Nutritional Screening and the Nursing Management of Malnutrition in Hospitalised Adults: A Literature Review

Background to Nutritional Screening

Malnutrition, sometimes called undernutrition, is a state in which a deficiency of energy, protein or other nutrients causes measurable adverse effects on body composition, function and clinical outcome. It weakens the immune system, delays wound healing, reduces muscle strength and increases the risk of pressure ulcers, falls and infections. In older adults, it contributes to frailty and loss of independence.

Screening is a rapid process designed to identify people who are malnourished or at risk, so that they can receive a fuller assessment and appropriate care. It differs from a full nutritional assessment, which is usually carried out by a dietitian and examines diet, biochemistry and clinical history in detail. In the United Kingdom, the National Institute for Health and Care Excellence (NICE, 2006) recommends that all hospital inpatients receive nutritional screening on admission and weekly thereafter, carried out by staff with appropriate training, and that the outcome is acted upon.

The most widely used tool in the United Kingdom is the Malnutrition Universal Screening Tool (MUST), developed by the British Association for Parenteral and Enteral Nutrition. It combines three scores: body mass index, unplanned weight loss over the previous three to six months and the effect of acute illness on food intake. The total score places the patient at low, medium or high risk and links each category to a management plan. Other tools, such as the Nutritional Risk Screening 2002 (NRS 2002), are used in other parts of Europe, and choosing a validated tool is an important part of effective nutritional screening.

Search Strategy and Methods

Evidence for this example was identified through targeted searches of openly accessible bibliographic records, publisher websites and the reference lists of key reviews. Search terms combined keywords for the intervention (“nutritional screening”, “malnutrition screening”, “MUST”, “NRS 2002”) with terms for the population and outcomes (“malnutrition”, “hospital*”, “inpatient*”, “nursing assessment”, “length of stay”, “mortality”, “barrier*”), joined with the Boolean operators AND and OR. A full narrative review for assessment would run the same strategy in CINAHL, PubMed/MEDLINE, the Cochrane Library and Embase and report the number of records screened in a PRISMA flow diagram.

Sources were eligible if they addressed nutritional screening, the consequences of malnutrition or the effect of nutritional support in adult hospital inpatients, with relevance to nursing practice. Validation studies, cohort studies, randomised trials, national guidelines and reviews were included. Studies confined to children, care homes or community settings, and studies of specific diseases without general relevance, were excluded.

Five sources published between 2004 and 2019 were included: one national guideline, one tool validation study, one prospective cohort study, one large randomised controlled trial and one systematic review of barriers and facilitators (Table 1). The small number reflects a deliberate focus on landmark studies that shape current practice. Each source was appraised using the Critical Appraisal Skills Programme (CASP) checklist appropriate to its design. Findings relevant to nutritional screening were then compared and grouped into themes.

Key Findings on Nutritional Screening

Three themes were identified: the scale and consequences of malnutrition in hospital, the evidence that screening followed by nutritional support improves outcomes, and the barriers and facilitators that shape nursing practice. Table 1 summarises the included sources.

Author, year	Design	Setting and sample	Key finding
Stratton et al. (2004)	Tool validation study	Several inpatient and outpatient groups; UK	19–60% of inpatients at risk on MUST; MUST agreed well with other tools and took 3–5 minutes.
NICE (2006)	National guideline (CG32)	Adults in hospital and the community; England	Screen all inpatients on admission and weekly; staff should be trained; act on the result.
Lim et al. (2012)	Prospective cohort study	818 adult inpatients; Singapore	29% malnourished; longer stay, almost twice the readmission risk and much higher mortality.
Green and James (2013)	Systematic review	11 studies of nurses and screening	Barriers: culture, competing priorities, reliance on judgement, training gaps; attitudes not matched by practice.
Schuetz et al. (2019)	Randomised controlled trial (EFFORT)	2,088 medical inpatients at nutritional risk; Switzerland	Individualised support cut adverse outcomes (23% vs 27%) and 30-day mortality (7% vs 10%).

Theme 1: The Scale and Consequences of Malnutrition

Malnutrition affects a substantial proportion of hospital inpatients. In a study comparing several screening tools across different patient groups, Stratton et al. (2004) found that between 19% and 60% of inpatients were at risk of malnutrition according to MUST, depending on the ward and population studied. In a prospective study of 818 adults in a Singapore hospital, Lim et al. (2012) found that 29% were malnourished on admission when assessed with a validated assessment method.

