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JOURNAL OF GERONTOLOGICAL NURSING
29
F
ood is necessary to sustain
physiological existence and
food sharing patterns, prefer-
ences, and traditions are integral to
family life. Many of us remember
family gatherings around the dinner
table, both at times of celebration and
at everyday meals. The socialization
and reminiscing that occurred on
these occasions strengthened family
ties and values. Nursing home resi-
dents have similar memories and their
accomplishment of vital developmen-
tal tasks such as life review (Butler &
Lewis, 1973), generativity, and
achievement of ego integrity (Erik-
son, 1963) is rooted in their ability to
socialize and interact with others in
the nursing home. Food and the
experience of eating can be a catalyst
for this socialization.
The presentation and quality of
food served in nursing homes can
appreciably influence socialization
and quality of life for
residents. If food does
not look appetizing or
taste good, residents will not eat it,
generating resident discontent, an
increased number of resident com-
plaints, and food wastage (Katzman,
1999). Poor food intake can lead to
weight loss, increased morbidity, and
possible death (Callahan, Stump,
Stroupe, & Tierney, 1998). The pur-
poses of this article are to explore the
meaning of food to nursing home
residents, to examine residents’ per-
spectives related to nursing home
food and food service, and to identi-
fy strategies for improving food and
food service in nursing homes.
The study addressed the follow-
ing research questions:
● What meaning does food have
for nursing home residents?
● Can nursing home residents
identify the effect of food or food
service on quality of life?
● Could nursing home residents
articulate changes in food or
Improving Nursing
Home Food Service
Uncovering the Meaning of
Food Through Residents’ Stories
ABSTRACT
The meaning of food to nursing
home residents is explored to exam-
ine residents’ perspectives related to
nursing home food and food service,
and to identify strategies for improv-
ing food and food service in nursing
homes. An interpretive phenomeno-
logical approach was used to uncover
meaning in a series of “tell me a
story” interviews about food and
food service with nine residents from
an eastern Washington nursing
home. Analysis revealed 14 domains
of meaning, each containing multiple
codes with specific descriptions and
exemplars of resident expression
about food service. Themes that cut
across these codes were generated
and further organized into three
rubrics. They were: Mimicking Home,
Making Choices, and Tailoring the
System. Specific information found
under these three rubrics can be used
as a blue print for quality improve-
ment interventions implemented by
nursing home staff and management,
thereby improving quality of life for
nursing home residents.
NEVA L. CROGAN, PhD, APRN, BC, BRONWYNNE EVANS, PhD, RN,
BILLIE SEVERTSEN, PhD, RN, AND JILL A. SHULTZ, PhD
30
F
EBRUARY 2004
food service to improve their quality
of life?
Although altered competence in
activities of daily living may result in
nursing home placement, older adults
in nursing homes bring a wealth of
rich lived experience to interactions
with their caregivers and with other
residents. These residents require an
increasingly supportive environment
to promote adaptation (Lawton,
1982). Interview data gathered from
these residents, as well as from
younger residents, help staff better
understand the importance of food in
family memories and ethnic identity,
the role of food in socialization, and
desires in relation to food service in
the nursing home. Exploring the
meaning of food and food service, a
major part of a nursing home resi-
dent’s life, could uncover strategies for
improvement that staff and manage-
ment could implement, thereby
improving quality of life for residents.
However, no other studies can be
found that explore the lived experi-
ence of food and food service in the
nursing home population.
THEORETICAL FRAMEWORK
AND REVIEW OF LITERATURE
Phenomenology
The goal of interpretive phenome-
nology is to understand the world of
participants, including phenomena
and their accompanying contexts. An
understanding is reached by uncover-
ing commonalities and differences in
culturally grounded meanings. Five
sources of commonality in phenome-
nology are (Benner, 1994; Benner &
Wrubel, 1989; Leonard, 1994):
● Situation (current and historical).
● Embodiment (recognition of
the person as a unified being rather
than possessing a body, “we are one
with it”).
● Temporality (the qualitative,
lived experience of time).
