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Mealtimes as Active Processes in Long-term Care Facilities
Abstract
Mealtimes are central to the nutritional care of residents in long-term care facilities. There has been little Canadian research to guide interdisciplinary practice around mealtimes. This study included a grounded theory approach to explore mealtime experiences of 20 people with dementia living in two long-term care facilities, and the meal-related care they received from registered nurses, health care aides, and dietitians. Theoretical sampling directed the collection and analysis of data from mealtime observations in special care units and key informant interviews with care providers. The constant comparison method was used to analyze and conceptualize the data. A substantive theory emerged with three key themes:
Each mealtime is a unique process embedded within a long-term care facility's environment. Residents are central to the process through their actions (i.e., arriving, eating, waiting, socializing, leaving, and miscellaneous distracted activities). Internal (i.e., residents’ characteristics) and external (i.e., co-resident, direct caregiving, indirect caregiving, administrative, and government activities) influences affect residents’ actions at mealtimes.
The theory suggests that optimal mealtime experiences for residents require individualized care that reflects interdisciplinary, multi-level interventions.
... Eleven studies were qualitative. Of these, nine included observation of mealtimes in their data collection (Driessen & Ibáñez Martín, 2020;Gibbs-Ward & Keller, 2005;Hung & Chaudhury, 2011;Kayser-Jones & Schell, 1997a, 1997bPalese et al., 2018;Pasman et al., 2003;Pierson, 1999;Van Ort & Phillips, 1992) and two used focus groups and/or interviews only Nell et al., 2016). Two studies used mixed methods: Chang and Roberts (2008) and De Bellis et al. (2003). ...
... De Bellis et al. (2003), Kayser-Jones and Schell (1997b), Nell et al. (2016), Palese et al. (2018), Pasman et al. (2003), and Pierson (1999) investigated care staff's perceptions of, and approaches to, mealtime care. Gibbs-Ward and Keller (2005) and Murphy et al. (2017) used qualitative data to develop a conceptual understanding of mealtime care. Kayser-Jones and Schell (1997a) and Van Ort and Phillips (1992) described and analysed carer strategies to assist residents at mealtimes. ...
... The failed criteria were different in each case and included the following: 'Were the outcomes measured in a valid and reliable way?'; 'were confounding factors identified?' and 'were treatment groups similar at baseline?' The highest-scoring qualitative study (Gibbs-Ward & Keller, 2005) met all criteria. The lowest-scoring qualitative study (Chang & Roberts, 2008) was rated No for three criteria and Unclear for six others. ...
People with dementia who live in care homes often depend on care home staff for help with eating and drinking. It is essential that care home staff have the skills and support they need to provide good care at mealtimes. Good mealtime care may improve quality of life for residents, and reduce hospital admissions. The aim of this systematic review was to identify good practice in mealtime care for people with dementia living in care homes, by focusing on carer-resident interactions at mealtimes. Robust systematic review methods were followed. Seven databases were searched: AgeLine, BNI, CENTRAL, CINAHL, MEDLINE, PsycINFO and Web of Science. Titles, abstracts, and full texts were screened independently by two reviewers, and study quality was assessed with Joanna Briggs Institute tools. Narrative synthesis was used to analyse quantitative and qualitative evidence in parallel. Data were interrogated to identify thematic categories of carer-resident interaction. The synthesis process was undertaken by one reviewer, and discussed throughout with other reviewers for cross-checking. After title/abstract and full-text screening, 18 studies were included. Some studies assessed mealtime care interventions, others investigated factors contributing to oral intake, whilst others explored the mealtime experience. The synthesis identified four categories of carer-resident interaction important to mealtime care: Social connection, Tailored care, Empowering the resident, and Responding to food refusal. Each of the categories has echoes in related literature, and provides promising directions for future research. They merit further consideration, as new interventions are developed to improve mealtime care for this population.
... Second, dining together creates opportunities for older adults to develop new friendships and informal support networks (Gibbs-Ward & Keller, 2005;Hopper, Cleary, Baumback, & Fragomeni, 2007). This is an important means for residents in nursing homes to develop and maintain relationships (Reimer & Keller, 2009), especially when a family-style dining atmosphere is created (Altus, Engelman, & Mathews, 2002). ...
... Park (2009) found that older adults who dined together in assisted living facilities reported lower depressive symptoms than those who dined alone. Indeed, shared meals not only meet older adults' needs for nutritional intake but also create a social milieu (Gibbs-Ward & Keller, 2005). ...
... Recognizing sociocultural characteristics of older adults' mealtime interactions is critical. For example, Gibbs-Ward and Keller (2005) reported that the dining setting of big, round tables in Chinese restaurants encouraged more interaction among older Canadian Chinese women than a non-Chinese dining setting did. This finding offers a cultural perspective on the atmosphere of congregate dining for Chinese older adults. ...
This chapter depicts the micro-level interaction dynamics among elderly clients during their mealtime in the HCBS program service centers. First, we review previous literature on older adults’ mealtime interaction in public dining places. In particular, taking two competing theoretical perspectives—socioemotional theory and activity theory—we examine how these interactions relate to older adults’ life satisfaction. From these competing perspectives, we perform secondary data analysis to test older adults’ mealtime interactions in the service centers. We conclude with a discussion on the value of casual, daily interactions (e.g., mealtime interactions) in the service centers to illuminate the social meanings of mealtime interactions for older adults within the micro level of the community care ecology.
... As the most basic activity of daily living (ADL) for older adults, eating performance is usually the easiest function to restore after decline or loss (Liu et al., 2015b;Morris et al., 1999;Kovar and Lawton, 2017). Maintaining independent eating performance at mealtimes not only promotes social engagement and enjoyment of meals, but also enhances functional autonomy and ensures adequate food intake to maintain nutritional status as a fundamental health need (Gibbs-Ward and Keller, 2005;Palacios-Ceña et al., 2013). ...
... For nursing home residents with dementia, meals are embedded within the care environment (Gibbs-Ward and Keller, 2005). While some residents may dine in their own room or other areas in the nursing home, most meals take place in the dining room, where the resident shares the table with other residents. ...
... Beyond the intrapersonal factors, eating performance is also associated with multiple factors at the interpersonal, environmental, and policy levels (Liu et al., 2016a). Interpersonal factors that relate to caregiver characteristics include caregivers' perceptions and skills for engaging the resident in eating, dyadic communication and interaction, and mealtime assistance such as verbal cues and role modeling (Gibbs-Ward and Keller, 2005;Palacios-Ceña et al., 2013;Amella and Aselage, 2014;Liu et al., 2016b;Pelletier, 2005). Environmental factors include both physical environment (e.g., lighting, noise, tableware contrast, use of finger food, and availability of adaptive devices) (Slaughter and Hayduk, 2012;Liu, 2017;Brush et al., 2002), and social and cultural contexts (e.g., food delivery style, dining routines, social engagement, and cultural aspects of food choices) (Evans et al., 2005;Andreoli et al., 2007;Chang and Roberts, 2008). ...
Nursing home (NH) residents with dementia experience increased risk for compromised eating performance due to cognitive and functional decline and behavioral symptoms. Beyond the personal factors, there is a lack of evidence on how environmental stimulation at mealtime influence individuals’ eating performance. This study examined the association between environmental stimulation and eating performance among NH residents with dementia. A secondary analysis was completed of 36 baseline eating videos among 19 nursing assistants and 15 residents with dementia in 8 NHs from a communication intervention study. The dependent variable was eating performance (Level of Eating Independence scale). The independent variables were characteristics of environmental stimulation measured by the Person-Environment Apathy Rating-Environment subscale (stimulation specificity, interaction involvement, environmental feedback). Multilevel models were used to examine the association between eating performance and environmental stimulation adjusting for resident characteristics and nesting effects of resident and staff. Eating performance was significantly associated with stimulation specificity (how the stimulation is delivered and tailored to residents) and was not associated with other environmental stimulation characteristics, after controlling for resident characteristics. An environment with more specific stimulation is associated with better eating performance. For each 1 point increase in stimulation specificity, eating performance is increased by 8.78 points (95% CI=.59, 16.97). Environmental stimulation that is personally tailored to residents’ needs and preferences and directly offered to residents improves eating performance among residents with dementia. The findings will direct future development and implementation of person-centered mealtime care programs and dinning environment arrangements for residents with dementia in NH settings.
... As the most basic activity of daily living (ADL) for older adults, eating performance is usually the easiest function to restore after decline or loss (Liu et al., 2015b;Morris et al., 1999;Kovar and Lawton, 2017). Maintaining independent eating performance at mealtimes not only promotes social engagement and enjoyment of meals, but also enhances functional autonomy and ensures adequate food intake to maintain nutritional status as a fundamental health need (Gibbs-Ward and Keller, 2005;Palacios-Ceña et al., 2013). ...
... For nursing home residents with dementia, meals are embedded within the care environment (Gibbs-Ward and Keller, 2005). While some residents may dine in their own room or other areas in the nursing home, most meals take place in the dining room, where the resident shares the table with other residents. ...
... Beyond the intrapersonal factors, eating performance is also associated with multiple factors at the interpersonal, environmental, and policy levels (Liu et al., 2016a). Interpersonal factors that relate to caregiver characteristics include caregivers' perceptions and skills for engaging the resident in eating, dyadic communication and interaction, and mealtime assistance such as verbal cues and role modeling (Gibbs-Ward and Keller, 2005;Palacios-Ceña et al., 2013;Amella and Aselage, 2014;Liu et al., 2016b;Pelletier, 2005). Environmental factors include both physical environment (e.g., lighting, noise, tableware contrast, use of finger food, and availability of adaptive devices) (Slaughter and Hayduk, 2012;Liu, 2017;Brush et al., 2002), and social and cultural contexts (e.g., food delivery style, dining routines, social engagement, and cultural aspects of food choices) (Evans et al., 2005;Andreoli et al., 2007;Chang and Roberts, 2008). ...
Background:
Nursing home residents with dementia experience increased risk for compromised eating performance due to intrapersonal, interpersonal, and environmental factors. Environmental stimulation is physical, social, and/or sensory stimulation present in the environment that can potentially trigger individuals' emotion or motivate physical reactions. Beyond the personal factors, there is a lack of evidence on how environmental stimulation influences individuals' eating performance at mealtimes.
Objectives:
This study examined the association between environmental stimulation and eating performance among nursing home residents with dementia.
Design:
This study was a secondary analysis using baseline videos selected from a communication intervention study, where videos were recorded to capture staff-resident interactions during care activities for nursing home residents with dementia. Videos were included in this study only if residents demonstrated eating activities at mealtimes.
Sample and setting:
A total of 36 videos were selected (mean length=4min). The sample included 15 residents with dementia (mean age=86), and 19 certified nursing assistants (mean age=36) in 8 nursing homes.
Methods:
The dependent variable was eating performance as measured by the Level of Eating Independence scale (range: 15-36, with higher scores indicating better eating performance). The independent variables were characteristics of environmental stimulation measured by the Person-Environment Apathy Rating-Environment subscale (stimulation clarity, stimulation strength, stimulation specificity, interaction involvement, physical accessibility, and environmental feedback). Each characteristic was rated on a 1-4 scale with higher scores indicating more desirable environmental stimulation. Multilevel models were used to examine the association between eating performance and environmental stimulation, adjusting for resident characteristics (i.e., age, gender, dementia stage, function, comorbidity, psychoactive medication use) and nesting effects of residents and staff.
Results:
Resident participants demonstrated moderate levels of eating performance (M=27.08, SD=5.16). Eating performance was significantly lower among older residents, those with more advanced dementia, and higher comorbidity. After controlling for resident characteristics, eating performance was significantly associated with stimulation specificity (how the stimulation is delivered and tailored to the resident), and was not associated with other environmental stimulation characteristics. For each 1 point increase in stimulation specificity, eating performance increased by 8.78 points (95% CI=0.59, 16.97).
Conclusions:
Environmental stimulation that is personally tailored to a resident' needs and preferences and directly offered to a resident contributed to better eating performance among residents with dementia. The findings will direct future development and implementation of person-directed mealtime care programs and dining environment arrangements for residents with dementia in nursing homes.
