, illness of 2–3 days, hypoalbuminaemia and mild muscle loss. High risk factors include: a calorific intake of less than 80% RER for more than 5 days, severe vomiting or diarrhoea, a body condition score (BCS) of less than four out of nine, moderate or severe muscle loss, and illness exceeding a duration of 3 days (Perea, 2012; Taylor et al, 2022). Significant weight loss is defined as a loss of 5% within 5 days or 10% gradual loss, without fluid deficits (Fabretti et al, 2020). Other risk factors include anorexia of more than 5 days, sepsis, and wounds and burns which cause protein loss (Chan and Freeman, 2006). A stable patient with two or more high-risk factors should receive prompt nutritional intervention (Perea, 2012; Taylor et al, 2022). Moreover, during illness, stress starvation may occur, which is the catabolism of lean body mass as a result of an inadequate calorific intake. This negatively influences immune function, wound healing and muscle strength (Chan, 2020). Overall, the effects of malnutrition during hospitalisation include longer hospitalisation and elevated risk of sepsis (Chan, 2015).

Nutritional assessment

According to the World Small Animal Veterinary Association (WSAVA), nutritional status forms the fifth vital assessment (Freeman et al, 2011). Under the American Animal Hospital Association (AAHA) assessment guidelines, a nutritional screening evaluation should be performed daily in hospitalised patients, plus an extended evaluation if a patient has any nutrition-related risk factors (Cline et al, 2021). The WSAVA have provided guidance on how to perform a nutritional evaluation, plus tools to support this including a nutritional checklist for a systematic approach (Freeman et al, 2011).

When evaluating the signalment and history, a physical examination is performed including body weight (BW), BCS, and muscle condition score (MCS) (Eirmann, 2016). The most-used validated BCS is the nine-point scoring system developed in 1997 which the WSAVA adapted (https://wsava.org/wp-content/uploads/2021/04/WSAVA-Global-Nutrition-Toolkit-English.pdf).

The nine-point system was tested using DEXA to show a high correlation to adipose tissue (Laflamme, 1997a; 1997b), unlike the five-point system (Shoveller et al, 2014). However, a BCS does not measure lean body mass. It is subjective, affected by breed variability, and some studies have shown no variation in the BCS with bodyweight during calorie restriction (Nakajima et al, 2014). Cachexia can be a consequence of illness, a risk factor for malnutrition, and can act as a negative prognostic indicator (Freeman, 2012). Although the sample size was small and cats were under-represented, one survey found a link between mortality in 71% of dogs and 25% of cats with abnormal MCSs (Vandendriessche et al, 2017). Therefore, a BCS and MCS should be considered together where the MCS involves visual assessment and palpation of skeletal muscle of the spine, scapula, skull and pelvis (Michel et al, 2004).

Diagnostic testing is another important stage (Eirmann, 2016). A study using 215 hospitalised dogs found low body mass index, anaemia, low haemoglobin concentrations, low albumin and increased gamma-globulin (consisting of immunoglobulins) were associated with malnutrition (Fabretti et al, 2015). Biochemistry is critical where refeeding syndrome is a risk of nutritional intervention, when rapid over-feeding occurs after anorexia. This may trigger serious electrolyte derangements including hypophosphataemia, hypokalaemia, and haemolytic anaemia. Hypophosphataemia increases the risk of acquiring infection and affects oxygen delivery to tissues; hypokalaemia is associated cardiac arrhythmias; and anaemia affects oxygen delivery to tissues (Edgley, 2019).

The final element to consider is the normal diet which can be assessed using a diet history form. However, research has highlighted only 43% of veterinary professionals collect this information (Lumbis and de Scally, 2020).

Nutritional support

The aims of intervention are to provide ongoing energy, nutrients, minimise loss of lean body mass, correct deficiencies and prevent metabolic derangements, with optimising body condition as a long-term goal (Ackerman, 2019). The WSAVA feeding instructions and monitoring chart are useful tools when formulating a plan (https://wsava.org/wp-content/uploads/2021/04/WSAVA-Global-Nutrition-Toolkit-English.pdf).

Monitoring is then required to evaluate the effectiveness of the plan. This includes measuring the BW, BCS, MCS, hydration and daily food intake (Freeman et al, 2011; Tonozzi, 2016). BW is a vague measure as it is affected by lean mass, body fat and hydration (Leung et al, 2023). Therefore, oral or intravenous fluids should also be monitored as these can affect weight. However, a change in BCS indicates severe metabolic challenge, therefore immediate intervention is indicated. Mentation should be assessed as alterations could also indicate electrolyte derangements, refeeding syndrome, blood glucose changes, or protein related hepatic encephalopathy (Freeman et al, 2011; Tonozzi, 2016). Finally, an MCS of mild, moderate or severe wasting requires further investigation (Cline et al, 2021).

