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Commentary on Lopez R, Amella E, Mitchell S & Strumpf N (2010) Nurses' perspectives on feeding decisions for nursing home residents with advanced dementia. Journal of Clinical Nursing 19, 632-638.

In the article by Lopez et al. (2010), a new vantage point is brought to the discussion of tube-feeding placement in persons with advanced dementia – what do nurses in the skilled nursing facility (SNF) know, what do they believe, and what is their role when the time comes to make a decision about continuing careful hand-feeding or tube-feeding? The findings from the interviews of 11 licensed nurses in the USA indicated three themes: nurses were uneducated about empirical evidence to either support or refute use of tubefeeding, expressed ambiguity about their role in feeding decisions, and compartmentalised moral judgments when supporting families in feeding decision (Lopez et al. 2010). The authors astutely point out these findings could be due to the level of training and professional nursing found in the SNF setting. There is generally a lack of preparation within the US workforce to care for older adults, especially those with dementia (Institute of Medicine of the National Academies 2008). The authors also point out that nurses are not ‘alone in the darkness’ on this issue; many physicians are there also. To date, the only training related to developing hand-feeding skills in the literature has been directed toward Certified Nursing Assistants (CNAs) and did not include licensed nurses (Chang & Lin 2005). Similar programs need to be created for licensed nurses to support their role and improve knowledge and promote engagement in the feeding decision process. The majority of nurses in the SNF are Licensed Practical Nurses (LPNs), and only 25% of the Registered Nurses (RNs) employed in SNFs are baccalaureate prepared nurses (BSNs) (Health Resources and Services Administration 2004, Lopez et al. 2010). Interestingly, the education of the RNs included in the sample closely mirrors the national distribution: six LPNs and five RNs – only one (20%) was BSN prepared. Licensed nurses at the BSN level of education are introduced to critical thinking about research methodologies and evidence-based nursing practice as a concept. With the lack of professional nursing in the SNF, evidenced-based protocols will exist for nursing management of feeding difficulties in dementia in textbooks and online but integrating them into the SNF setting will be a problem (Beck 2001, Amella 2008a,b). Many nurses view hand-feeding within the realm of nursing expertise, but when mealtime difficulties emerge and the person with dementia begins to experience adverse consequences (e.g. loss of eating ability, compromised nutritional status and increased risk of death) and a decision is made to place a feeding tube, nurses may see this decision as a ‘medical’ one – outside their realm of expertise (Pasman et al. 2003, Aselage & Amella 2010, Lopez et al. 2010). Advanced Practice Nurses (APNs) will have the additional education and training to support families with this complex decision and can serve as the expert nurse as a member of the interdisciplinary team in the SNF (Todd et al. 2005, Lopez et al. 2010). In addition to basic education and licensure, RNs and APRNs in these roles should consider strengthening their core competencies through certification in gerontology and/or palliative care (American Nurses Credentialing Center 2010, National Board for Certification of Hospice and Palliative Care Nurses 2010). The overarching emotional and moral need for physicians, nurses, and families to ‘do something’ may reflect inadequate palliative care in our nursing homes (Finucane et al. 1999, Ferrell & Coyle 2006). It is also a reflection of inadequate