... 7,9 Previous studies have shown that food in nursing homes is relevant to quality of care at several different levels, and its importance goes beyond the satisfaction of nutritional requirements 5,10 and hunger satiation. 2 Important aspects of the mealtime experience include the site where food is served, 2 the familiarity of the environment, 8 the mealtime schedule, 11 whether the personnel are present at mealtimes, 12 the education of the personnel, 4 personal interactions between personnel and residents at mealtimes, 7 the attitudes of the personnel towards mealtimes, 13 interactions among residents at mealtime, 2,14 and the freedom of residents to choose what, when and with whom to eat. 7,8,10 Additionally, food has its own meanings: one of social connection and relationships, 5,7 security, 2,8 and individual identity. ...
... 7,8,10 Additionally, food has its own meanings: one of social connection and relationships, 5,7 security, 2,8 and individual identity. 5,10 These meanings are built from previous emotional and social experiences, and from the personal history of each individual, 11,13 their family history, 14 their beliefs, 7 and their cultural and/or ethnic influences. 5,11 In Spain, no qualitative studies addressing the mealtime experience in nursing homes have been carried out. ...
... 8,14 An ideal mealtime is one in which the unique needs of every resident, their preferences, and responses to each activity are understood and integrated into the mealtime process, in order to maximize autonomy, promote positive social experiences, optimize dietary intake and ultimately improve quality of life. 13 Hsiu-Hsin et al. discussed how "eating" is the main occupation at the residency, the activity around which the daily routines are organized. 25 Mealtimes provide the residents with a feeling of security, continuity and control over their daily activities. ...
In nursing homes, a number of barriers to the expression of sexuality exist, such as the lack of privacy, certain attitudes on behalf of the staff and the family, the lack of a sexual partner, and physical limitations. The aim of this study was to describe the lived experience of sexuality in elderly Spanish women residing in nursing homes. A qualitative phenomenological approach was followed. Data were collected over an 18-month period between 2013 and 2015. Purposeful sampling was conducted with Spanish residents in nursing homes in Madrid. Data were collected using unstructured and semi-structured interviews. The data were analyzed using thematic analysis. Twenty female residents participated. Three main themes emerged from the data: a) expressing sexuality, b) sexuality as a duty and c) respecting vows. Female residents reported key elements influencing how they manage their sexuality in Nursing Homes. These results serve to improve our understanding regarding the expression of sexuality in older female nursing home residents.
... Eating independently by oneself without supervision or assistance is an important indicator of quality of life for LTC residents, both physically and psychosocially (Keller et al. 2010). In addition, eating is not just a process to get adequate nutrition and intake but also a pathway to enjoy food and social interaction during mealtimes (Gibbs-Ward & Keller 2005, Palacios-Ceña et al. 2013. Mealtime experience should continue to be pleasant for individuals with cognitive impairment as they live in LTC facilities. ...
... In addition, many caregivers and family members believe that feeding an older adult is a way of being caring and nurturing (Chee 2000). Additional interpersonal interactions that are associated with eating performance include such things as role modelling by caregivers and other residents to eat independently (Gibbs-Ward & Keller 2005, Palacios-Ceña et al. 2013, communication with caregivers and other residents about eating and food during mealtimes (Amella 2002, Chang & Roberts 2008 and social support from caregivers and peer residents who sit adjacently (Crogan & Shultz 2000, Pelletier 2005 Figure 1 Social Ecological Model (SEM) of factors that influence eating performance. ...
... aspiration and choking) (Chang & Roberts 2008). Moreover, custodial care practice policies that focus on intake of food and task completion in an effort to ensure expediency, as opposed to ensuring an enabling and therapeutic meal experience, can diminish eating performance (Gibbs-Ward & Keller 2005, Pelletier 2005). Specifically, insufficient staffing and policies to prevent weight loss in LTC settings result in caregivers electing to hand feed residents or modify food and fluid consistency to maintain caloric intake and complete feeding quickly (Crogan & Shultz 2000, Cowan et al. 2004). ...
Aims:
The aim of this study was to examine the association of specific personal and environmental factors with eating performance among long-term care residents with moderate-to-severe cognitive impairment.
Background:
Eating is the one of the most basic and easiest activities of daily living to perform. While multilevel factors can be associated with eating performance, the evidence among those with dementia was insufficient.
Design:
A secondary analysis of baseline data collected between March and September in 2012 from 199 residents in eight long-term care facilities.
Methods:
Eating performance was conceptualized using the single self-care 'feeding' item in the Barthel Index and was scored based on four levels of dependence and assistance required. Binary logistic regression was used to examine the adjusted association of specific factors with eating performance.
Results:
Almost one-third of the residents needed help with eating. After adjusting the type of facility, number of comorbidities, chair-sitting balance, agitation and depression, compromised eating performance was associated with severe cognitive impairment and low physical capability.
Conclusion:
This study supported the association of eating performance with cognitive impairment and physical capability among long-term care residents with moderate-to-severe cognitive impairment. Targeted interventions should be implemented to reduce the impact of cognitive decline on eating performance and promote physical capability to optimize eating performance. Future work need to use validated multiple-item measures for eating performance and test the association of personal and environmental factors with eating performance among a larger heterogeneous group of long-term care residents to enhance understanding of the factors.
... Autonomy at mealtimes is an important indicator of quality of life, both physically and psychosocially, for older adults living with dementia (Keller et al., 2010). Mealtime is not just a process to ensure adequate nutrition and intake, but also a pathway to enjoy social contact and interaction, as well as food (Gibbs-Ward & Keller, 2005;Palacios-Ceña et al., 2013). Mealtime experiences should continue to be pleasurable events for older individuals with dementia, as compromised eating performance has a significant impact on health outcomes and quality of life (Hanson, Ersek, Lin, & Carey, 2013). ...
... However, due to institutional barriers such as insufficient staffing and policies to prevent weight loss, caregivers may primarily focus on maintaining caloric intake and help too much with feeding in order to complete eating tasks quickly (Crogan & Shultz, 2000). Excessive or unnecessary assistance with feeding, regardless of residents' self-feeding ability, may result in unintended dependence, interfere with residents' autonomy, decrease mealtime pleasure, and elicit resistance and aggressive behaviors (Amella, 2002;Gibbs-Ward & Keller, 2005). ...
... There are also some institutional factors such as appropriate staffing for mealtime supervision and assistance, high workload, and staff turnover . The policy factors include custodial care management styles, policies that are task-oriented instead of resident-oriented, and focus on adequate intake and expediency instead of optimizing self-feeding independence (Gibbs-Ward & Keller, 2005). ...
Review of research to date has been focusing on maintaining weight and nutrition with little attention on optimizing eating performance.
To evaluate the effectiveness of interventions on eating performance for older adults with dementia in long-term care (LTC).
A systematic review was performed. Five databases including Pubmed, Medline (OVID), EBM Reviews (OVID), PsychINFO (OVID), and CINAHL (EBSCOHost) were searched between January 1980 and June 2014. Keywords included dementia, Alzheimer, feed(ing), eat(ing), mealtime(s), oral intake, autonomy, intervention. Intervention studies that optimize eating performance and evaluate change of self-feeding or eating performance among older adults (≥65 years) with dementia in LTC were eligible. Studies were screened by title and abstract, and full-texts were reviewed for eligibility. Eligible studies were classified by intervention type. Study quality was accessed using the Quality Assessment Tool for Quantitative Studies, and level of evidence using the 2011 Oxford Centre for Evidence-Based Medicine (OCEBM) Levels of Evidence.
Eleven intervention studies (five randomized controlled trials; RCTs) were identified, and classified into four types: Training program, mealtime assistance, environmental modification, and multicomponent intervention. The quality of the 11 studies was generally moderate, with the main threats as weak designs, lack of blinding and control for confounders, and inadequate psychometric evidence for measures. Training programs targeting older adults (Montessori methods and spaced retrieval) demonstrated good evidence in decreasing feeding difficulty. Mealtime assistance offered by nursing staff (e.g., verbal prompts and cues, positive reinforcement, appropriate praise and encouragement) also showed effectiveness in improving eating performance.
This review provided preliminary support for using training and mealtime assistance to optimize eating performance for older adults with dementia in LTC. Future effectiveness studies may focus on training nursing caregivers as interventionists, lengthening intervention duration, and including residents with varying levels of cognitive impairment in diverse cultures. The effectiveness of training combined with mealtime assistance may also be tested to achieve better resident outcomes in eating performance.
© 2015 Sigma Theta Tau International.
... Mealtimes are not only central to a resident's nutritional care, but are also a vital daily activity (Gibbs-Ward & Keller, 2005). Despite their challenges, mealtimes are most often the high point of the day (Keller et al., 2007). ...
... Communication during mealtimes is essential to the resident's mealtime experience. For many, it can be the most rewarding social interaction of the day (Gibbs-Ward & Keller, 2005). This is a time when residents can develop new relationships and share memories of home with each other (Evans et al., 2005). ...
... Mealtimes in long-term care can be a time of social interaction, staff attention and enjoyment of food (Bryon et al., 2008). They encompass the process of arriving to the dining room, the resident being acknowledged by other residents and staff, socializing, the act of eating, and various other activities that can occur during the meal (Gibbs-Ward & Keller, 2005). Mealtimes are therefore not just about the food on the plate, but rather the entire experience (Sidenvall, Fjellstrom & Elk, 1994) and can help to foster independence, support self-esteem, promote interactions with others and make the resident feel more comfortable in their surroundings (Speroff, Davies, Dehr & Larkins, 2005). ...
... Specifically, residential care homes tend to prioritize dining room functionality over homelikeness (Chaudhury et al., 2017) and efficiency over meaningful social interaction (Hung & Chaudhury, 2011;Lowndes et al., 2017). Moving residents into the dining room, taking orders, providing food quickly, and removing residents from their tables in an almost assembly-line fashion, are hallmarks of taskfocused mealtime care (Gibbs-Ward & Keller, 2005). This care sector is recognizing that both the physical and social dining environments need improvement, as food service and the mealtime experience are perceived by residents and families as a key marker of the quality of care provided in a home (Watkins et al., 2017). ...
... CHOICE+ supports residential care settings to promote and support relationship-centred mealtime practices using six key principles, with the letter of each principle spelling out the program name: Connecting, Honouring dignity, Offering support, Identity, Creating opportunities, and Enjoyment (Table 1) (Keller et al., 2020;Wu et al., 2018). This program was developed over several years of research that identified an incongruence between the social significance of eating with others and the undervaluing of mealtime experiences in residential care settings, in addition to opportunities to vastly improve dining in this sector (Ducak et al., 2015;Gibbs-Ward & Keller, 2005;Keller et al., 2020;Wu et al., 2018). The Knowledge-to-Action Cycle (Straus et al., 2017) guided the development of CHOICE+ to ensure that program components were 'tailorable' to meet the current needs of those who eat and work in a particular dining room (i.e., residents, staff, families, volunteers). ...
Context: Mealtimes in residential care homes are important for social engagement and can encourage resident relationships. Yet, training programs to improve mealtime care practices in residential care set- tings remain limited in learning approaches and scope.
Objectives: To determine whether a one-day Champion Training session would improve participants’ knowledge, skills, and confidence to implement a relationship-centred mealtime program (CHOICE+) in their homes.
Methods: The study employed a pre-/post-test design to evaluate a train-the-trainer model using paper- based questionnaires. Thirty-four participants attended the training session; 25 participants completed pre/post training questionnaires based on Kirkpatrick’s evaluation model. Training included: 1) program implementation manual, 2) best-practices document, 3) educational resources and evaluation tools, 4) presentation on theory-based implementation strategies and behaviour change techniques, and 5) group discussion on applying strategies and techniques, problem-solving for implementation facilitators and barriers.
Findings: More than half of attendees worked as Food Service Managers or Registered Dietitians. Par- ticipants identified several organizational factors that could impact their home’s readiness to implement CHOICE+, though they felt training to be acceptable and feasible for their homes. Participants reported increase in knowledge (8.4 ± 1.1), confidence (8.3 ± 1.4), and commitment (8.8 ± 1.4) to implement the relationship-centred mealtime program. There was no association with pre-training readiness, leadership, or home characteristics.
... Taken together, the number and variety of these themes generated by the focus groups clearly reflect that there are multiple barriers and facilitators in providing mealtime assistance to nursing home residents with dementia. This is also supported in the literature across the globe, where researchers have reported on the "complex and interrelated" (Nell et al., 2016) factors that influence the mealtime experiences of residents with dementia and their caregivers (Chang & Roberts, 2008a;Furåker & Nilsson, 2009;Gibbs-Ward & Keller, 2005;Nell et al., 2016). ...