Early nutritional intervention is crucial with benefits including the prevention of protein malnutrition, bacterial translocation, shorter recovery times, increased mucosal integrity and reduced risk of sepsis. However, due to the risk of refeeding syndrome, introduction of nutrition should be gradual (Edgley, 2019; Ackerman, 2019). RER should start at a third and increase by a third each day, or less if deficiency is severe (Chan, 2020). If the nutritional intake is less than RER for 3–5 days, nutritional support should be planned (Delaney, 2006).

Cats versus dogs

Cats have a higher protein requirement than dogs, which may be due to a lack of enzymatic adaptation (Rogers et al, 1977), hence reduced ability to adjust the rate of protein breakdown. Although cats are metabolically flexible, cats may require more protein than dogs to minimise lean mass catabolism (Taylor et al, 2022). Unlike dogs, cats are obligate carnivores and cannot synthesise the amino acid taurine which deems this another essential nutrient. Cats also require dietary retinol as they have a reduced ability to use beta-carotene as a source of vitamin A, which is also important for immunity (Taylor et al, 2022).

Nutritional assessment is similar in cats, except for spe-cies-specific MCS and BCS scales. One study found cats tend to have a lower BCS than dogs (Chandler and Gunn-Moore, 2004). Cats also have an increased ability to mask illness and pain compared to dogs (Taylor et al, 2022). Cats have highly specialised senses which increases the susceptibility to stress where decreased appetite may be a stress behaviour (Stella et al, 2013). Another consideration is the additional potential for food aversions, as feline food preferences tend to be established at an early age (Zoran and Buffington, 2011).

Attitudes

One study found only 27% of patients received over 95% RER (Remillard et al, 2001). Moreover, a questionnaire was completed by 2740 veterinary workers which found 64% acknowledged nutritional evaluation as the fifth vital assessment. However, of this, only 27% were aware of the WSAVA nutritional guidelines and only 4% used them. Notably, veterinary nurses/technicians were only 16% of the sample size (Lumbis and de Scally, 2020). A survey of veterinary nurses may be more relevant as they have a key role in supporting the assessment and implementation of nutrition (RCVS, 2011). The survey found factors that affected the performance of nutritional assessment included personnel, clinical history, lack of policy and practice type. Additionally, only 4.1% of respondents used a systematic nutritional assessment. In total 85% used both body weight and BCS, but only 17.6% used MCS. Only 3% calculated RER when a patient was deemed at risk of malnutrition, and only 19% formulated a plan for those malnourished or at risk. The reasoning behind this was due to personnel and practice policy (Lumbis and de Scally, 2020).

Aims

Current literature focusses on obesity, with minimal research surrounding malnutrition and species comparison. This study aimed to explore the current attitudes, awareness, and practises of veterinary nurses managing hospitalised cats and dogs at risk of malnutrition. It also aimed to assess veterinary nurses’ awareness of risk factors for malnutrition and knowledge of the associated consequences. Finally, barriers that may be inhibiting adequate nutritional support, awareness of tools and barriers for implementation were investigated.

Materials and methods

Study design

A cross-sectional online survey of twenty-eight questions was created using the software Microsoft Forms (2016). The participants were asked to rate their confidence assessing malnutrition in cats and dogs separately. Then, the participants were asked to list some indicators of a patient at a higher risk of malnutrition and some consequences of malnutrition. Following this, a series of questions assessed the timeliness of addressing malnutrition, what techniques are used to assess if a patient is receiving adequate nutrition, and what dietary temptation techniques are used. The survey then asked the participants to rate the importance of nutrition, then the satisfaction that malnutrition is addressed effectively in cats and dogs separately. Next, the participants were asked to select any barriers they have experienced and what nutritional tools they use. The final questions collected demographic information. The question types consisted of numerical rating scales, multiple choice questions and open-text questions. This produced both quantitative and qualitative data and this allows expansion of knowledge plus strengthens the validity and conclusions of a study (Schoonenboom and Johnson, 2017).