● Concerns (what matters to a
person).
● Common meanings (taken for
granted linguistic and cultural under-
standings).
Bearing in mind these sources of
commonality, the researcher listens to
the voice of participants and, in turn,
presents those voices to the reader,
along with clarifying commentary.
Perceptions About Food Service
Dube, Trudeau, and Belanger
(1994) studied satisfaction with food
service in 132 hospitalized Canadian
patients. Seven dimensions were
examined in relation to patients’ per-
ceptions of food service: food quality,
service timeliness, service reliability,
food temperature, attitude of staff
who deliver menus, attitude of staff
who serve meals, and customization.
Of these dimensions, food quality
was found to be the most important
indicator of patient satisfaction.
Sidenvall, Fjellstrom, and Ek
(1994) investigated food service in the
nursing home from the dual perspec-
tives of resident and nurse. Analysis
of separate in-depth interviews with
18 newly admitted residents and their
primary care nurses revealed that
nurses and residents agreed that the
goal of food service was to create a
meal situation as natural and indepen-
dent as possible, comparable to eating
in one’s own home. Residents also
reported they sometimes avoided
expression of their needs, while nurs-
es reported their own failure to ask
questions for fear of “prying.”
Sidenvall et al. (1994) concluded that
these different perceptions resulted in
care that was “not congruent with the
needs of the elderly patient.”
Quality food service is inextrica-
bly linked to nursing home staffing.
In their 4-year anthropological
study, Kayser-Jones and Schell
(1997a, 1997b) found that inadequate
numbers of staff resulted in nursing
assistants who resorted to time-sav-
ing strategies that made mealtime a
hurried, unpleasant experience,
putting residents at risk for inade-
quate food intake. Sufficient num-
bers of well-trained nursing assis-
tants, supervised by knowledgeable
licensed nurses, are needed to assure
quality food service.
Person–Environment Fit
Adaptation to the nursing home
can be assessed using the Person–
Environment Fit model (Lawton,
1982). This transactional theory
posits that behavior is a function of
an individual’s interaction with the
environment and that as individual
competence decreases, the environ-
ment must become more support-
ive to compensate. Residents are
challenged every day to “fit” into
their environments. The nursing
home environment and support
received from staff could impact
resident adaptation and influence
food intake and satisfaction with
food service.
For example, in a study by Elliott
and Poly (1999), the dining room
environment affected mood and
meal consumption in a 5-week
crossover study of 15 elderly nursing
home residents. Residents’ mood
brightened by 50% when color was
added to the eating environment and
rose by 60% with the addition of
soft lighting, although food intake
did not increase significantly. Music
enhanced food intake by 47%, while
aromatherapy boosted intake by
53%. This study demonstrates that
the dining room environment is an
important influence on food intake
while enhancing residents’ sense of
well being.
METHODOLOGY
Research Design
An interpretive phenomenologi-
cal approach (Benner, 1994) was
used to uncover meaning in a series
of “tell me a story” resident inter-
views about food and food service.
Phenomenology is both a method
and a philosophy (Cohen, 1987) that
helps one to understand the essence
of participants’ lived experience
within their worlds. Validity rests in
verisimilitude, the ring of truth, for
the reader. It also rests in the rich-
ness of the researcher’s commentary
and the applicability of those com-
ments to nursing practice (Morse &
Field, 1995).
JOURNAL OF GERONTOLOGICAL NURSING
31
Setting
Following approval by the Wash-
ington State University Institutional
Review Board, a local 140-bed nurs-
ing home agreed to participate in the
project. Although the facility was
unfamiliar to the interview team,
administrators welcomed them as
potential providers of information
that could improve the resident eat-
ing experience.
Sample
Participants included three men
and six women, including one man
in his 20s, two women in their 40s,
and one man in his fifth decade of
life. The remaining informants
ranged from ages 61 to 93. Criteria
for inclusion in the study were cur-
rent full-time residence in the nurs-
ing facility, ability to communicate
orally in English, ability and willing-
ness to express feelings or needs to
interviewer, and ability to attend to
and appropriately answer questions
posed by the interviewer.