... For example, communication was mentioned as both an individual skill and an interpersonal asset in the relationships that CNAs have with both their residents and other CNAs. As such, this indicates the need for multipronged interventions that target multiple influencing factors (Chang & Roberts, 2008a;Gibbs-Ward & Keller, 2005;Liu et al., 2015). ...
Background and objectives:
In long-term care facilities in the United States, certified nursing assistants (CNAs) provide mealtime assistance to residents with dementia, a task that substantially increases caregiver burden due to the time and attention required. The aim of this qualitative study was to explore the individual and interpersonal barriers and facilitators CNAs experience when providing mealtime assistance to residents with dementia.
Research design and methods:
Focus group questions were developed based on the corresponding levels of the Social Ecological Model. Using purposive sampling, nine focus groups were conducted with 53 CNAs who had at least one year of experience as a CNA working with older adults. Focus groups were audio recorded and transcribed verbatim. Data were analyzed using the directed content analysis approach.
Results:
CNAs reported individual skills, training, and personal characteristics that affected their ability to provide mealtime assistance. At the interpersonal level, CNAs identified their relationships with residents, residents' family members, and other healthcare professionals as factors that impact their ability to provide mealtime assistance.
Discussion and implications:
These findings provide evidence for strategies that administrators can utilize to reduce caregiver burden by improving the mealtime experience. First, CNAs need adequate training, particularly to develop communication skills. Developing verbal communication skills may improve interpersonal relationships between CNAs and residents' family members and other coworkers. Developing nonverbal communication skills may foster an improved relationship between CNAs and their residents with dementia. Future research should evaluate interventions that seek to improve these skills to determine their impact on the mealtime experience.
... & Ouellet, 2009). Other factors include the presence, attitudes and training of the staff in how they interact and support residents (Bourdel-Marchasson, 2010;Gibbs-Ward & Keller, 2005;Simmons & Levy-Storms, 2006), the quality of interactions between residents (Philpin, Merrell, Warring, Gregory, & Hobby, 2011), and the freedom of choice around food, place, time and companions (Carrier et al., 2009;Crogan, Evans, Severtsen, & Shultz, 2004;Watkins et al., 2017). ...
... Mealtimes are regarded as social events that foster a sense of community integration, the perception of normality and reinforce personal identity (Gibbs-Ward & Keller, 2005;Palacios-Ceña et al., 2013;Philpin et al., 2011;Watkins et al., 2017). Mealtimes involve social exchanges between those around the table, including sharing personal feelings, employing humour, displaying affection and appreciation, and perhaps less positively, rebuffing and avoidance (Curle & Keller, 2010). ...
Research stresses that mealtimes in care homes for older people are vital social events in residents’ lives. Mealtimes have great importance for residents as they provide a sense of normality, reinforce individuals’ identities and orientate their routines. This ethnographic study aimed to understand residents’ use of dining spaces during mealtimes, specifically examining residents’ table assignment processes. Data were collected in summer 2015 in three care homes located in England. The research settings looked after residents aged 65+, each having a distinct profile: a nursing home, a residential home for older people and a residential home for those with advanced dementia. Analyses revealed a two‐stage table assignment process: 1. Allocation – where staff exert control by determining residents’ seating. Allocation is inherently part of the care provided by the homes and reflects the structural element of living in an institution. This study identified three strategies for allocation adopted by the staff: (a) personal compatibilities; (b) according to gender and (c) ‘continual allocation’. 2. Appropriation – it consists of residents routinely and willingly occupying the same space in the dining room. Appropriation helps residents to create and maintain their daily routines and it is an expression of their agency. The findings demonstrate the mechanisms of residents’ table assignment and its importance for their routines, contributing towards a potentially more self‐fulfilling life. These findings have implications for policy and care practices in residential and nursing homes.
... This phenomenon does not necessarily suggest that older adults are incapable of remaining self-reliant but that they would choose to have food prepared for them as they become older, given the expectation of daily elaborate food preparation. Furthermore, older adults in Shanghai consider the community meal services a social milieu, with strong social and cultural associations to food (Chen, Ye, & Kahana, 2018;Gibbs-Ward & Keller, 2005;Ye et al., 2017). ...
... From this cultural perspective, caregivers' attitudes during mealtime were crucial to respondents. Also, public dining holds strong sociocultural meanings when older adults dine together (Gibbs-Ward & Keller, 2005;Ye et al., 2017). This finding is similar to Western evidence that arranging opportunities for socialization at mealtime has been found to improve meal service delivery in assisted living facilities (Chao et al., 2007). ...
Informed by Donabedian’s quality-of-care framework, this study aims to examine elderly clients’ service satisfaction and service recommendation for community-based meal services in Shanghai. We analyzed secondary survey data from randomly sampled elderly clients of a community-based meal service in the old Jing’an District in Shanghai (N= 690). Quality of food and caregivers’ attitudes were key to respondents’ service recommendation while tidiness of tableware and interactions with caregivers were positively related to their service satisfaction. Overlaps and differences between structure and process factors are discussed. We also provide tailored policy recommendations.
... Research to date has failed to use a comprehensive conceptual framework to understand and intervene on the multi-level and inter-related determinants of food intake in LTC residents [7,15,20,24]. The proposed study is built upon the M3 concept [25], which has its origins in the Social Ecological Model [26], the Five Aspects of Meal Model [27], and the Mealtimes as 'Active Processes' substantive theory [28]. The M3 conceptual model suggests that multi-level determinants influence food and fluid intake of residents. ...
... Apathy and depression have been found to be independently associated with weight loss in LTC residents [44] and may be influenced by a negative mealtime experience [42]. Two theories specific to persons with dementia (Mealtimes as Active Processes in LTC and the Life Nourishment Theory), demonstrate the importance and potential influence of the psychosocial environment on food intake [28,45]. It is hypothesized that positive social connections and honouring individual identities (e.g., food preferences) at mealtimes will promote food intake and quality of life. ...
Background
Older adults living in long term care (LTC) homes are nutritionally vulnerable, often consuming insufficient energy, macro- and micronutrients to sustain their health and function. Multiple factors are proposed to influence food intake, yet our understanding of these diverse factors and their interactions are limited. The purpose of this paper is to fully describe the protocol used to examine determinants of food and fluid intake among older adults participating in the Making the Most of Mealtimes (M3) study.
Methods
A conceptual framework that considers multi-level influences on mealtime experience, meal quality and meal access was used to design this multi-site cross-sectional study. Data were collected from 639 participants residing in 32 LTC homes in four Canadian provinces by trained researchers. Food intake was assessed with three-days of weighed food intake (main plate items), as well as estimations of side dishes, beverages and snacks and compared to the Dietary Reference Intake. Resident-level measures included: nutritional status, nutritional risk; disease conditions, medication, and diet prescriptions; oral health exam, signs of swallowing difficulty and olfactory ability; observed eating behaviours, type and number of staff assisting with eating; and food and foodservice satisfaction. Function, cognition, depression and pain were assessed using interRAI LTCF with selected items completed by researchers with care staff. Care staff completed a standardized person-directed care questionnaire. Researchers assessed dining rooms for physical and psychosocial aspects that could influence food intake. Management from each site completed a questionnaire that described the home, menu development, food production, out-sourcing of food, staffing levels, and staff training. Hierarchical regression models, accounting for clustering within province, home and dining room will be used to determine factors independently associated with energy and protein intake, as proxies for intake. Proportions of residents at risk of inadequate diets will also be determined.
Discussion
This rigorous and comprehensive data collection in a large and diverse sample will provide, for the first time, the opportunity to consider important modifiable factors associated with poor food intake of residents in LTC. Identification of factors that are independently associated with food intake will help to develop effective interventions that support food intake.
Trial Registration
ClinicalTrials.gov ID: NCT02800291, retrospectively registered June 7, 2016.
... Furthermore, dining together creates opportunities to form new friendship and informal support networks for older adults (Gibbs-Ward & Keller, 2005;Hopper, Cleary, Baumback, & Fragomeni, 2007). For example, dining together was an important means for residents in the nursing home to develop and maintain relationships (Reimer & Keller, 2009). ...
... Recognizing sociocultural characteristics of older adults' mealtime interactions is meaningful. For example, Gibbs-Ward and Keller (2005) reported that the dining setting of big round tables in Chinese restaurants encouraged more interaction among Canadian Chinese old ladies than did in a non-Chinese cultural setting. Given the large number of older adults who dine in senior centers in Shanghai, it is important to learn about older adults' mealtime interactions in a non-Western sociocultural context. ...
Objective:
We examined the association between older adults' mealtime interactions at senior centers in Shanghai and their life satisfaction. Competing hypotheses, derived from socioemotional selectivity theory and activity theory, were tested.
Method:
Data were obtained from the 2011 Shanghai senior center service utilization survey ( ITALIC! N= 320). Relationships between respondents' mealtime interactions and life satisfaction were tested using multilevel regression modeling.
Results:
After adjusting for demographics, interactions with tablemates (companionship, self-disclosure, and instrumental support) were positively associated with respondents' life satisfaction. These associations varied by senior centers. However, the number of tablemates was not significantly associated with respondents' life satisfaction.
Discussion:
Findings support the activity-theory-based hypothesis that mealtime interactions are related to older adults' life satisfaction independent of the number of tablemates. This study illuminates the value of social interactions in the context of community dining programs for the rapidly increasing older population in urban China.
... Vårdpersonal kan vid matning ha fokus på arbetsuppgiften att mata eller vara fokuserad på patienten. Om vårdpersonal har fokus på patienten vill den ge patienten en trevlig upplevelse av måltiden (Gibbs-Ward & Keller, 2005). Vårdarens relation till patienten och förmåga att integrera med patienten är en förutsättning för att måltiden ska bli bra. ...
... En vårdare i personalen beskrev i en intervju att en undersköterska hade bett patienten som hon matade att sluta prata med de andra boendena, hon sa "I don´t want you to talk, I want you to eat" (s.8). Vårdaren beskriver detta som att ha fokus på uppgiften (Gibbs-Ward & Keller, 2005). Uppgiftsfokusering handlar om rutin. ...
... The meal time is made up of a series of processes (e.g., preparing to eat, serving foods and fluids in multiple courses) and interactions (e.g., asking permission, sharing a laugh, giving a light comforting touch) between key players: care staff, residents, and family members (Gibbs-Ward & Keller, 2005). Research that has examined mealtime processes in LTC homes describes them as hectic and TF (Hung & Chaudhury, 2011;Sloane et al., 1998;Watkins et al., 2017). ...
Mealtimes in long-term care (LTC) can reinforce relationships between staff and residents through relationship-centred care (RCC) practices; however, meals are often task-focused (TF). This cross-sectional study explores multi-level contextual factors that contribute to RCC and TF mealtime practices. Secondary data from residents in 32 Canadian LTC homes were analyzed (n = 634; mean age 86.7 ± 7.8; 31.1% male). Data included resident health record review, standardized mealtime observation tools, and valid questionnaires. A higher average number of RCC (9.6 ± 1.4) than TF (5.6 ± 2.1) practices per meal were observed. Multi-level regression revealed that a significant proportion of variation in the RCC and TF scores was explained at the resident- (intraclass correlation coefficient [ICC]RCC = 0.736; ICCTF = 0.482), dining room- (ICCRCC = 0.210; ICCTF = 0.162), and home- (ICCRCC = 0.054; ICCTF = 0.356) levels. For-profit status and home size modified the associations between functional dependency and practices. Addressing multi-level factors can reinforce RCC practices and reduce TF practices.
... Interpersonal factors consist of the knowledge, attitudes, and behaviors contributing to direct care workers' interactions [7,12,15]. Environmental factors include aspects of the physical environment (e.g., type of meal, how food is served, and appropriate stafng levels) that might afect mealtime difculties [11,13,16,17] as well as care facility factors such as work-oriented policies and provision of appropriate accommodations [12,18]. ...