Participant recruitment

Participants were required to be either a currently practicing UK registered veterinary nurse (RVN) or student veterinary nurse (SVN) with a minimum of 8 weeks experience with cats and/or dogs within the last 12 months. Participants not fitting these criteria were excluded.

Survey distribution

The survey was distributed from 13 December 2022 to 31 January 2023 on social media platforms including Facebook and Instagram. Some Facebook groups such as Veterinary Nurses UK and Vet Nurse Chatter were approached to promote the survey. The British Veterinary Nursing Association (BVNA) promoted the survey on the BVNA Facebook page. Additionally, individual veterinary practices were approached to distribute the survey. The Royal College of Veterinary Surgeons provide a list of veterinary practices which was filtered to practices which treat dogs and cats, and there were 4675 practices as of 17 January 2023 (RCVS, 2021). A random number generator was used to select approximately 300 practices where simple random sampling allowed each practice an equal chance of being selected (Wang and Cheng, 2020).

Statistical analysis

Descriptive analysis such as frequency was used to analyse categorical data and the median and interquartile range (IQR) were used for ordinal data. Numerical rating scales were treated as ordinal data; hence, interpretation was based on the median rather than the mean (Harpe, 2015). Inferential analysis was conducted using the Statistical Package for the Social Sciences (IBM Corporation, 2022) with significance set at P<0.05. Furthermore, Stevens–Siegel–Sender's rule states non-parametric tests are appropriate for ordinal data (Harpe, 2015). A Mann-Whitney U test was used to test for a difference between SVNs and RVNs. Kruskal-Wallis H tests were used to test for significant associations with demographic data and confidence assessing malnutrition, satisfaction malnutrition is addressed in a timely manner, and satisfaction malnutrition is addressed effectively. Significant results produced by the Kruskal Wallis test were analysed using the Dunn's post hoc Bonferroni correction test for pairwise comparisons. Qualitative data were analysed using thematic analysis on a latent, interpretative level. This involves the identification of patterns based on the prevalence of themes (Braun and Clarke, 2006).

Ethical considerations

The survey was released after receiving ethical approval by the Health Science Student Research Ethics Committee at the University of Bristol (12882). As per the ethical decision, raw data will not be available to the public.

Results

Demographics

A total of 56 (71%) of RVNs and 23 SVNs (29%) took part. Generally, there was an even distribution between the number of years that respondents were qualified and the regions the respondents were based in, the most common being South East England (n=15, 19%).

Confidence identifying cats and dogs at risk of malnutrition

The median ratings of confidence for identifying malnutrition in cats and dogs were 7.0/10.0 and 8.0/10.0, respectively. Both results had a narrow IQR of 1, demonstrating minimal variance. The data are negatively skewed, with cats (−0.299) showing less negative skewness compared to dogs (−0.440), inferring that outliers for lower confidence occur more for cats (Figure 1).

A Mann-Whitney U test showed SVNs had a statistically significant lower median confidence rating when identifying cats at risk of malnutrition (U=336, P<0.001). Similarly, SVNs also had a significantly lower median confidence identifying dogs at risk of malnutrition compared to RVNs (U=422.5, P=0.014).

A Kruskal-Wallis H test showed a statistically significant difference between the number of years a respondent has been qualified and confidence identifying cats at risk of malnutrition (H=14.843, P=0.011). A Dunn's pairwise comparison with Bonferroni correction test highlighted there was significantly lower median confidence identifying malnutrition in cats in SVNs compared to nurses qualified for 11–15 years (P=0.009).

A Kruskal-Wallis H test showed there was no statistically significant difference in the routes of qualification and confidence ratings for identifying cats at risk of malnutrition (H=6.494, P=0.261) or dogs (H=4.762, P=0.446).

Are veterinary nurses satisfied malnutrition is addressed in a timely manner?

The participants rated their satisfaction regarding the timelines of addressing malnutrition, which produced a median score of 6.0/10.0 and a wide IQR of 3, indicating considerable variability in ratings. The skew is negligible (0.021), and the kurtosis is −0.743 which further demonstrates a large variability (Figure 2).

Further analysis was conducted to compare the type of practice accreditation to the satisfaction malnutrition is addressed in a timely manner. A Kruskal-Wallis H test found no statistically significant difference between these (H=1.905, P=0.592).

Qualitative analysis highlighted the most common reasons respondents were less satisfied included delayed tube placement (n=23, 29%), followed by negative attitudes and lacking understanding of the importance of addressing malnutrition (n=12, 15%), then delayed intervention (n=8, 10%) (Figure 3). Respondent 20 supports this claim: ‘I feel sometimes it takes too long for staff to intervene if patients are not eating-especially cats’. Conversely, reasons respondents were more satisfied included positive attitudes towards intervention (n=11, 14%), followed by keenness to tempt patients to eat (n=8, 10%) (Figure 4).