The consequences are serious. Lim et al. (2012) found that malnourished patients stayed in hospital for an average of 6.9 days compared with 4.6 days for well-nourished patients and were almost twice as likely to be readmitted within 15 days. Mortality was strikingly higher: 34% of malnourished patients had died within one year, compared with 4.1% of well-nourished patients, and the difference persisted at three years. After adjustment for other factors, malnutrition remained an independent predictor of death.

These findings show why nutritional screening matters. Malnutrition is common, is linked to longer stays, readmission and death, and may not be obvious from appearance alone. Without systematic screening, many at-risk patients will not be identified until complications have already developed, by which point opportunities for early intervention may have been lost.

Theme 2: Does Nutritional Screening Improve Outcomes?

Screening is only useful if the tool is accurate and practical. Stratton et al. (2004) found that MUST showed excellent agreement with several other validated tools and was among the quickest to complete, taking around three to five minutes. Its simplicity makes it suitable for use by nurses on busy wards, and its link to a clear management plan helps to translate the screening score into action.

For many years, the main weakness of the evidence was a lack of large trials showing that acting on screening results improves outcomes. The EFFORT trial addressed this gap. Schuetz et al. (2019) screened medical inpatients in Swiss hospitals using NRS 2002 and randomised 2,088 patients at nutritional risk to individualised nutritional support or standard hospital food. Adverse outcomes, including death, intensive care admission, readmission, major complications and functional decline, occurred in 23% of the intervention group compared with 27% of the control group, and mortality at 30 days was 7% compared with 10%.

The EFFORT trial is important because it links nutritional screening to a measurable benefit when followed by individualised support. It suggests that screening is not simply a box-ticking exercise but the first step in a pathway that can reduce complications and save lives. However, the intervention involved dietitians setting individual targets and adjusting support during the stay, so the benefit depended on what happened after screening, not on screening alone.

Theme 3: Nursing Practice, Barriers and Facilitators

Despite clear guidance, nutritional screening is not always completed or acted upon. In a systematic review of 11 studies, Green and James (2013) identified five themes explaining why nurses may not screen patients: organisational culture, competing priorities, a reliance on clinical judgement instead of a formal tool, gaps in training and education, and differences between nurses’ positive attitudes towards screening and what they actually did in practice. Most studies were carried out in acute hospitals.

Green and James (2013) concluded that routine nutritional screening is unlikely to happen unless it is seen as a core part of nursing assessment, supported by policy and properly resourced. Nurses in the included studies often valued screening but felt that more urgent tasks took priority, particularly on busy admission shifts. Some believed they could recognise malnutrition by looking at a patient, an assumption that the prevalence figures of Stratton et al. (2004) and Lim et al. (2012) suggest is unreliable.

The same review points to factors that may support practice. Its conclusions suggest that policy which makes nutritional screening a required part of admission, training that explains why screening matters as well as how to complete the tool, and adequate resources such as working scales are all needed. Leadership from ward managers and the visible involvement of dietitians may also help nurses to see that their screening results lead to action. However, facilitators were studied far less often than barriers, and the authors called for research testing interventions to remove the barriers (Green & James, 2013).

Accuracy is a further concern. Screening depends on reliable measurements of weight and height and on accurate recall of recent weight loss, yet patients may be too unwell to stand on scales, and estimated weights are often used instead. Alternative measures, such as mid-upper arm circumference or recalled height, can help when direct measurement is not possible, but nurses need training to use them. Inaccurate inputs can lead to a falsely reassuring score and missed opportunities for support.

Discussion

This review shows that malnutrition is common among hospitalised adults, that it is associated with longer stays, readmission and higher mortality, and that screening followed by individualised nutritional support can improve outcomes. Together, these findings provide a strong rationale for nutritional screening as a routine part of admission, as recommended by NICE (2006).

However, the evidence also reveals a gap between policy and practice. Screening tools such as MUST are quick and validated, yet nurses do not always use them, and screening is sometimes completed without any change to the patient’s care. The barriers identified by Green and James (2013) are largely organisational rather than individual, which suggests that solutions must address workload, training and leadership rather than relying on reminders to individual nurses.