Aim(s). This study conducted a multilevel analysis of mealtime difficulties in older adults with dementia based on the social-ecological model. Background. Mealtime difficulty in this population should be examined from an extensive perspective, rather than approaching it as an individual problem. Method(s). This was a cross-sectional study involving 342 participant dyads from 57 long-term care facilities; 114 direct care workers; and 342 older adults with dementia. A multilevel regression analysis was conducted using the MPlus 8.0 program. Results. Among intrapersonal factors, age, cognitive function, activities of daily living, and number of beds in the facility were identified as affecting mealtime difficulty. Environmental factors included meal assistant education experience and whether an environment suitable for eating had been established. Conclusion(s). The results show that intrapersonal factors exert a large influence on the mealtime difficulties of older adults with dementia in long-term care facilities and support the need to improve environmental factors, which are modifiable. Implications for Nursing Management. This study provided useful information about the influence of leaders on mealtime difficulties in older adults with dementia. Leaders should establish an environment in the facility for reduced mealtime difficulties.
... Mealtimes and dining with others in residential care (e.g., retirement home, assisted living, and long-term care homes) offer unique opportunities to foster a sense of community and reinforce residents' autonomy through involvement in meaningful meal-related activities (Genoe et al., 2010;Gibbs-Ward & Keller, 2005;Henkusens, Keller, Dupuis, & Schindel Martin, 2014). The dining room is often the central focal point in many residential care homes, as this space and activity support the development and reinforcement of relationships amongst those who live and work in these homes, particularly for those residents living with dementia (Campo & Chaudhury, 2012). ...
This study describes changes in dining practices and provider perspectives on meal-related challenges due to the coronavirus disease (COVID-19) pandemic. An online survey was disseminated between July and September 2020 through stakeholder networks and social media with 1,036 respondents. Altered dining practices included residents eating in rooms (54.3%), spacing residents in common areas for meals (69.3%), and disposable dish use (44.9%). The most common mealtime challenges were reduced socializing opportunities at meals (29.3%), inadequate staffing (22.8%), reduced family/volunteer help (16.7%), and assisting residents to eat (10.5%). Many participants (72.2%) felt conflict balancing safety and relationship-centred care. Geographic region, home size, building age, respondent’s job title, pre-pandemic relationship-centred practices, and mealtime satisfaction, and some pandemic-initiated practices were associated with mealtime challenges and feeling conflicted in binary logistic regression analyses. Considering trade-offs between safety and relational aspects of mealtimes during the pandemic is crucial.
... Caring [25] Where individuals with varying levels of dementia ate together without the staff, the person with lower dementia became the caregiver to those with severe dementia [7] Individualising feeding assistance one-to-one; activating the primary nurse in mealtime care; the same carer feeding the patient; enhancing the quality of the interaction between the dyad; offering touch, guidance, redirection, providing compassionate care; offering mealtime assistance [7,8,10,27,32] Reducing the separation of eating from meal preparation especially for older woman; engaging in meal creation that may stimulate the appetite; food prepared in areas adjacent to or in dining area to stimulate appetite [21,23,25,27] Enhancing dining programmes at NH level; incorporating nutrition as part of good quality care; training staff; offering feeding skills training programmes [10,21] Changing food service and routines, offering feeding assistance; a training programme on dementia care including supervision sessions and work groups and an environmental redesign; assessing the entire process (e.g. nutritional supplements, changes in food provision) and training carers [31,32] Feeding difficulties [34] Mealtime difficulties [33] Socio-ecological model [46,47] Mealtimes as active processes [48] Five Aspects of Meal Model [49] Making ...
Background:
Addressing eating difficulties among older individuals with dementia living in nursing homes requires evidence-based interventions. However, to date, there is limited evidence of effective interventions designed to maintain and/or increase independent eating. In a field in which evidence is still lacking, a critical analysis of the state of research describing its main features can help identify methodological gaps that future studies should address. Hence, the aim of this study was to map the state of the research designed to maintain and/or promote independent eating in older individuals with dementia living in nursing homes.
Methods:
A scoping review was performed by following the Preferred Reporting Items for Systematic Reviews and Meta-analyses. Reviews and conceptual analyses performed with different methodological approaches, published in indexed journals, and written in English were included. Keywords Were searched for in the MEDLINE, the Cumulative Index of Nursing and Allied Health, and in the Scopus databases to identify papers published up to 31 May 2018.
Results:
17 reviews were included, assessing interventions' effectiveness (n = 15) and providing conceptual frameworks for eating/mealtime difficulties (n = 2). Conceptual frameworks supporting interventions' effectiveness have rarely been described in available studies. Moreover, interventions tested have been categorized according to non-homogeneous frameworks. Their effectiveness has been measured against (1) eating performance, (2) clinical outcomes, and (3) adverse event occurrence.
Conclusion:
An increased use of conceptual frameworks in studies, as well as greater clarity in intervention categorization and outcomes, is necessary to enhance the reviews' value in providing useful cumulative knowledge in this field. Interventions delivered should embody different components that integrate individual, social, cultural, and environmental factors, while when evaluating an intervention's effectiveness, eating performance, clinical outcomes and adverse events should be considered. Together with more robust studies, involving clinicians could prove to be useful, as their knowledge of practice developed from direct experience can help develop innovative research questions.
... To promote person-centered dining culture, staff could periodically join residents for meals, and facilitate mealtime conversations among residents, to reminisce about food traditions and favorite recipes. Gibbs-Ward and Keller 31 found that participants in their study-residents in special care units of LTC communities-were likely to respond to social ques of caregivers, but were less likely to initiate conversation, themselves. Residential activities could also include cooking demonstrations as a way to familiarize residents and dining staff, and build trust in staff skills, ingredients, and food quality. ...
This study investigated barriers to fulfilling food preferences from nursing home (NH) residents’ perspectives, and the reasons preferences changed (situational dependencies). Interviews were completed with 255 residents in 28 NHs across greater Philadelphia, PA using six food items from the Preferences for Everyday Living Inventory-NH (PELI-NH). Participants were predominantly white (77%), female (67.8%), and widowed (44%) with high school educations (48%). Content analysis was used to identify n = 386 barriers and n = 57 situational dependencies. Participants reported provider policies and staff proficiency as environmental barriers to preference fulfillment regarding what, when, and where to eat. Perceived health and personal resources were barriers to obtaining snacks, take-out, and dining out. Situational dependencies resulted from residents’ perceived health and quality of family relationships. Results have implications for providers to centralize food preference fulfillment in care planning, and to use food preferences to address dining quality concerns.
... The majority of patients with tube feeding complain of distress regarding the gustatory deprivation experiences related to drinking liquids, chewing, tasting and swallowing food, exposure to unsatisfied appetites for certain food and forbidden foods, the experiences of dry mouth and thirst (17). In addition, there is the suffering related to the deprivation of social activities usually associated with having food together with friends and relatives (18). ...
Nutritional support for patients with esophagectomy is very important especially for patients with malnutrition. But there is significant variation in nutritional support between different hospitals. Traditionally, 5 to 7 days of nil by mouth is required to allow healing of the anastomosis after esophagectomy; a feeding tube (usually jejunostomy tube) placed before or during the operation provides enteral access for patients with esophagectomy. However, there is no consensus of the timing of oral intake after esophagectomy. We reviewed the published data about early oral feeding (EOF) after esophagectomy. At present, there were only four studies, including two randomized studies, investigating the feasibility and safety of EOF for patients with esophagectomy. The results of the current studies show that EOF after esophagectomy do not increase postoperative complications and motility. However, evidence from large multicenter randomized controlled clinical trials is still lacking. In the future, the long-term outcomes, including body weight loss, quality of life (QOL), laboratory nutritional markers and survival, should be investigated in the field of EOF protocols. EOF after esophagectomy may require the application of the most recent knowledge and the perioperative practice of multi-disciplinary team medical care, according to the situation of each medical center.
... 45 Furthermore, according to the ethics of care, 32 in the three cases that emerged, HCPs did not pay moral attention to the complexity of the situation and the adoption of negative prompts suggests that eating assistance was perceived as a routine task among others. Similarly, in accordance with previous studies, 46 HCPs failed to recognise the importance of the psychosocial aspects of mealtimes and, given that all cases emerged from focus groups and not from singular interviews, factors at the NH levels could have played a strong influence in shaping mealtime interventions, for example, NH policies are often task-oriented aimed at guaranteeing adequate caloric intake, 47 thus threatening other dimensions of mealtime. ...
Background:
Psychological abuse of older people is difficult to recognise; specifically, nursing home residents have been documented to be at higher risk of psychological abuse during daily care, such as during feeding. Healthcare professionals adopt positive and negative verbal prompts to maintain residents' eating independence; however, negative prompts' purposes and implications have never been discussed to date.
Research aims:
To critically analyse negative verbal prompts given during mealtimes as forms of abuse of older individuals and violation of ethical principles.
Research design:
This is a secondary analysis of three cases of negative prompts that emerged in a large descriptive study based upon focus group methodology and involving 13 nursing homes and 54 healthcare professionals.
Participants and research context:
This study included 3 out of 13 nursing homes caring for residents with moderate/severe functional dependence in self-feeding mainly due to dementia; in these nursing homes, we conducted three focus groups and 13 healthcare professionals participated.
Ethical considerations:
This study was conducted in accordance with the Human Subject Research Ethics Committee guidelines after being approved by the Review Board of the Trust.
Findings:
With the intent of maintaining self-feeding independence, negative verbal prompts have been reported as being used by nursing home teams. By critically analysing these negative prompts, it turned out they could trigger intimidation, depression and anxiety and thus could be considered as forms of abuse; moreover, negative prompts can threaten the ethical principles of (1) autonomy using a paternalist approach, (2) beneficence and non-maleficence as with the intent to act in the best interests of residents (to maintain self-feeding independence) they are harmed in their dignity and (3) justice, given that residents who received negative prompts are treated differently from those who received positive prompts.
Discussion:
Eating should be a pleasant experience with a positive impact on physiological, psychological and social well-being. However, negative prompting can lead to abuse and violation of basic ethical principles, destroying the healthcare professional resident and relative relationships strongly dependent on trust.
Conclusion:
Negative verbal prompting must be avoided.
... A recent study in a Canadian facility found that only 1 in 10 (11%) residents were well nourished; more than half (58%) residents were at risk for malnutrition, and about one-third (31%) were malnourished (Boström et al., 2011). Numerous studies have reported not only concerns of nutritional care, but also limited social interactions among residents in the dining rooms of long-term care facilities (Curle & Keller, 2010;Gibbs-Ward & Keller, 2005;Whear et al., 2014). Mealtimes are not only nutritionally important, but also have powerful personal, social, and cultural meanings. ...
Objective: To describe and present reliability statistics of
DEAP. DEAP is used to assess the physical environmental features
of a dining area. Safety, security and accessibility are key
features of this tool, which was initially developed for LTC
environments, specifically for persons with dementia.
Method: With two trained raters, inter-rater reliability was
tested in 10 different dining areas in three LTC homes (70%
dementia units). Two scales (1 low–8 high) were used to rate
home-likeness and functionality of the space in an empty dining
room. Intra-class correlation (ICC) was used to determine
reliability.
Results: ICC was 0.68 for home-likeness and 0.70 for functionality
of the space. Dining rooms had 9.7 ± 1.2 tables
(mean ± SD), 19.4 ± 3.5 chairs, 2.6 ± 1.4 stools for staff, and
2.1 ± 0.32 entry/exit ways. Common features of the physical
environment were: good contrast between table and dishes
(80%); posted menu (100%), accessible washroom for residents
nearby (90%); secured kitchen, stove, and non-edibles/
detergent (100%); accessible kitchen for residents/family
(100%); servery/pass through not accessible for residents/
family (80%); dining room open between meals (50%); 50%
or more of residents can view gardens from dining area
(50%). The following features were relatively uncommon:
short distance to bedrooms; dining room visually accessible
from bedrooms; accessible beverage service; clock (only in 10%);
rounded edges of furniture; adjustable tables (only in 10%); and
contrast between the table and floor (only in 20%). Mean
score for functionality was 5.3 ± 0.82, while the score for
home-likeness was lower at 3.5 ± 1.35.
Implications & Conclusions: The DEAP is the first reliable
tool to rate the physical features of LTC dining areas and
can assist with enhancing the eating environment. It was subsequently
used in the Making the Most of Mealtimes prevalence
study to characterize dining areas.