In qualitative research, sample
size is limited by the size of the
anticipated text and the number of
researchers available for analysis
(Benner, 1994). Given the resources
of the research team, a sample size of
20 was selected. This sample also was
deemed adequate to obtain data sat-
uration. The report of this prelimi-
nary, descriptive study will consider
the first nine interviews that were
used to field-test an interview proto-
col and a contact summary sheet.
The contact summary allowed the
researcher to document nonverbal
and paraverbal data, demographic
data, medical diagnoses, and obser-
vations about the mood tone of the
resident. Following the interview,
the researcher also recorded the
main themes and issues raised by the
resident, along with reflections on
the interaction.
During the analysis of these initial
interviews, the interview protocol and
contact summary were evaluated for
their ability to capture relevant data,
and revised accordingly. When the
contact summary had been refined, it
was then used to guide planning for
subsequent contacts, to suggest codes,
to assist coordination among the
researchers, and as an adjunct to data
analysis (Miles & Huberman, 1994).
The final purpose of analyzing the
first nine interviews was to develop
and refine a coding manual that
could be used during analysis of the
remaining 11 interviews and brought
forward to succeeding studies.
Data Collection Methods
Qualitative data were collected
using individual tape-recorded inter-
views that explored the meaning of
food for each participant in the study.
The chosen data collection method,
interviewing, is “one of the most com-
mon and most powerful ways we use
to try to understand our fellow human
beings” (Fontana & Frey, 1998).
Procedure
Staff nurses made the initial
approach to 20 informants who met
the study criteria. Upon agreement
by each resident, a letter was sent to
the participant confirming an inter-
view appointment and a researcher
obtained informed consent immedi-
ately prior to the interview.
A semi-structured protocol guided
the face-to-face interviews conducted
by a doctorally prepared community
nutritionist and a nursing master’s
student. Participants were asked to
tell the interviewer a story about a
time in their lives when food tasted
good and they really enjoyed eating,
as well as a story about a typical meal-
time at the nursing home. Residents
also provided information on how
they felt about the food and food ser-
vice, along with the best and worst
things about it. Finally, they were
asked two hypothetical questions: “If
you had the power to control the food
and food service here, and you want-
ed to make mealtime perfect, what
would you do?” and “What would it
be like if it was perfect?” Contact
summary sheets completed by the
interviewer recorded additional data
not captured through transcription
such as mood tone, appearance and
frailty of the resident, need for assis-
tive devices, and environmental events
such as noise or interruptions by a
third party.
Data Analysis
Using an interpretive phenome-
nological approach, one member of
the research team coded each inter-
view according to pre-established
decision rules set forth in a coding
manual designed by the team for this
study. This preliminary analysis was
then presented to the group for con-
sensus. Exemplars were extracted
from the data and codes were refined
and grouped into categories, or
domains, of meaning.
RESULTS
Analysis revealed 14 of these
domains of meaning, each containing
multiple codes which were catego-
rized according to “a kind of” or “a
way to:”
● Support nutritional health.
● Cook and serve food to one’s
liking.
● Requirement of good cooking.
● Enjoy the experience of eating.
● Lack enjoyment in eating.
● Exercise choice in eating.
● Lack choice.
● Provide quality service.
● Provide poor food service.
● Waste food.
● Eating to maintain health.
● Achieve self-actualization.
● Choose to accept.
● Refuse to eat.
Thematic analysis across codes
within these 14 domains disclosed
meaningful patterns and repeated
concerns (Benner, 1994). Searching
across themes produced three main
rubrics, or classifications: Mimicking
Home, Making Choices, and
Tailoring the System, as shown in
Tables 1 through 3.
Mimicking Home
The first of these rubrics,
Mimicking Home (Table 1), con-
32
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tained themes that appeared across
nine of the 14 domains in this study.
Themes are discussed in the
sequence shown in Tables 1 through
3 and are indicated throughout the
text in italics.