How long does it take to consider and implement interventions?

The largest proportion of respondents reported they would wait 2 hours (n=13, 16%) to consider additional temptation techniques to encourage voluntary oral nutrition in dogs and 4 hours in cats (n=15, 18%) (Figure 5). The largest proportion of respondents reported they would wait 2 days (n=34, 43%) to consider suggesting placement of a feeding tube. The largest proportion of respondents reported it takes between 2 and 4 hours (n=23, 29%) for a feeding tube to be implemented once this issue has been identified with the veterinary surgeon. However, 25% (n=20) of respondents reported it may take more than 10 hours.

Indicators and consequences of malnutrition

When respondents were asked to list indicators of malnutrition, qualitative analysis demonstrated the most common themes were reduced nutritional intake (n=44, 56%), followed by fluid loss (n=24, 30%) and stress (n=16, 20%) (Figure 6).

Respondents were asked to list the consequences of malnutrition and qualitative analysis highlighted the most common themes were weight loss (n=26, 33%) and delayed wound healing (n=25, 32%). Next was delayed recovery (n=19, 24%), then muscle loss (n=16, 20%) (Figure 7). There were non-specific mentions of reduced bodily function, for example: ‘reduced bodily function’, ‘decline in physical health’, and ‘body system shutdown.’ Three respondents (3.8%) listed a low BCS. Ten percent (n=8) of respondents listed less than three consequences and 11% (n=9) of respondents did not understand the question.

Methods used to assess malnutrition

Qualitative analysis showed the most common method respondents used to assess malnutrition was energy requirement calculations (n=40, 51%). Next was monitoring food intake (n=24, 30%), followed by body weight (n=18, 23%), then care plans and hospital sheets (n=16, 20%) (Figure 8). Respondent 71 identified a fault and explained ‘we have a hospitalisation chart, but I feel this could be more detailed’. However, 19% of respondents (n=15) stated they use no method to assess malnutrition. More respondents use BCSs (n=9, 11%) than MCS (n=2, 2.5%). Four respondents (5%) reported using the WSAVA guidelines or toolkit and four respondents (5%) also highlighted the ineffective use of RER – respondent 25 explained RER ‘isn't calculated on inpatients without feeding tubes’.

Attitudes

Most respondents (n=59, 75%) rated the importance of nutrition 10/10 with no scores below 7/10. The respondents also rated whether they felt malnutrition is addressed effectively lower in cats 6.0/10.0 (median) compared to dogs 7.0/10.0 (median) (Figure 9). A Kruskal-Wallis H test showed there was no statistically significant difference between the accreditation of a practice and the satisfaction that malnutrition is addressed effectively in hospitalised cats (H= 3.016, P=0.389) or dogs (H=5.187, P=0.159).

Barriers to assessing and addressing malnutrition

The most commonly selected barrier was a lack of nutritional protocols (n=53, 67%), followed by a lack of standardised nutritional risk assessment (n=49, 62%), then a lack of time (n=38, 48%) (Figure 10). Other notable barriers included a lack of an evaluation process (n=36, 46%), a lack of skills or knowledge (n=30, 38%), poor communication (n=28, 35%), and poor team compliance (n=28, 35%).

Awareness and use of nutritional tools

The most used generic tools in practice were body weight (n=69, 87%), followed by BCS (n=66, 84%), and hydration status (n=58, 73%). Tools least used included the MCS (n=18, 23%), short diet history form (n=9, 11%), and nutritional assessment checklist (n=8, 10%) (Figure 11). Figure 12 shows the branded tools respondents use.

Finally, qualitative analysis was performed to extrapolate reasons respondents do not use the selected tools despite awareness. The most common theme was lack of awareness and knowledge (n=16, 20%) as expressed by respondent 28 stating there is ‘not enough training on how to assess’. Some respondents expressed interest in using the tools due to the awareness of them after the survey, but some indicated there is a lack of availability of the tools in practice. However, some simply use alternative brands (n=15, 19%). There is an issue with compliance (n=13, 16%) and a lack of time (n=12, 15%), plus the restriction in practice policy and protocol was also highlighted (n=9, 11%) (Figure 13). Finally, respondent 16 said ‘there is not enough confidence of some to implement these options in practice.’