... A recent study in a Canadian facility found that only 1 in 10 (11%) residents were well nourished; more than half (58%) residents were at risk for malnutrition, and about one-third (31%) were malnourished (Boström et al., 2011). Numerous studies have reported not only concerns of nutritional care, but also limited social interactions among residents in the dining rooms of long-term care facilities (Curle & Keller, 2010;Gibbs-Ward & Keller, 2005;Whear et al., 2014). Mealtimes are not only nutritionally important, but also have powerful personal, social, and cultural meanings. ...
Purpose:
This paper presents the first standardized physical environmental assessment tool titled Dining Environment Audit Protocol (DEAP) specifically designed for dining spaces in care homes and reports the results of its psychometric properties. Items rated include: adequacy of lighting, glare, personal control, clutter, staff supervision support, restraint use, and seating arrangement option for social interaction. Two scales summarize the prior items and rate the overall homelikeness and functionality of the space.
Methods:
Ten dining rooms in three long-term care homes were selected for assessment. Data were collected over 11 days across 5 weeks. Two trained assessors completed DEAP independently on the same day. Interrater-reliability was completed for lighting, glare, space, homelike aspects, seating arrangements and the two summary scales, homelikeness and functionality of the space. For categorical measures, measure responses were dichotomized at logical points and Cohen's Kappa and concordance on ratings were determined.
Results:
The two overall rating scales on homelikeness and functionality of space were found to be reliable intraclass correlation coefficient (ICC) (~0.7). The mean rating for homelikeness for Assessor 1 was 3.5 (SD 1.35) and for functionality of the room was 5.3. (SD 0.82; median 5.5).
Implications:
The findings indicate that the tool's interrater-reliability scores are promising. The high concordance on the overall scores for homelikeness and functionality is indicative of the strength of the individual items in generating a reliable global assessment score on these two important aspects of the dining space.
... It is also possible that this topic was influenced by the three groups' living situations and opportunities for social interaction, e.g. the SA group might have the ability to "go out" more. The importance of food and mealtime setting for older adults has been previously described [25,26]. Furthermore, experiencing gut health was discussed as an important factor for optimal functionality, however, in contrast to previous research from our group this was not discussed by the SA [27]. ...
Background:
Decreased independence and loss of functional ability are issues regarded as inevitably connected to old age. This ageism may have negative influences on older adults' beliefs about aging, making it difficult for them to focus on their current ability to maintain a good health. It is therefore important to change focus towards promoting Optimal Functionality (OF). OF is a concept putting the older adult's perspective on health and function in focus, however, the concept is still under development. Hence, the aim was to extend the concept of optimal functionality in various groups of older adults.
Methods:
A qualitative study was conducted based on focus group discussions (FGD). In total 6 FGDs were performed, including 37 older adults from three different groups: group 1) senior athletes, group 2) free living older adults, group 3) older adults living in senior living homes. All data was transcribed verbatim and analyzed following the process of deductive content analysis.
Results:
The principal outcome of the analysis was "to function as optimally as you possibly can", which was perceived as the core of the concept. Further, the concept of OF was described as multifactorial and several new factors could be added to the original model of OF. Additionally the findings of the study support that all three cornerstones comprising OF have to occur simultaneously in order for the older adult to function as optimal as possible.
Conclusions:
OF is a multifaceted and subjective concept, which should be individually defined by the older adult. This study further makes evident that older adults as a group are heterogeneous in terms of their preferences and views on health and should thus be approached as such in the health care setting. Therefore it is important to promote an individualized approach as a base when caring for older adults.
... Community-based dining dervices: From the perspectives of culture and health A common Chinese saying is that "food is living" (Min yi shi wei tian). In other words, meals not only satisfy our biological needs but have strong social and cultural meaning related to food preparation and a shared social experience (Gibbs-Ward & Keller, 2005). The dining service in the service centers paired with the nutritional meals has spurred a strong demand among the elderly in Shanghai and has been the focal point of communitybased eldercare for the Shanghai government (Shanghai Civil Affairs Bureau, 2008). ...
Facing dramatic growth in its elderly population, Shanghai, China's economic center, has strategically exercised decentralized policy-making power to develop community-based service centers for the elderly. A growing number of elders have been using such services, particular dining services, since 2007. We discuss the evolution in community-based elder care services in Shanghai, using dining services as an example. We also compare these service centers in Shanghai to multipurpose senior centers in the United States to offer policy recommendations for Shanghai and China's growing elder care industry. Tailored policy recommendations are discussed.
... Independent eating performance also promotes food enjoyment and social interaction during mealtimes, and helps maintain range of motion in upper extremities among residents. 15,16 In addition, it is likely that optimal self-feeding performance may help to improve overall intake and nutritional status, and optimize weight management for those who are under-or overweight. 17 ...
The objective of this study was to evaluate the impact of a well-developed theory-based function-focused care for cognitively impaired (FFC-CI) intervention on eating performance among long-term care (LTC) residents with moderate-to-severe cognitive impairment.
A secondary analysis of longitudinal data from 2 cluster-randomized controlled trials that originally tested the impact of FFC-CI on all function and physical activities.
Participants were 199 residents with moderate-to-severe cognitive impairment from 4 nursing homes and 4 assisted living facilities.
Data at baseline, and 3 and 6 months were used. Resident outcome data used in this analysis included eating performance conceptualized using the single self-care "feeding" item in the Barthel Index, cognitive function by Mini-Mental State Examination, sitting balance conceptualized using the single "chair sit-sitting balance" item in the Tinetti Gait and Balance scale, physical capability by Physical Capability Scale, depression by Cornell Scale for Depression in Dementia, and agitation by Cohen-Mansfield Agitation Inventory (short form).
At baseline, almost one-third (32.2%) of the 199 residents needed help with eating. There was no significant change with regard to eating performance over time in both groups, and no significant treatment by time difference between groups in eating performance (P = .195).
Current findings support a need to revise the FFC-CI to better address eating performance. Future work may benefit from a stronger focus on eating performance rather than the more commonly addressed functional tasks, such as bathing, dressing, and ambulation. In addition, the inclusion of a more heterogeneous group of LTC residents with regard to eating performance is needed to test the impact of the revised approach on eating performance.
Copyright © 2015 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.
... Factors like individual preferences and choices of the residents were emphasised in the current study, especially in order to improve the mealtime ambience. Gibbs-Ward and Keller reported that an optimal mealtime experience requires individualised care, which in turn promotes autonomy, as well as dietary intake, and a better quality of life (39). In addition, the staff at the EF units decided to make mealtime ambience a priority for change, and thus, the EF strategy was amenable to the staff's motivation. ...
Studies on implementation techniques that focus on nutrition in the setting of elderly care are scarce. The aims of this study were to compare two implementation strategies i.e., external facilitation (EF) and educational outreach visits (EOVs), in order to introduce nutritional guidelines (e.g. screening, food quality and mealtime ambience), into a nursing home (NH) setting and to evaluate the clinical outcomes.
A controlled study with baseline and follow-up measurements.
Four NHs.
A total of 101 NH residents.
The EF was a one-year, multifaceted intervention that included support, guidance, practice audits, and feedback that were provided to two NHs. The EOVs performed at the other NHs consisted of one session of three hours of lectures about the guidelines. Both interventions targeted a team of the unit manager, the head nurse, and 5-10 of the care staff.
The outcomes were nutritional status (Mini Nutritional Assessment-Short Form, MNA-SF), body mass index (BMI), functional ability (Barthel Index, BI), cognitive function (Short Portable Mental Status Questionnaire, SPMSQ, performed in a subgroup of communicative NH residents), health-related quality of life (EQ-5D), and the levels of certain biochemical markers like for example vitamin D, albumin and insulin-like growth factor 1.
After a median of 18 months, nutritional parameters (MNA-SF and BMI) remained unchanged in both groups. While there were no differences in most outcomes between the two groups, the cognitive ability of those in the EOV group deteriorated more than in individuals in the EF group (p=0.008). Multiple linear regression analyses indicated that the intervention group assignment (EF) was independently from other potentially related factors associated with less cognitive decline.
An extended model of implementation of nutritional guidelines, including guidance and feedback to NH staff, did not affect nutritional status but may be associated with a delayed cognitive decline in communicative NH residents.
... stress, social support, and feeling less isolated (20). As mealtime experiences encompass all of the social and physical interactions between individuals and their environment (7,(62)(63)(64)(65), several outcomes are plausible and potentially as relevant and meaningful as food intake for the LTC environment. For example, in one of the most rigorous and successful intervention studies to date in LTC, Nijs and colleagues demonstrated that implementing a multicomponent intervention described as ''family style dining'' that included physical (e.g., table set up) and psychosocial environmental changes (e.g., tablemate interactions) and staff training, resulted in improved food intake, body weight, and maintained quality of life and physical performance in persons without dementia (18,48). ...
Poor food intake in residents living in long-term care (LTC) homes is a common problem. The mealtime experience is known to be important in the multifactorial causes of food intake. Diverse interventions have been developed, implemented, and/or evaluated to improve the mealtime experience in LTC; it is possible that multicomponent interventions will have a greater benefit than single activities. To identify the range of feasible and potentially useful interventions for including in a multicomponent intervention, this scoping review identified and summarized 58 studies that described and/or evaluated mealtime experience interventions. There were several randomized controlled trials, although most studies used less rigorous methods. Interventions that are multicomponent (e.g., food service, dining environment, staff education) and target multilevel factors (e.g., residents, staff) in LTC appear to be feasible, with a variety of outcomes measured. Further research is still needed with more rigorously designed studies, confirming effectiveness, feasible implementation, and scaling up of efficacious interventions.
... Organizational factors that have been found to impact resident outcomes are: staffing patterns, type of ownership (not-for-profit versus for-profit), chain affiliation, resident room size, privacy, noise, number of beds, and amount of time spent with residents by the nursing home staff (Castle & Mor, 1998;Copeman, 2000;Duncan Forbes-Thomson, & Bott, 2008;Kayser-Jones, Schell, Lyones, Kris, Chan & Beard, 2003). Organizational factors shown to impact resident food consumption are: the physical environment of the dining room (Mathey, Vanneste, deGraff, deGroot, & van Staveren, 2001;Roberts & Durnbaugh, 2002), lack of assistance and encouragement (Simmons & Patel, 2006), inadequate number of staff (Dyck, 2007;Kayser-Jones, 1997;Kayser-Jones & Schnell, 1997;Woo, Chi, Hui, Chan, & Sham, 2005), lack of leadership and supervision in the dining room (Gibbs-Ward & Keller, 2005;Kayser-Jones et al, 2003), incorrect documentation (Scnhelle, Bates-Jensen, Chu, & Simmons, 2004), quality of nursing staff and resident interaction (Pearson, Fitzgerald, & Nay, 2003;Schell & Kayser-Jones, 1999;Remsburg, 2004), staff's feeding beliefs (Crogan & Shultz, 2000;Pelletier, 2005), and inadequate nutrition knowledge in nurses (Crogan & Shultz, 2000;Crogan, Shultz, & Massey, 2001;Kayser-Jones & Schell, 1997;Lindseth, 1994;Pelletier, 2005;Perry, 1997;Schnelle, Bates-Jensen, Chu, & Simmons, 2004). ...
... The rituals and activities surrounding food eating can also provide a link to personal identity (Evans, Crogan & Shultz, 2005). Previous studies have reported that nursing staff in care facilities tend to focus on the mechanical task of feeding but overlook the individual needs and psychosocial aspects of residents' experiences during mealtimes (Gibbs-Ward & Keller, 2005;Moore, 2004;Pearson, FitzGerald & Nay, 2003;Schell & Kayser-Jones, 1999;Sydner & Fjellström, 2005). As Savishinsky (2003) described, food in nursing homes can become merely a medicalized commodity, clinicians focusing mainly in terms of what and how much goes into and out of the body but overlooking the individual preferences and psychosocial aspects of the experience for the residents. ...
Despite the shift toward using person-centered approaches in dementia care, the relevance and applicability of the concept “personhood” remains unclear in everyday practice and activities, such as mealtime experience for residents with dementia. Based on a qualitative study, this paper presents emergent themes at mealtimes that support or undermine personhood of twenty residents with dementia in two long-term care facilities. Methods of data collection included conversational interviews with residents with dementia, participant observations, focus groups with staff and examination of available documents. Data analysis identified eight themes: (1) outpacing/relaxed pace, (2) withholding/holding, (3) stimulation, (4) disrespect/respect, (5) invalidation/validation, (6) distancing/connecting, (7) disempowerment/empowerment, and (8) ignoring/inclusion. These findings raised questions about current practice and identified areas for improvement. Although staff approaches seemed to have the greatest impact on residents' experiences, the physical environment and organizational milieu were also responsible for hindering and facilitating staff to provide the best possible care and interaction.