Stories echoed with nostalgia as
residents spoke fondly of their child-
hood memories when delicious food
was made from scratch and enjoyed
during family gatherings. Linda, an
informant in her late 40s reminisced:
My mother was a real good cook
and everything was homemade from
scratch....It seemed like every time I
had a meal that it was good. [She]
used to make homemade cinnamon
rolls and she would put in walnuts....
I haven’t tasted anything like them.
Another woman in her mid-40s,
Mary, remembered
It was morning out in the
woods...you start hearing chopping of
wood or starting the boat to go out
fishing...there’s nothing better than the
smell of coffee and fresh fried potatoes
on the stove and the smell of bacon.
These homemade foods were
carefully prepared (cooking lovingly)
with the family’s likes and dislikes in
mind. Victor, a 70-year-old active
resident said, “It was lovingly
cooked...the cook knew me and my
family quite well so she knew what
we liked and I guess that is all you
can ask for.”
Sharing companionship was an
integral part of these family gather-
ings. “When I was young, me and my
brother-in-law used to see who’d eat
the most...we would always eat ice
cream or [peanut butter],” reported
Linda. “[We had] picnics. My grand-
pa and grandma would always be
there and all the kids, married kids,
single kids, we had good times.”
Part of the fun was sharing and try-
ing new recipes with loved ones and
friends. As a 15-year-old state forest
lookout, Victor had been on duty for
a month and had used up almost all
his supplies when he improvised an
apricot-butterscotch pie that sparked
memories of home. He said:
That’s the time I remember most
when I enjoyed food, not because I
cooked it but because it tasted like
something that was close to home....I
made the pie for my family and they
liked it. My mother took it to her
PEO and they put it in their cook-
book and they called it “Vic’s
Lookout Pie.”
Residents wished for traditional
foods that were part of their food his-
tory and held great value for them. “I
love German cake and custards...and
I have a fruit salad that I make,” said
Harriet, an older resident. They also
yearned for personal preferences, “I
haven’t had cottage cheese in ages...I
like macaroni salads, beans, and bar-
becued things.” However, many real-
ized that pleasing individual tastes
could be problematic in the nursing
home, for example, “Getting a menu
to suit 200 people of every shape and
description is very hard to do.”
Getting food served at the right
temperature was a constant issue.
Seasoning was deemed important, but
opinions varied reflecting personal
tastes and habits at home. Some resi-
dents thought food was well seasoned
while others believed that it was occa-
sionally too spicy or sometimes with-
TABLE 1
RUBRIC: MIMICKING HOME
Themes
● Making food from scratch.
● Cooking lovingly.
● Sharing companionship.
● Sharing and trying new recipes.
● Supplying “traditional” foods.
● Pleasing individual tastes.
● Serving food at the right temperature.
● Cooking and presenting well-seasoned, tasty, appetizing food.
● Serving food family-style.
● Offering a variety of foods.
● Providing desired food when requested.
● Bringing food when you are ill.
TABLE 2
RUBRIC: MAKING CHOICES
Themes
Category of Providing:
● Attention to resident input.
● Choices of new foods for menu.
● Favorite foods.
● Alternative foods.
● Extra treats from staff or machines.
Category of Allowing:
● Choice about when, where, or what to eat.
● Refusal of “hated” food.
● “Complaining” as a means of expression.
● “Take-out.”
● Celebrating with food.
JOURNAL OF GERONTOLOGICAL NURSING
33
out seasoning. Linda remarked, “I
feel that if it’s spicy for me, I don’t see
how the older residents...well, there’s
a lot of times they don’t eat it either.”
Closely allied to these issues were
notions of presentation and tastiness
of food, where opinions also varied.
For example, one resident remarked,
“The other day when we had
spaghetti, they did a good job on it
for once, it didn’t taste like they just
added ketchup or tomato paste.”
Another older resident complained,
“Sometimes there is brown gravy that
smells terrible and looks worse.”
