Nutrition Special issue
How a service user transformed our approach to food refusal: the development and implementation of a toolkit to improve outcomes and support nurses
Liz Barnacle, Linda Harris and Angela Star
Service user A was refusing to eat and presented as physically unwell and dehydrated. They were diagnosed with psychosis and believed they were being poisoned. They did not want to engage with the healthcare team. How could we balance their right to make their own choices about their body with our duty of care? This is just one of several food refusal cases we have dealt with in our prison healthcare service, where a combination of mental health issues and food refusal have sparked significant challenges for nursing.
The complexity of this particular case was an important driver for creating a food refusal policy and, subsequently, a food refusal toolkit to support nurses with similar cases.
Food refusal can be simply defined as when a person refuses to eat. However, behind the simple definition are potentially complicated causes, particularly when the service user has mental health issues such as psychosis, depression, bipolar disorder or other factors that may impact their mental capacity such as an eating disorder, a history of self-harm or dementia.
It can be complex to balance a person’s right to make choices about their own body and a nurse’s duty of care.
Less frequently, service users can also refuse fluids. Although our food and fluid refusal processes are similar and include consideration of some of the same issues, refusing food does not have the same physical consequences as refusing fluids and requires nurses to think differently.
The number of cases of food refusal per year may not be high – we recorded 70 cases over six months in 2023 – but they can be high-risk and complex.
Our experience is in English prisons for people aged 18+ and immigration removal centres, but other settings such as care homes, supported living, hospitals and hospices may also find our toolkit and learning useful.
Abstract
Food refusal is when a person refuses to eat. One service user refusing food helped us reflect on improving our practice and providing staff with effective resources to deal with food refusal. The number of food-refusing people is low, but they are a high-risk and complex cohort. We have developed and implemented a food refusal toolkit to help nurses and colleagues in health and partner organisations provide care and make appropriate decisions, including when mental capacity is an issue. Our food refusal work is mainly in prison, where mental health can be a crucial factor, especially as one in seven people in prison receives support from mental health services. An audit of cases before and after the launch of the toolkit found improvements in practice. Our underlying principles of trauma-informed and individualised care have relevance beyond food refusal and the prison setting.
Key words
Food refusal, prison, mental capacity, mental health, effective practice, toolkit, multidisciplinary team