Background
Mealtimes are embedded routines of residents living in residential aged care facilities (RACFs) that directly impact their health and quality of life. Little is known about how mealtime experiences are informed and affected by structures such as government and organisational policies and processes. This scoping review used Giddens’ (The constitution of society: outline of the theory of structuration, 1984) Structuration Theory to investigate how governance structures related to mealtime practices inform residents’ mealtime experiences.
Methods
Using Arksey and O’Malley’s (Int J Soc Res Methodol 8:19–32, 2005) scoping review framework, a systematic database, grey literature and policy search was completed in May 2020 and updated in July 2021. From 2725 identified articles, 137 articles were included in data charting and deductive analysis, and 76 additional Australian government policy papers were used interpretatively.
Results
Data charting identified that the included studies were prominently situated in Western countries, with a progressive increase in publication rate over the past two decades. Qualitative findings captured structures that guide RACF mealtimes, how these relate to person-centred mealtime practices, and how these facilitate residents to enact choice and control.
Conclusions
Current policies lack specificity to inform the specific structures and practices of RACF mealtimes. Staff, residents, organisational and governance representatives possess different signification, legitimation and domination structures, and lack a shared understanding of policy, and how this influences processes and practices that comprise mealtimes.
Background The care home sector provides 24-hour residential care or nursing care to more than 450,000 vulnerable older people in the UK with complex needs and high levels of dependency. These services face many challenges in relation to funding, increasing demand, staff shortages and relying on an unregistered workforce with almost 40% possessing no qualifications. Care homes present a unique setting that provides care to individuals at significant risk of harm but has received little attention or research. Care homes provide a particularly rich context in which to study safety, as they are inherently complex organisations that have historically suffered many catastrophic failures and scandals and continue to struggle to achieve safety goals. It was widely accepted that organisational culture was important for patient safety. Both the organisational culture and patient safety literature have been dominated by the positivist assumption that organisations are part of an external reality that can be both measured and manipulated. Many scholars now argue that positivist approaches do not reflect the complexity of contemporary organisations as they only capture the very surface of organisational cultures. The deeper levels of organisational culture and its impact upon safety have received little exploration in the patient safety literature and have not before been explored in the context of care homes. Aim The thesis aimed to empirically explore organisational culture and how this related to safety in care homes. The thesis focused on how residents, relatives and staff in this context made sense of their reality by investigating the basic underlying assumptions that underpin human perception and behaviour, specifically in relation to quality and safety. Through this exploration the thesis also captured how different groups contributed to and negotiated quality and safety. Research Question The thesis addressed the central research question: • How do employees, residents and relatives give meaning to and value issues of safety in care homes? Methodology The thesis aligned with the interpretive paradigm and adopted an ethnographic case study approach within the care home sector. Over 200 hours of observations and interviews with 50 participants took place across two care homes between January – December 2018. Inductive thematic analysis was used to analyse both interview and observational data. Research Gaps and Intended Contribution This study adds to the limited evidence base through its interpretive, ethnographic approach, accepted as a method suited to achieving a deeper level of cultural analysis. The approach taken has not previously been used to address safety in the care home sector, which presented a setting that was theoretically and empirically distinguished from mainstream care settings. Due to the under-researched nature of this care setting the study also enabled theoretical contribution to the patient safety literature. The findings from this study make a contribution to current debates around care home policy and practice, which was of particular relevance given the recent impact of the COVID-19 pandemic upon the care home sector. The thesis makes a new contribution to the literature around patient safety by presenting a conceptual understanding of how culture relates to safety in care homes that comprises of Uncertainty, Identity and Role, Responsibility and Relationships. My study argues that within care homes there was a disconnect between the formal culture and approaches, and the informal culture within the care home. The study has highlighted that traditional patient safety orthodox approaches being used within care homes may be inappropriate due to the unpredictability and the assumptions that underpin how people give meaning to and value safety in care homes. Moreover, my study has shown that safety in care homes was achieved through attempts to get to know residents, focusing on their identity, building relationships and the importance of promoting resident autonomy and responsibility for their own safety.
Background. Mealtimes are embedded routines of residents living in residential aged care facilities (RACFs) that directly impacts their health and quality of life. Little is known about how mealtime experiences are informed and affected by structures such as government and organisational policies and processes. This scoping review used Gidden’s (1984) Structuration Theory to investigate how governance structures related to mealtime practices inform residents’ mealtime experiences.
Methods. Using Arksey and O’Malley’s (2005) scoping review framework, a systematic database, grey literature and policy search was completed in May 2020 and updated in July 2021. From 2725 identified articles, 137 articles were included for in data charting and deductive analysis, and 76 additional Australian government policy papers were used interpretatively.
Results. Data charting identified that the included studies were prominently situated in Western countries, with a progressive increase in publication rate over the past two decades. Qualitative findings captured structures that guide RACF mealtimes, how these relate to person-centred mealtime practices, and how these facilitate residents to enact choice and control.
Conclusions. Current policies lack specificity to inform the specific structures and practices of RACF mealtimes. Staff, residents, organisational and governance representatives possess different signification, legitimation and domination structures, and lack a shared understanding of policy, and how this influences processes and practices that comprise mealtimes.
Using valid instruments to measure dyadic interactions and physical and social environment during mealtime care of persons with dementia is critical to evaluate the process, fidelity, and impact of mealtime interventions. However, the characteristics and quality of existing instruments remain unexplored. This systematic review described the characteristics and synthesized the psychometric quality of instruments originally developed or later modified to measure mealtime dyadic interactions and physical and/or social dining environment for people with dementia, on the basis of published reports between January 1, 1980 and December 31, 2020. We identified 26 instruments: 17 assessed dyadic interactions, one assessed physical environment, and eight assessed physical and social environment. All instruments were used in research and none in clinical practice. All instruments were observational tools and scored as having low psychometric quality, except for the refined Cue Utilization and Engagement in Dementia (CUED) mealtime video-coding scheme rated as having moderate quality. Reasons for low quality are the use of small samples compared with the number of items, limited psychometric testing, and inadequate estimates. All existing tools warrant further testing in larger diverse samples in varied settings and validation for use in clinical practice. The refined CUED is a potential tool for use and requires testing in direct on-site observations.
Background
As dementia progresses, people with dementia experience many problems during mealtimes that seriously affect their physical, psychological, and social health and quality of life. Formal caregivers play an important role in optimizing mealtime care.
Objective
To systematically review and synthesise relevant qualitative studies exploring the experience and perceptions of formal caregivers regarding optimizing mealtime care for people with dementia.
Design
A systematic review of qualitative research.
Data sources
The PubMed, Web of Science, Cochrane Library, Embase, CINAHL, CNKI, WanFang and Vip databases were systematically searched.
Review methods
Two reviewers independently screened the titles and abstracts, extracted the data and performed critical appraisals of each included study. The data synthesis was conducted using thematic analysis.
Findings
A total of 10 studies were included. The formal caregivers included nursing assistants, nurses, speech and language therapists, nursing students, dietitians, social worker, professional educator, physiotherapists, health care aides, kitchen staff, diversional therapy assistants and other unidentified care staff. The findings were synthesised into the following 3 analytical themes: (1) tailored rather than standardized; (2) emotional nurturance; and (3) beyond the individual level.
Conclusions
Mealtimes involve complex physiological and psychological processes. Formal caregivers should develop tailored care practices based on individual patients’ preferences and needs. Emotional connection plays a key role and has a positive impact on the mealtime experience. Further research is needed to explore the specific effects of emotional connections on optimizing mealtime care.
Although early oral feeding (EOF) is an element often included in enhanced recovery protocols after gastrointestinal surgery, there is no consensus regarding when to resume oral feeding after esophagectomy. Restoration of alimentary continuity following an esophagectomy requires an esophagoenteric anastomosis that is perforce located in the proximal upper gastrointestinal tract. Traditionally, 1 week or longer of nil by mouth is maintained postoperatively for anastomotic healing; during this period a feeding tube (jejunostomy tube or nasointestinal tube) is placed to provide enteral nutrition. At present, there are only five studies, including three randomized clinical trials, that investigate the feasibility and safety of EOF for patients recovering from an esophagectomy. The results of the current studies suggest that EOF protocols do not increase postoperative complications, can shorten the length of postoperative stay, and improve short-term quality of life for patients with esophagectomy. However, evidence from large multi-center randomized controlled clinical trial is still lacking. The ideal route for resuming enteral nutrition in the early post-operative period remains unclear.
This chapter summarizes how HCBS influences community care ecology for older adults in Shanghai. Through the HCBS program, older adults interact with the macro, meso, and micro levels of the community ecology, respectively. Informed by community gerontology and the social-ecological framework, this chapter reviews the previous chapters and illustrates how the HCBS program encompasses and unites these three levels, producing a community care ecology for older adults. The chapter concludes with suggestions for future directions in eldercare policy and practice development in Shanghai.
Throughout ageing, it becomes difficult to consume sufficient protein to prevent protein energy undernutrition. Finding solutions to assist older adults in reaching optimal protein intake is necessary. This thesis describes our efforts to increase protein intake of older adults by using protein-enriched meals.
By first asking both professionals and older adults about the requirements for such meals, we aimed to stay close to the needs and preferences of older adults who are at risk of undernutrition. Using this knowledge, we then developed protein-enriched meals, which turned out to be highly liked by our elderly participants and indeed led to a higher protein intake. These promising findings indicated that we achieved a good match between older adults’ needs and preferences regarding protein intake. Still, we propose three necessary conditions to successfully manage undernutrition: address awareness in both older adults and professionals, facilitate continuous collaboration between professionals, and offer protein-enriched products expediently.
Aims and objectives:
To investigate the effectiveness of spaced retrieval for improving hyperphagia in patients with dementia in residential care settings.
Background:
Although 10-30% of patients with dementia have hyperphagia, most studies have focused on eating difficulties. Only a few studies have focused on hyperphagia. Various memory problems cause hyperphagia in patients with dementia. Spaced retrieval, a cognitive technique for information learning, can be used as a training method to improve memory loss. Recent studies showed that patients who received the training successfully memorised information learned in the training and correctly applied it to their daily lives.
Study design:
Single-blind experiments were performed.
Methods:
The 97 subjects with dementia were recruited from seven institutions. All research participants were stratified into three groups according to cognitive impairment severity and Hyperphagic Behavior Scale scores and then randomly assigned to the experimental and control groups. The experimental group received a six-week one-by-one spaced retrieval training for hyperphagia behaviour. The control group received routine care.
Results:
After the intervention, the frequency and severity of hyperphagia in the patients with dementia, and food intake were significantly lower in the experimental group than in the control group. However, body mass index did not significantly differ.
Conclusion:
Our results suggest that the spaced retrieval training could decrease the frequency and severity of hyperphagia in patients with dementia. The content of this training programme is consistent with the normal manner of eating in daily life and is easy for patients to understand and perform. Therefore, it can be applied in residents' daily lives.
Relevance to clinical practice:
This study confirms the efficacy of the spaced retrieval training protocol for hyperphagia in patients with dementia. In future studies, the follow-up duration can be increased to determine the long-term effectiveness of the intervention.
Lynn Malloy shared her views on studies on the mealtime experience for people with dementia informal care settings. She specifically focused on the measures that potentially helped mealtimes to provide food for the soul, energy and strength for the body, and the importance of guidance and emotional support for care staff. She focused on the five categories of interventions that emerged from the thirteen reviewed studies. Four of the studies explored the dining room environment or how meals were served and whether changes made a difference to the amount of food eaten, interaction levels, and levels of agitation. Two studies explored the use of listening to music during mealtimes and the impact on calorie intake or the percentage of food eaten. One of the studies was also interested in exploring the use of music on agitation levels in residents and to explore a possible correlation between agitation and the amount of food consumed.