Discussion

The respondents were more confident identifying malnutrition in dogs as opposed to cats, aligning with the lower satisfaction that malnutrition is addressed effectively in cats compared to dogs. It is possible increased confidence assessing malnutrition in cats may aid with satisfaction, therefore feline-focussed education related to nutritional assessment is justified. There is a significantly lower confidence rating in SVNs when identifying both cats and dogs at risk of malnutrition compared to RVNs qualified for 11–15 years, the obvious factor here being practical experience. Although a lower confidence is to be expected, it would have been beneficial to know at what stage of training the students were at, as other factors such as student support, nutrition education and availability of tools in practice may be contributing factors. For example, one survey discovered factors impacting veterinary nurses’ clinical learning included poor support, engagement and no time for training with clinical supervisors. Others included training practice factors such as limited cases which may link to the theory of an issue with a lack of practical experience (Holt et al, 2023). These results indicate more practical learning experiences and support may be needed for SVNs to enhance their confidence identifying cats at risk of malnutrition.

Studies have reported shorter hospitalisation periods with early nutritional intervention (Liu et al, 2012). However, the respondents were not satisfied that malnutrition is addressed in a timely manner due to delay in placing feeding tubes and intervention. It is established that protein is needed to facilitate wound healing, antibody production and immune function (Latimer-Jones, 2020). Arginine and taurine play a key particular role in eliminating pathogens and supplementing arginine to cats has beneficial immunomodulating effects (Li and Wu, 2023). Moreover, insufficient glutamine can lead to cachexia, reduced gastrointestinal barrier, increased bacteria translocation, and immune system dysfunction (Kerl and Johnson, 2004). Therefore, it is important this issue of delayed intervention is addressed to facilitate recovery. Negative attitudes and a lack of understanding towards the importance of adequate nutrition were other reasons given for the lack of timely nutritional support. Despite this, the largest proportion of respondents reported waiting 2 days to consider suggesting placing a feeding tube which is in line with the literature (Fascetti and Delaney, 2012). However, the data also demonstrated a large distribution in the number of hours respondents would wait before considering intervention which infers there is inconsistency across the profession. Moreover, a quarter of respondents (n=20) reported it takes more than 10 hours to implement tube feeding after it is suggested. A patient with two or more moderate risk factors for malnutrition requires assisted feeding within 2–3 days (Fascetti and Delaney, 2012). Therefore, this delay in placing a feeding tube may negatively impact the moderate–high-risk patient significantly. These findings show practices may benefit from an increased use of a standardised protocol for intervention to minimise this delay. This would include information such as when is appropriate to provide nutritional support and when a feeding tube is required, plus how to place these. It would also provide instructions on how to construct a plan, what kind of support is appropriate, and how to monitor and evaluate the plan. A human trial of a nutritional protocol found a reduction in time before initiation of enteral feeding from 3.2 to 2.9 days, although this was not significant. The authors suggested the protocol raised awareness, but other barriers may be inhibiting intervention, such as absence of a protocol for placing feeding tubes. The authors suggested that future research needs to focus on reasons for non-compliance and suggested measuring protocol adherence and performance may aid with this issue (Barr et al, 2004).

Some respondents reported they would wait 2 hours to consider tempting a dog to eat (n=13, 16%) and a similar proportion of respondents would wait 4 hours for cats (n=15, 18%). Studies have highlighted the tendencies for poor nutritional statuses in cats, suggesting this may be due to the difficulty in assessing the BCS (Chandler and Gunn-Moore, 2004). Another study found cats with lower BCS tend to have awareness of the issue of malnutrition in cats and education regarding assessment.

When asked to list the indicators that a patient is at risk of malnutrition, the most common answers included reduced nutritional intake, fluid loss and stress. This is in line with literature highlighting that vomiting and diarrhoea are indicators of a patient at moderate risk of malnutrition (Fascetti and Delaney, 2012), where decreased appetite is also a stress behaviour in cats (Stella et al, 2013). However, respondents did not specify what was classed as a reduced nutritional intake, its duration, or the percentage of body weight loss. According to the literature, intake less than RER for 3–5 days indicates a moderate risk of malnutrition and more than 5 days at a high risk (Fascetti and Delaney, 2012). Only 2.5% (n=2) of respondents mentioned muscle loss and 1.3% (n=1) listed low BCS as indicators. The literature has shown that a BCS of less than four out of nine and moderate or severe muscle loss puts a patient at high risk of malnutrition (Perea, 2012; Taylor et al, 2022). Consequently, patients may be at risk and not receiving appropriate preventative intervention. Furthermore, 7.6% (n=6) of respondents failed to list three indicators. This indicates there is a lack of knowledge and increased awareness could prompt identification which minimises the risks of malnutrition (Lumbis and Rinkinen, 2022).