The EFFORT trial highlights that nutritional screening is only the first step. Its benefits depended on prompt dietetic involvement and individualised support, which requires adequate dietitian staffing and close teamwork with nurses. On many wards, nurses also play a direct role in improving intake, by protecting mealtimes, providing assistance with eating, offering snacks and supplements and recording food charts accurately. A positive screening result that does not lead to these actions is unlikely to benefit the patient.

The evidence also has implications for patients who do not appear malnourished. Rising rates of obesity mean that many adults at nutritional risk have a normal or high body mass index, and their weight loss or reduced intake may be overlooked. Because tools such as MUST include unplanned weight loss and the effect of acute illness, nutritional screening can identify risk in these patients when appearance alone would not. This reinforces the case for screening every patient rather than relying on clinical impression.

The evidence base has limitations. The prevalence and outcome data came from different countries and used different tools, making direct comparison difficult. The EFFORT trial included only medical inpatients and used NRS 2002 rather than MUST, so its findings may not apply equally to surgical patients or to every screening tool. The review of barriers included only 11 studies, mostly from acute hospitals. This review relied on openly accessible, English-language sources. Future research should test interventions to improve the completion of nutritional screening and the actions that follow it.

Implications of Nutritional Screening Evidence for Practice

For adult nurses, the evidence on nutritional screening supports completing a validated tool such as MUST for every patient within 24 hours of admission and repeating it weekly, or sooner if the patient’s condition changes. Patients at medium or high risk should have a care plan, food and fluid intake should be recorded, and patients at high risk should be referred to a dietitian. Weight should be measured rather than estimated wherever possible, and screening should form part of a wider nursing assessment that considers swallowing, oral health and the need for help at mealtimes.

Managers should ensure that scales are available and calibrated, that staff receive training and that screening completion is audited alongside the actions taken. Nutrition is closely linked to other aspects of acute care: malnourished patients are more vulnerable to infection, so recognising deterioration through the Sepsis Six is important, and accurate fluid balance monitoring often accompanies food charts. Good nutrition also supports recovery on enhanced recovery pathways and should be included in discharge planning.

Conclusion

This narrative review examined the evidence on nutritional screening for hospitalised adults. Malnutrition affects a large proportion of inpatients and is associated with longer stays, readmission and higher mortality. Validated tools such as MUST are quick and practical, and the EFFORT trial shows that screening followed by individualised support can reduce adverse outcomes and deaths.

The main challenge is ensuring that nutritional screening is completed consistently and followed by action. Nurses can lead this by screening every patient, acting on the result and helping patients to eat and drink, but lasting improvement depends on organisations that treat nutrition as a core part of care, with the training, equipment, dietetic support and leadership that this requires.

References

Green, S. M., & James, E. P. (2013). Barriers and facilitators to undertaking nutritional screening of patients: A systematic review. Journal of Human Nutrition and Dietetics, 26(3), 211–221. https://doi.org/10.1111/jhn.12011

Lim, S. L., Ong, K. C. B., Chan, Y. H., Loke, W. C., Ferguson, M., & Daniels, L. (2012). Malnutrition and its impact on cost of hospitalization, length of stay, readmission and 3-year mortality. Clinical Nutrition, 31(3), 345–350. https://doi.org/10.1016/j.clnu.2011.11.001

National Institute for Health and Care Excellence. (2006). Nutrition support for adults: Oral nutrition support, enteral tube feeding and parenteral nutrition (Clinical guideline CG32; updated 2017). https://www.nice.org.uk/guidance/cg32

Schuetz, P., Fehr, R., Baechli, V., Geiser, M., Deiss, M., Gomes, F., Kutz, A., Tribolet, P., Bregenzer, T., Braun, N., Hoess, C., Pavlicek, V., Schmid, S., Bilz, S., Sigrist, S., Brändle, M., Benz, C., Henzen, C., Mattmann, S., … Mueller, B. (2019). Individualised nutritional support in medical inpatients at nutritional risk: A randomised clinical trial. The Lancet, 393(10188), 2312–2321. https://doi.org/10.1016/S0140-6736(18)32776-4

Stratton, R. J., Hackston, A., Longmore, D., Dixon, R., Price, S., Stroud, M., King, C., & Elia, M. (2004). Malnutrition in hospital outpatients and inpatients: Prevalence, concurrent validity and ease of use of the ‘malnutrition universal screening tool’ (‘MUST’) for adults. British Journal of Nutrition, 92(5), 799–808. https://doi.org/10.1079/BJN20041258