Evidence-based clinical interventions to prevent and treat unintentional weight loss in elderly persons are outlined in the literature, but evidence-based strategies on the organizational level are less readily available and are therefore underutilized. Yet evidence-based organizational strategies have the potential to improve resident care to a far greater extent than clinical interventions implemented by a single healthcare professional treating individual residents. In this article, the authors discuss evidence-based organizational strategies to prevent weight loss in frail elders residing in long-term care settings. The organizational strategies reviewed focus on staffing, planning, leadership/supervisory, educational, environmental, and interdisciplinary interventions. Based on their findings, the authors conclude that nurse leaders need to be more aggressive in implementing management and leadership decisions that are evidence-based and lead to organizational improvements.
Food and mealtimes should be adapted to the older person's individual needs and desires, a fact that is often ignored in favour of a functional mealtime organisation. This study was grounded in participatory action research (PAR), and the aim of the study was to illuminate a PAR process to assist care providers in constructively dealing with their troubled conscience generated from perceived shortcomings in providing an individualised meal schedule in residential care for older people. Care providers and their manager participated in twelve PAR sessions. The participants' troubled conscience was eased by reflecting on and sharing their thoughts about their perception of a lack of individualised meal schedule and a lack of opportunities for meaningful interventions. The researchers in PAR became the bridge between the care providers and the management that was needed to improve individualised mealtime schedule. This study pinpoints how difficult it can be to make small changes in a rigid organisation that is run by a management that does not have the hands-on knowledge about the daily care provided by the organisation. This study points to the need of creating communication arenas wherein all personnel involved in care for older people, at all organisational levels, together meet to create a good care for older people. However, the care providers have been provided with tools, uncomplicated to use, to continue to let their voices being heard.
© 2015 Nordic College of Caring Science.
Aim: To investigate the foodservice, menu and meals in the aged-care residential setting to identify promoters and barriers to achieving optimum nutrition.
Method: An observational study conducted by the University of Otago Dietetic Training Programme. Rest home dietitians around New Zealand identified a final convenience sample of 50 facilities. Ten final-year student dietitians each spent two days in their designated rest homes, administering a 19-item questionnaire to ascertain practices relating to staffing, dining environment, menu, meals, snacks, feeding assistance, fluids, special diets, nutrition care, medications, nutrition policy and access to sunlight. Observations describing foodservice and meal-related activities only are reported in this paper.
Results: Most rest homes had the ability to provide for the needs of residents. Ninety per cent of facilities offered menu cycles of at least four weeks long. Potential barriers to meeting needs were inadequate amounts of protein-rich food for numbers served and lack of perceived choice in menus and meal service. Lack of foodservice staff training and poor uptake of training opportunities contributed to these barriers.
Conclusions: This is the first such study conducted in New Zealand. Results should be of interest to the Ministry of Health and district health boards that are charged with the responsibility to ensure that meals in long-term care facilities meet the nutritional needs of this potentially vulnerable population. Shortcomings identified in the present study require a multidisciplinary approach that should include district health boards, auditing agencies, aged-care organisations, training providers and dietitians.
interdisciplinary teams are a particularly appropriate way to organize health care for geriatric patients, who typically have complex, chronic problems / the interdisciplinary team provides care in which several disciplines coordinate assessment and treatment so that problems can be dealt with consistently and comprehensively / interdisciplinary teams are characterized by a nonhierarchical organization in which responsibility for the effective functioning of the team is shared by all team members / this requires that team members be excellent representatives of and advocates for their disciplines / it also requires that team members have training in team theory, leadership skills, and communication skills, including conflict resolution skills
[suggest that] interdisciplinary teams are committed to the idea that patients will be best served when their care is coordinated and provided by team members who learn from each other, rely on each other, and are willing to challenge each other when appropriate / interdisciplinary teams require the wise and creative integration of diverse viewpoints and function best when team members value diversity, remain cohesive when viewpoints conflict, and negotiate agreement to which all team members are committed (PsycINFO Database Record (c) 2012 APA, all rights reserved)
BACKGROUND: Assessment of and interventions for promoting eating in persons with late-stage dementia have primarily focused on facilitation of safe feeding and methods to promote ingestion of nutrients via several routes. Using Social Exchange Theory, this study examined how the quality of the interaction between care giver and care receiver influenced the proportion of food consumed by persons with late-stage dementia.METHODS: Fifty-three dyads composed of nursing home residents with late-stage dementia and Certified Nursing Assistants (CNAs) were observed during the breakfast meal. The proportion of food consumed by the residents was measured by weight. The study included measures of the quality of interaction between the resident and the CNA (Interaction Behavior Measure-Modified (IBM-M) and the IBM), CNA empathy (Interpersonal Reactivity Index), and CNA power (Control subscale of the FIRO-B).RESULTS: Specific resident behaviors and the CNA's ability to allow another person to control a relationship were most predictive of the variance in the proportion of food consumed (R2 =. 41; F3,49 = 12.54; P <. 001). The quality of the resident-CNA interaction accounted for 32% of the variance in the proportion of food consumed. One aspect of power was correlated significantly to the proportion of food consumed whereas CNA empathy was not.CONCLUSIONS: Because eating is the most social of all ADLs and is culturally bound, clinicians need to examine the interactional components of meals within the caregiving dyad when a person with late-stage dementia fails to ingest adequate nutrients.
Dialogue On Origins Qualitative Research - Janice M Morse Fact or Fantasy? Dialogue On Learning Qualitative Methods Abstract Knowing - Katharyn A May The Case for Magic in Method Dialogue More on Theory 'Emerging from the Data' - Janice M Morse The Cognitive Processes of Analysis in Qualitative Inquiry Dialogue The Democracy of Interpretation The Proof Is in the Pottery - Margarete Sandelowski Toward a Poetic for Qualitative Inquiry Dialogue On Qualitatively Derived Intervention Inside the Black Box - Janice M Swanson and Linda Chapman Theoretical and Methodological Issues in Conducting Evaluation Research Using a Qualitative Approach Basic Versus Applied Ethnography Evaluation Criteria and Critique of Qualitative Research Studies - Madeleine Leininger Dialogue Good Phenomenology is... The Richness of Phenomenology - Marilyn A Ray Philosophic, Theoretic and Methodologic Concerns Dialogue Clarifying Phenomenological Methods Schools of Phenomenology - Marlene Zichi Cohen and Anna Omery Implications for Research Dialogue On Emic and Etic Styles of Ethnography - Joyceen S Boyle Dialogue Sorting Out the Styles... On the Evaluation of Ethnographies - Majorie A Muecke Dialogue More on Muddling Methods Eroding Grounded Theory - Phyllis Noerager Stern Dialogue Questions About Focus Groups The Group Effect in Focus Groups - Martha Ann Carey Planning, Implementing, and Interpreting Focus Group Research Dialogue Using Videotaped Data Using Videotaped Recordings in Qualitative Research - Joan L Bottorff Dialogue On Mentoring Secondary Analysis in Qualitative Research - Sally Thorne Issues and Implications Dialogue On Writing It Up Qualitative Research Methods From the Reviewer's Perspective - Melanie Dreher Dialogue Researcher-Participant Relationships Research and Therapeutic Interviews - Sally Hutchinson and Holly Wilson A Poststructuralist Perspective Dialogue On Being a Stranger in the Field Research Teams - Toni Tripp-Reimer et al Possibilities and Pitfalls in Collaborative Qualitative Research Dialogue The Politics of Writing Ethical Issues in Ethnography - Juliene G Lipson Dialogue Sloppy Science Promoting Academic Integrity in Qualitative Research - Kathleen A Knafl
The purpose of this study was to describe the observed experiences and resident perceptions of a nursing home group dining room. Data collection for the qualitative study was done using participant observation in a large group dining activity and in-depth interviews with 10 residents. Using the constant comparative method of data analysis, a model was generated from the data called Managing the Work of Eating. This model included the specific tasks or challenges of eating in the group dining room. Major categories of the model included: Negotiating the Environment, Coping with Frailty, Dealing with Colleagues, and Responding to the System. Implications for practice include development of strategies designed to promote resident independence and avoid excess disability.
In a qualitative study, the researcher’s curiosity, relationships with participants, and conceptual lenses through which data are gathered and interpreted have significant bearing on the research. This reflective account of the author’s experiences conducting a study of prenatal care use among low-income women reveals the necessarily personal nature of her work. She address some of her motives for carrying out the study, feelings that arose during interactions with participants and responses to those feelings, challenges in managing her role as researcher, and strategies to make meaning of gathered data. The author makes explicit how her self was a significant influence on the process of inquiry. Locating oneself in the research endeavor in this manner is essential for establishing a context within which others can appreciate the evolving search for new understanding and the creation of a final research product.
Does the postmodern climate mark the certain death of theory in ethnographic work? In this article, the author argues that postmodernity does mark the death of traditional forms of theory but it need not mark the end of theorizing activity in ethnography. What is required to keep theory in play is a rearticulation of what theory is in the postmodern view. To this end, the author examines how theory has been treated in the interpretive tradition and then discusses what theory is or can be in postmodern ethnography. Specifically, the author focuses on the relationship between theory and the theory teller, the characteristics of postmodern ethnographic theory, and the textual form of ethnographic theory. Throughout this discussion, the self is problematized in the theory endeavor.
Qualitative researchers relish the knowledge derived from multiple perspectives. They pride themselves on capturing the complexity of their informants’ experiences, they savor their ways of describing them, and they build models grounded in their narratives. Seldom do qualitative researchers ponder how their models might be different if those who refused to participate had talked to them. This article discusses sampling problems the authors encountered in a study of African American elders’ long-term care choices and preferences. They conducted 60 qualitative interviews with elders and caregivers of elders receiving one of three types of care: kin care, formal services, or nursing home care. Gatekeeper bias, refusals to participate, sampling frame, pragmatic constraints, and institutional barriers were major sources of sampling bias.
This article argues that the concept of grounded theory, widely used in research in the human sciences, has not been adequately analyzed as to its structure as a theory. Analyzing grounded theory from predictionist and accommodationist views, as well as focusing on the issue of inference to the best explanation, it is concluded that this form of theorizing is basically accommodationist. Moreover, grounded theory, in terms of providing explanations, is simply a different version of a standard inductive argument. However, grounded theory’s strength lies in its potential to articulate a unique context and logic of discovery.
background literature on quality of life [in the frail elderly] will be discussed selectively / medical and nonmedical views will be contrasted and the need for a theoretically coherent conception discussed / [discusses] persistent issues in quality of life research: objective and subjective perspectives, positive and negative qualities, and the processes by which people regulate their preferred mix of qualities of life / it will be argued that a theoretical framework which subsumes all of what is meant by quality of life may be applied to people in every state of health
major conclusion is that life qualities which depart in the positive direction from neutral have been relatively neglected in both theory and empirical research dealing with quality of life (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Most writing on sociological method has been concerned with how accurate facts can be obtained and how theory can thereby be more rigorously tested. In The Discovery of Grounded Theory, Barney Glaser and Anselm Strauss address the equally Important enterprise of how the discovery of theory from data--systematically obtained and analyzed in social research--can be furthered. The discovery of theory from data--grounded theory--is a major task confronting sociology, for such a theory fits empirical situations, and is understandable to sociologists and laymen alike. Most important, it provides relevant predictions, explanations, interpretations, and applications. In Part I of the book, "Generation Theory by Comparative Analysis," the authors present a strategy whereby sociologists can facilitate the discovery of grounded theory, both substantive and formal. This strategy involves the systematic choice and study of several comparison groups. In Part II, The Flexible Use of Data," the generation of theory from qualitative, especially documentary, and quantitative data Is considered. In Part III, "Implications of Grounded Theory," Glaser and Strauss examine the credibility of grounded theory. The Discovery of Grounded Theory is directed toward improving social scientists' capacity for generating theory that will be relevant to their research. While aimed primarily at sociologists, it will be useful to anyone Interested In studying social phenomena--political, educational, economic, industrial-- especially If their studies are based on qualitative data.
This study examines the work of the nurse's aide through a combination of participant observation and in-depth interviews with 30 nurse's aides. Data were analyzed using the grounded theory method of constant comparative dimensional analysis. Findings suggest that strategies developed by individual nurse's aides to organize their work are important determinants of both the quality of care and worker turnover. Quality of care may be better explained by Litwak's theory about the difficult juxtaposition between primary and formal groups than by the nurse's aides' lack of knowledge.