Another older gentleman, who
thought the food was tasty, enjoyed
the family-style serving. He said,
“The food served here is just as good
or better than what I get at
home...because of the big crowd, it’s
family-style with bowls and dishes.”
Many residents spoke emphati-
cally about their wish for a variety of
foods. Some were pleased with the
nursing home’s choices, saying,
“There is a variety of stuff, like they
have the same thing every week and
it rotates every other week so that
makes it nice.” However, most were
not so happy. They described
monotonous meals, saying, “They
cook a lot of scrambled eggs” and
“This last month they had a kick on
rice...we’ve been getting it for lunch
and dinner all month long.” A resi-
dent in her 70s said:
For a while, it was carrots twice a
day and one day we had carrots and
scrambled eggs. Did you ever hear of
such a thing for breakfast?...I used to
like carrots at home....but you wouldn’t
want them three times a day.
Despite the lack of variety, resi-
dents could ask for and receive
desired alternate foods. For exam-
ple, one resident said, “When there
is pork on the menu I get a substi-
tute...sometimes it’s a sandwich but
that’s all right.” One elderly woman
said on days when she felt ill and
could not come to the dining room,
“They are good to you here...when
you have to lay in bed they bring it
to you.”
Making Choices
This rubric appeared across 10 of
the 14 domains in the study (Table 2).
As with the first rubric, Mimicking
Home, the stories were full of fond
remembrances, ranging from posi-
tive, (e.g., “celebrating an occasion
with food”) to negative stories sug-
gesting a failure by the staff to
respond to even simple food requests.
Themes in this rubric were organized
into two categories: “providing,”
which illustrated ways that staff
could provide for increased choice
and “allowing,” which focused on
giving residents’ opportunities to
exercise their own preferences apart
from what staff could provide.
Providing. Under the category of
“providing,” five themes emerged.
Frustration about attention to resi-
dent input figured prominently, with
residents lamenting their lack of
voice. “We have talked to the nutri-
tionist and the dietitian and they
don’t seem to change anything when
we give any suggestions,” remarked
Harriet. Other residents also
believed their input was not well
received, nor attended to, saying,
“The residents here have all com-
plained about the food, I think you
will find out. I’ve talked to different
ones and they say they have just
given up on it.”
The lack of choices of new foods
for the menu was another theme.
This common complaint was
summed up by Mindy’s loss of hope
for change:
[At resident council] They ask you
if you are satisfied, just like you are
asking me...but we don’t see a change.
I have talked to [other residents]
when we get together to play cards
and they....just accept it. We are here
because we are here.
Mindy’s words also suggest that
some residents may experience feel-
ings of isolation or banishment in the
nursing home environment. Food
choices, or lack thereof, may alleviate
or underscore these feelings. Other
residents who consider the nursing
home to be simply a new phase of life
may marshal their familiar coping
mechanisms, actively adapt to the
new situation, and tolerate change
and lack of choice more easily.
Favorite foods held a special nos-
talgia for many informants. One res-
ident spoke sadly about a favorite
food item being discontinued: “Well,
I wanted eggs Benedict in the morn-
ing and they quit serving it....I never
got another one like that.” However,
other informants spoke of the will-
ingness of the staff to obtain alterna-
tive foods for them, enhancing their
quality of life. One resident reflect-
ed, “They are always really nice if
you want them to go down and get
something different.” Residents sin-
gled out both nurse aides and
kitchen workers in this regard,
observing that “They go way out to
come up with something.”
Willingness of the staff also
extended to provision of extra treats
from staff or machines. Mary appre-
TABLE 3
RUBRIC: TAILORING THE SYSTEM
Themes
● Hiring experienced cooks who can serve well-cooked meals on time.
● Hiring and keeping “good people” with pride in what they do.
● Providing courteous, well-trained staff.
● Providing adequate, well-maintained equipment.
● Ordering adequate amounts of fresh, good quality food.
● Furnishing fresh fruits and vegetables.
● Educating residents in how to “work the system” and adjust to change.