Figure 9 showed the most reported consequences of malnutrition. Muscle loss was reported as a consequence of malnutrition by 20% (n=16) of respondents, yet only 2.5% (n=2) listed muscle loss as an indicator that a patient is at risk of malnutrition, even though moderate muscle loss places a patient at a high risk of malnutrition (Perea, 2012; Taylor et al, 2022). This demonstrates that the respondents have an awareness and knowledge of the consequences of malnutrition, however, lack awareness that a low MCS and BCS are indicators that a patient is at risk of malnutrition. Some authors have identified that 47% of veterinary workers would use a short video demonstrating how to perform a MCS (Lumbis and de Scally, 2020), plus it may be useful to provide models of dogs and cats of various muscle conditions to practice with.

Nineteen percent (n=15) of respondents stated they do not use any methods to assess malnutrition. There were also concerns about the effective use of the RER calculations, which was also highlighted by other authors who found only 33% of respondents calculated the RER if a patient was malnourished, ill or at risk of malnutrition (Lumbis and de Scally, 2020). Few respondents use the BCS or the WSAVA Nutritional Guidelines or Toolkit, and even fewer use an MCS. Similarly, previous studies found only 18% of respondents used the MCS (Lumbis and de Scally, 2020). The results support the suggestion that a more objective, systematic tool may also prove useful, or tools to improve the use of the MCS.

The most reported barriers for assessing and addressing malnutrition were a lack of nutritional protocols, followed by a lack of standardised nutritional risk assessment, then a lack of time. Other notable barriers included a lack of an evaluation process, a lack of skills or knowledge, poor communication and poor team compliance. These findings align with previous studies which found similar barriers such as practice policy and compliance (Lumbis and de Scally, 2020). The data highlight that an objective, standardised assessment and evaluation process may be beneficial in practice and may address the issue of communication and compliance. To aid identification of a patient at risk of malnutrition, a study investigating the use of a simplified checklist of risk factors for malnutrition as part of a hospitalisation monitoring chart would be insightful. For example, an adapted version of the WSAVA nutritional checklist (WSAVA, 2012). One author produced and adapted similar checklists (Taylor et al, 2022). Ideally, this checklist would be performed daily. Additionally, another author suggested that risk factors are awarded points where the maximum number of points is 24 and a score of six or more requires action (De Scally, 2019). However, only 30% (n=24) of respondents are aware of the WSAVA nutritional checklist and only 29% (n=23) use it. The reasons respondents do not use nutritional tools is due to lack of awareness and knowledge, using alternative brands, and restriction in practice policy and protocol. Therefore, awareness and encouragement to use these is needed.

Limitations

Due to time constraints, only 79 responses were collected. The target sample size was calculated as 385 responses using 95% confidence intervals, 5% margin of error, and 50% of occurrence (Taherdoost, 2017).

Implications and future research

The reported delay to implementing nutritional support suggests a need for practices to reflect on practice protocol. The aim would be to ensure patients are receiving high quality care through early nutritional intervention which may in turn reduce hospitalisation time.

The results also indicate a need for education regarding the indicators of a patient at risk of malnutrition and awareness of the increased risk in cats.

Further research into the reasons why there is a delay in intervention and placing feeding tubes would also be valuable. RVNs are permitted to place naso-oesophageal and nasogastric tubes (Gray, 2018), therefore it would be prudent to investigate what percentage of RVNs perform this and feel confident doing so.

Conclusions

Respondents were less confident in identifying malnutrition risk in cats compared to dogs. Likewise, the respondents were less satisfied that malnutrition is addressed effectively in cats compared to dogs. Cats are also receiving intervention later than dogs and there was overall inconsistency in determining when to intervene. Overall, the respondents were not satisfied that malnutrition is addressed in a timely manner, and this is due to the delay in nutritional interventions, including placing feeding tubes. Veterinary nurses may require increased education and awareness of the risk factors of malnutrition. Moreover, there are barriers to implementing tools due to lack of awareness and knowledge. Barriers to addressing malnutrition in practice include a lack of protocols and a lack of standardisation of the nutritional risk assessment.