1. The aim of nurses assisting elders with eating is to maintain the resident's existing abilities or recover, as much as possible, lost abilities. 2. The findings of this study indicated that nurses did not understand the importance of sitting while feeding elderly residents. 3. More than one quarter (28%) of the nursing staff surveyed were unable to identify age-related changes that may increase the possibility of choking.
Loss of independent eating capacity is a major problem for the institutionalized elderly. Few studies have examined the factors associated with loss of functional eating capacity. The authors cross-sectionally studied 240 residents of a skilled nursing facility, classified their functional eating status, identified correlated deficits, and followed these residents for six months. Information was gathered through questionnaires, chart review, and physical examinations. Residents were stratified into independent (68%, N = 164) and dependent (32%, N = 76) eating status groups according to the need for physical assistance during meals. Dependency status did not correlate with age (P = .88) or weight loss (P = .27). Loss of independence in eating was associated with impaired mobility (P = .0001), impaired cognition (P = .0001), modified consistency diets (P = .0001), upper extremity dysfunction (P = .0001), abnormal oral-motor examinations (P = .0002), absence of teeth and dentures (P = .002), behavioral indicators of abnormal oral and pharyngeal stages of swallowing (P = .0001), and increased mortality within six months (P = .0001). Eating dependency is therefore associated with multiple impairments and early mortality.
To determine the prevalence of undernutrition and overnutrition in long-term care elderly patients and the functional, behavioral, environmental, nutritional, and medical variables associated with this prevalence.
Cross-sectional, observational.
Long-term care hospital in Canada.
Two hundred elderly patients (n = 166 male), average age 78.5 years.
Assessment of nutritional status and presence of specific behavioral, medical, environmental, and functional characteristics known to impact on nutritional status. Nutritional status was determined by weight, % weight loss, BMI, skinfolds, arm circumference, area measurements, and % body fat. Multiple regression analyses were performed to identify the factors associated specifically with undernutrition and overnutrition in this population.
Severe undernutrition was present in 18% (n = 36) and severe overnutrition in 10% (n = 20). Mild/moderate undernutrition was present in 27.5% (n = 55) and mild/moderate overnutrition in 18% (n = 36). Overnutrition was positively associated with primary diagnosis and number of medications and negatively associated with poor appetite, number of feeding impairments, protein intake, and mental state. Undernutrition was positively associated with dysphagia, slow eating, low protein intake, poor appetite, presence of a feeding tube, and age and negatively associated with primary diagnosis.
Undernutrition exists at a level that is high (45.5%) but not unusual for this type of institutional setting. Behavioral, environmental, and disease-related factors greatly influence nutritional status. Undernutrition appears to be affected by nutritional factors more than overnutrition. Efforts should be directed toward influencing some of these factors to decrease undernutrition in the institutionalized elderly.
This study aimed at increasing the understanding of feeding problems in severely demented patients cared for in a task assignment system. Twenty-three video-recordings made during the feeding of 15 severely demented patients and 55 focused interviews with 45 caregivers, who fed the 15 patients during that period were analysed regarding the feeding problems seen from a task aspect and from a relationship aspect. The result indicated that the problems were partly of a more constant nature and partly fluctuated from meal to meal. Feeding problems regarding the task aspect were mentioned first by the caregivers in the interviews in spite of the fact that the patients had severe communication problems which could be expected to cause great problems in the relationship between the patient and his caregiver. Reasons for these findings are suggested.
The feeding problems of demented elderly people are well documented and the need for research into the assessment of feeding difficulty and intervention by nurses has been raised. The present paper reviews the literature in this area of care and outlines the problems which exist in attempting to investigate the feeding difficulty of demented patients. Demented elderly people display a range of behaviours related to feeding including excessive eating in the early stages of dementia and then difficulty with feeding, refusal to eat and, finally, inability to self-feed at all. The problems with research in this area revolve around the issue of measurement of feeding difficulty. There are problems in deciding what to measure and in how measurements should be made which are clinically meaningful. A possible strategy for investigating the feeding difficulty of demented elderly patients is suggested which includes the design of a tool for measurement and the application of single-case studies. Any tool which is used for measurement should enable researchers, in the first instance, and then clinicians to categorize the feeding difficulty of individual patients. Moreover, such a tool should also be sufficiently sensitive to respond to change in feeding ability. The single-case methodology is considered to be the most ethically and statistically appropriate for research with this particular group of patients.
In a study of cognitively impaired nursing home residents, excess disability was found in the specific mealtime task of drinking liquids and among those eating a puréed diet. Nursing home staff tended to rely on spoonfeeding, a process in which the resident is a passive recipient of care rather than an active participant in it, as an intervention among residents who were partially able to feed themselves. Feeding techniques other than spoonfeeding--including verbal and nonverbal prompts, and physical guiding--can support residents' participation in feeding even when independence is no longer possible.
Malnutrition, a common problem among nursing home residents, contributes to: a) higher rates of infection, b) an impaired immune response, and c) the development of pressure sores. Eating habits are highly individualized and eating problems often occur due to a complex constellation of interacting factors such as poor oral health, medications, clinical conditions, and lack of attention to individual food likes and dislikes. By educating nursing assistants on how to provide individualized care at mealtime and ensuring that an adequate number of staff are available to assist those who need help, mealtime rather than being a task-oriented procedure will be an individualized, pleasant social event.
At the Behavioral Health Unit of Baton Rouge General Medical Center, the author and registered dietitians of the Clinical Nutrition Department developed "utensil-less" diets for patients with acute psychiatric conditions.
Initially, the diet was developed for patients with dementia; however, the staff quickly realized that the diet would be appropriate for patients with many acute psychiatric disorders, or for those patients with physical limitations.
The "Dementia Diet" includes five nutritionally balanced, small meals each day, consisting of finger foods such as sandwiches, vegetable sticks, fruit slices, and other items that patients can eat on their own without feeding assistance or utensils (Figure).
After introducing the diet on the Behavioral Health Unit, the staff found that 7 of 10 patients on the diet improved their food intake and gained weight.
Not only were nutritional needs met, but mealtimes became more enjoyable for the patients, families, and staff (Table).
Unit safety advanced, and most importantly, quality of life and self-esteem were cultivated by helping adult patients regain some of their independence associated with meal times.
Inadequate staffing has serious consequences for the nutritional care of nursing home residents. A sufficient number of well-educated and supervised staff members are critical to improving care.
Quality of life (QOL) is defined both conceptually and operationally in terms of essential characteristics of evaluational stance, multidimensionality, and subjective-versus-objective aspects. Necessary dimensions for QOL assessment include both subjective and objective components, specifically attributes falling into sectors of behavioral competence, self-assessed quality of domains of everyday life, environment, and generalized psychological well-being. None of these QOL facets should be excluded from assessment in people with dementia, but many such people require the use of indicators that do not depend on self-report. Existing measures and assessment techniques are discussed as grouped into attribute ratings (single ratings provided by someone who observes the person over some extended period of time) and direct observational methods (only behavior as it is observed in ongoing fashion). Attribute ratings are the domains of time use quality, social interaction, and affect states, and direct observation in domains of behavior, affect display, and environmental quality are discussed.
Alzheimer's disease raises numerous ethical issues which vary and evolve over the course of the illness. In recognition of the need for ongoing discussion of these issues, the Alzheimer Society of Canada established a Task Force on Ethics in 1995. Through a process of "discourse ethics" and consultation on a national scale, the Task Force produced a series of guidelines dealing with the issues of: communicating the diagnosis, driving, respecting individual choice, quality of life, participation in research, genetic testing, the use of restraints, and end-of-life care. This manuscript presents a summary of these guidelines as well as a summary of the ideas on which they were based. It was the hope of the Society that the publication of these guidelines will serve to facilitate discussion of the ethics of care of those with Alzheimer's disease.
In this qualitative study of mealtime in a nursing home, data were collected on the verbal and nonverbal interaction between certified nursing assistants (CNAs) and completely eating-dependent residents. Although some caregivers were seen to give care in a creative, empathetic manner, others were task-driven and mechanistic. The difference in caregiving was, in part, accounted for by the degree to which individual caregivers were able to engage in role taking, that is, the ability to see the world from the resident's perspective. Recommendations for enhancing role-taking ability include (a) asking caregivers to reflect on their own mealtime experiences, (b) encouraging staff to eat with residents, (c) having staff practice feeding one another, and (d) providing role modeling and supervision by professional nursing staff at mealtime.
The dietitian plays a leadership role in improving the quality of life of nursing home residents. A better understanding of this role can strengthen practice in this area. This paper attempts to define the role of the dietitian in the nutritional care of the elderly in long-term care facilities. The impact of poor appetites, extended stays and nutrient requirements on menu planning and recipe development are discussed. Resident empowerment, improvement of the dining environment, evaluation of eating skills, and eating rehabilitation are proposed as new roles for the dietitian in the promotion of food consumption. The characteristics of nutritional assessment and therapeutic diets as they relate to long-term geriatric care are discussed.
Assessment of and interventions for promoting eating in persons with late-stage dementia have primarily focused on facilitation of safe feeding and methods to promote ingestion of nutrients via several routes. Using Social Exchange Theory, this study examined how the quality of the interaction between care giver and care receiver influenced the proportion of food consumed by persons with late-stage dementia.
Fifty-three dyads composed of nursing home residents with late-stage dementia and Certified Nursing Assistants (CNAs) were observed during the breakfast meal. The proportion of food consumed by the residents was measured by weight. The study included measures of the quality of interaction between the resident and the CNA (Interaction Behavior Measure-Modified (IBM-M) and the IBM), CNA empathy (Interpersonal Reactivity Index), and CNA power (Control subscale of the FIRO-B).
Specific resident behaviors and the CNA's ability to allow another person to control a relationship were most predictive of the variance in the proportion of food consumed (R2 = .41; F(3,49) = 12.54; P < .001). The quality of the resident-CNA interaction accounted for 32% of the variance in the proportion of food consumed. One aspect of power was correlated significantly to the proportion of food consumed whereas CNA empathy was not.
Because eating is the most social of all ADLs and is culturally bound, clinicians need to examine the interactional components of meals within the caregiving dyad when a person with late-stage dementia fails to ingest adequate nutrients.
This study is a multi-method, intrinsic case study of social interaction in a special care unit (SCU) for cognitively impaired older persons. It is found that residents are capable of developing a range of social bonds even though the SCU in question is found to have several organizational and physical factors that unwittingly thwart its therapeutic potential. These limitations are illuminated by consideration of the congruence between the conceptualization of the dining areas held by staff and that held by residents as revealed through the process of negotiation occurring in social interaction. The study adopts an environment-behavior perspective following the theoretical development of Lawton (1986) and merges it with the qualitative approach to place pursued by Goffman (1961) and Gubrium (1978). It is suggested that a focus on place as a unit of analysis offers potential for bridging Quality of Life with the cognitively impaired.
To determine whether body weight can be maintained or improved in dementia residents of special care units (SCUs) using a comprehensive intervention strategy.
Quasi-experimental with an interventional site and a noninterventional site.
Four SCUs in two long-term care facilities in Ontario.
The intervention site included 33 residents; the comparison site included 49 residents.
Weight change over time was the primary outcome. Three time periods were compared: 9-month baseline period, 9-month intervention period (enhanced dietitian monitoring and menu changes at intervention site), and 12-month postintervention period (only menu changes at intervention site). Comparisons were made within and between sites. Full nutritional assessments were completed for the intervention group. Medical charts and basic anthropometric, behavioral, and cognitive measures were completed in both groups to determine baseline site differences. Weight change over time was analyzed with a repeated measures analysis, controlling for various covariates. Bivariate analyses were completed for other outcomes of death, number of infections, falls, and hospital days.
The intervention period that included the dietitian time and menu changes significantly promoted weight gain, compared with the standard treatment at the comparison facility. Other covariates of pacing, type of dementia, sex, age, number of comorbid conditions, and medications were also significant predictors of weight change. Weight gain or maintenance regardless of site was associated with survival.
Body weight can be maintained in residents of SCUs regardless of pacing and other clinical characteristics. The comprehensive intervention of clinical dietitian time and an enhanced menu designed to be individualized for ambulatory people with dementia promoted significant gains in body weight. A minimum 5% weight gain is associated with survival in these residents of SCUs.
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