34
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EBRUARY 2004
ciated vending machines close to the
kitchen and the helpfulness of a
kitchen worker. She said, “They are
so willing to get you anything....she
has even thrown in some cookies.”
Allowing. Under the category of
“allowing,” five additional themes
emerged. Many residents exercised
choice about when, where, or what to
eat in novel ways, sometimes avoiding
certain eating environments or mask-
ing the taste of foods. Victor observed:
I eat in my room rather than the
dining room for lots of reasons.
Sometimes that’s the only time when
you can get privacy, is at mealtime....I
learned to use a lot of pepper and
sometimes I would use so much to
really hide the taste.
Occasionally, residents felt that
refusal of hated food was impossible.
They seemed caught between eating
unpalatable food and not eating at all.
Mindy shared her recent dilemma:
It’s pretty hard when you get my
age to have to eat something you just
hate....The other morning I had some
toast and I guess it was gravy over it
and it just looked like a cat had threw
up on my plate, but I had to eat it. I
didn’t have any other food.
Still other residents used com-
plaining as a means of expression, a
way of making choices and exercising
control over the environment. Mary
seemed to enjoy this activity. “Well, I
wouldn’t want it [the food] to be
completely perfect because then I
wouldn’t have anything to complain
about,” she smiled. Many other resi-
dents also exercised their right to
complain, persisting in calling atten-
tion to problems with the food or the
food service.
Sometimes residents solved the
problem of limited choice or unpalat-
able food by ordering take-out, that
is, bringing in food from a restaurant.
Mary implied that ordering take-out
was a common occurrence and that it
was done collaboratively among dis-
satisfied residents. She said:
When worse come to worse, we
just order out. Just for a change we
order pizza, we love pizza. Sometimes
we like it when it’s bad food or what
we don’t want, because then we order
out. Then we are all happy.
Finally, many residents reported
celebrating with food. They
expressed memories of and the desire
to link food to celebratory events in
their lives. Their reports ranged from
nostalgic memories of friends and
family eating together to recent
events when special food was
brought to the nursing home to cele-
brate an occasion.
Tailoring the System
The third rubric, Tailoring the
System (Table 3), contained seven
themes. These themes reflected resi-
dents’ opinions about the overall
management of food service in the
nursing home. Central to the infor-
mants’ stories were the importance of
hiring experienced cooks who can
serve well-cooked meals on time and
hiring and keeping “good people”
with pride in what they do. Residents
wondered what happened to the idea
that the individuals who prepare and
serve the food should have experi-
ence, and take pride, in their work.
For example, Mary asked, “If they
hire a cook, they should be able to
cook, don’t you think?” Victor
thought the answer was to build the
cooks’ pride in their work. He said:
I’d say, “Now, look, you are doing
a great job, you are going to get a hell
of a recommendation”...The more
people you get to have pride in what
they do, the better service you get.
Providing courteous, well-trained
staff was also of interest to residents,
who appreciated pleasant staff atti-
tudes and behaviors. One informant
stated, “The help is awful good to me.
They try hard.” Another resident
added, “They are always really cour-
teous, they are not handing you your
plate saying, ‘Here you are, this is
what you get.’ They are not like that.”
Providing adequate, well-main-
tained equipment was considered basic
food service. For example Sam said:
Sometimes they don’t get their
dishwasher [to work] and then we
usually have to have food on styro-
foam plates and it doesn’t stay warm.
Many residents focused their crit-
icisms on the food itself. They felt
that ordering adequate amounts of
fresh, good quality food and furnish-
ing fresh fruits and vegetables were
crucial for good food service. One
informant wished for “a nice big
salad with some vinaigrette dressing
and I would serve a fresh vegetable
like maybe some fresh broccoli.”
Linda reported:
On one salad, they will put two
really good looking tomatoes and on
another salad they will put awful
looking tomatoes...sometimes the let-
tuce is brown and uneatable.
Finally, educating residents in how
to work the system and adjust to
change helped some residents
become comfortable with the food
service. Residents like Victor were
more satisfied when they changed
their approach to, or perceptions of,
the food. For example, Victor “doc-
tored up” his breakfast.
I always take the two half pieces of
toast and the two pieces of bacon and
I make one quarter sandwich out of it,
then eat my egg with the sandwich....6
or 7 months ago I would have said it
was rotten and ill prepared and ill
timed...but after being here a while
and getting used to it, it isn’t so bad.
I’ve learned to love the salts and the
peppers.
He also recognized the impor-
tance of adjustment to his new envi-
ronment.
I realized I was a diabetic and I
couldn’t keep throwing the food away
because I had to eat. You have got to
get used to it. It isn’t food adjusting to
you, it’s you adjusting to the food...I
found that once you know how to live
with the system or “work with the
system” as they say, you can eat any-
way that you want. You have to be
flexible, but you can.
DISCUSSION
Residents articulate the individual
meaning that food carried for them
and described the impact of the envi-
JOURNAL OF GERONTOLOGICAL NURSING
35
ronment change occasioned by the
nursing home food and food service.
Moreover, they articulated desired
changes, which are described below.
Common themes described by
residents in this study could
undoubtedly be recognized across
many nursing homes. These themes
can be examined according to the
five sources of commonality in phe-
nomenology (Benner, 1994; Benner
& Wrubel, 1989; Leonard, 1994):
Situation
All too often, these residents felt
bored or lonely and missed the envi-
ronment of the family home. They
grieved multiple losses and felt
devoid of control. Their decreasing
competence in self-care required a
more supportive environment to
compensate, according to the
Person–Environment Fit model
(Lawton, 1982), but residents could
not always identify the necessary
supports.
Lawton’s model (1982) figured
prominently in the Making Choices
section of the analysis. Residents
understood the importance of food
in their daily lives and wished to
control, as much as possible, their
choices of food and the ambiance of
the environment where food was
served. Staff support of these choices
appeared to be a key to resident food
intake and satisfaction with food ser-
vice. Residents also had definite
opinions on how food service staff
should be chosen and trained,
including staff willingness to pro-
mote quality of life. Additionally,
some residents actively participated
in their own adaptation to the envi-
ronment by learning to work with
the system to have their desires met.
Embodiment
An individualized living environ-
ment is quickly becoming the stan-
dard of care for older adults (Tavor-
mina, 1999). As anticipated, residents
of all ages in this study craved foods
that tasted like home and reminded
them of their ethnic identities, a con-
tinuing developmental need. Their
bodies and minds hungered after hot
appetizing food and the increased
conviviality that mimicked the dinner
table of childhood. Despite the diffi-
culty of actually pleasing everyone’s
unique preferences at each meal, the
importance of recognizing the mean-
ing of those preferences seemed fun-
damental to these residents as they
remembered “cooking lovingly” in
their families of origin.
Temporality
Residents were quick to leave the
temporality of the nursing home
through their descriptions of child-
hood meals, dinners with friends,
and cooking preferences in their
own kitchens. Their lived experience
of time in the nursing home was
described as qualitatively different
from their lived experience in the
community where choices in food
and manipulation of the environ-
ment were still possible.
Concerns
The first rubric, Mimicking
Home, identified concerns and feel-
ings of many nursing home resi-
dents. For example, the desire for
appropriately cooked and attractive-
ly served food was strong among all
the informants. The rubric of
Tailoring the System dealt with their
concerns about preparation of the
food itself, staff who prepared and
served the food, and equipment used
in preparation.
Common Meanings
“Good” food seemed to recall
happy times and symbolized com-
fort for these residents, and was,
therefore, an important quality of
life indicator. Staff efforts to assess
and respond to the deep desires of
residents related to food were noted
and appreciated by the interviewees.
CONCLUSIONS AND
IMPLICATIONS FOR NURSING
In this study, residents longed for
home and for family rituals surround-
ing eating. They remembered them-
selves, their lived experiences, and
their loved ones through stories of
food and reminiscing about their abil-
ities to choose, provide, prepare, and
serve food as a measure of caring and
companionship. They gained comfort
from memories of special foods,
remembering warmth of family and
delicious aromas. Recommended diet-
ary practices derived from these find-
ings and targeted toward Mimicking
Home and Making Choices include
regularly assessing resident dietary
desires, honoring residents’ wishes for
specific foods, and establishing and
ongoing quality improvement pro-
gram for residents and staff to address
resident concerns related to meal ser-
vice. Improvements in meal service
aimed at mimicking a family dining
experience for residents include:
● Provision of a home-like envi-
ronment with tablecloths, placemats,
and centerpieces for dining room
tables.
● Serving food choices without
using trays (e.g., serving plates of hot
food from steam tables or hot carts
located in dining rooms).
● Seating six to eight residents at
a table where food is served family
style, enhancing residents’ rights to
choose foods and amounts of food
they want to eat.
● Serving cultural or ethnic
foods at least monthly during “spe-
cial occasions.”
● Evaluating food and food ser-
vice with a feedback slip (including a
space for special requests) to be
completed by residents after each
meal, and attending to those requests
so residents have a voice in their care
and can gain comfort from their eat-
ing experience.
Tailoring the System issues raised
in this study, such as dietary staff hir-
ing practices and nursing assistant
training, were similar to those found
by Kayser-Jones and Schell (1997a,
1997b). Sufficient numbers of well-
trained nursing assistants, supervised
by knowledgeable licensed nurses, are
needed to assure quality food service.
36
F
EBRUARY 2004
Addressing these issues in a quality
improvement program is imperative.
For example, allowing nursing assis-
tants a voice in the hiring of their
peers could improve staff morale and
retention. Hiring staff with similar
experiences and values could also
improve the cohesiveness of the nurs-
ing or dietary “team,” thus improving
services to residents. Residents could
also participate in the hiring process
through use of an interview question-
naire based on their shared values.
Additionally, management could use
this tool as a basis for hiring dietary
and nursing personnel.
Nursing assistants need additional
training focused on interpersonal
communication, cultural differences,
comfort care, and feeding skills to
better understand and “make the con-
nection” with residents in the dining
room. This improved connection
could positively impact the quality of
the dining experience for residents.
Finally, regularly scheduled staff-
resident meetings could address
troublesome areas and provide an
opportunity for collaborative prob-
lem solving. Separate staff and resi-
dent meetings could also be useful
by providing group support.
It must be acknowledged that not
all residents are amenable to change,
positive or not. However, a quality
improvement program responsive to
resident desires could result in a
food service program acceptable to
almost everyone, thereby enhancing
quality of life for residents in nurs-
ing homes.
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ABOUT THE AUTHORS
Dr. Crogan is Assistant Professor,
College of Nursing, University of
Arizona, Tucson, AZ. Dr. Evans is
Assistant Professor and Dr. Severtsen is
Associate Professor, Intercollegiate
College of Nursing, Washington State
University, Spokane, Washington. Dr.
Shultz is Associate Professor,
Department of Food Science and
Human Nutrition, Washington State
University, Spokane, Washington.
KEYPOINTS
IMPROVING NURSING
H
OME FOOD SERVICE
Crogan, N.L., Evans, B., Severtsen, B., & Shultz, J.A. Improving
Nursing Home Food Service: Uncovering the Meaning of Food
Through Residents’ Stories.
Journal of Gerontological Nursing
,
2004, 30(2): 29-36.
1
Sufficient numbers of well-trained nursing assistants, supervised
by knowledgeable licensed nurses, are needed to assure quality
food service.
2
Regular assessment of resident dietary desires, honoring residents’
wishes for specific foods, and establishing an ongoing quality
improvement program that addresses resident concerns are key to
improved quality of life for residents in nursing homes.
3
Nursing assistants need additional training focused on interper-
sonal communication, cultural differences, comfort care, and
feeding skills to better understand and “make the connection”
with residents in the dining room.
4
Regularly scheduled staff–resident meetings could address trou-
blesome areas and provide an opportunity for collaborative
problem-solving.
