Transitions to long-term care: how do families living with dementia experience mealtimes after relocating?

Multi-Level Factors Associated with Relationship-Centred and Task-Focused Mealtime Practices in Long-Term Care: A Secondary Data Analysis of the Making the Most of Mealtimes Study

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.

Disruptions in Relational Continuity: The Impact of Pandemic Public Health Measures on Families in Long-Term Care

Although the value of family caregivers' involvement with relatives in long-term care (LTC) is well recognized, tensions remain regarding their role. Such tensions were exacerbated during the COVID-19 pandemic as strict public health measures restricted family access to LTC homes. Using interpretive description, we examined the impact of visitation restrictions on family caregivers' experiences caring for a relative in LTC between March 2020 and June 2021. In-depth interviews were conducted with 14 family caregivers (five spouses and nine adult daughters) and two key themes were identified. The first theme, "seeking to maintain relational continuity," illustrates how caregivers sought to sustain connections with residents prior to and during the pandemic. The second theme, "disrupted relational continuity," highlights the impact of severed relational connections on caregivers' sense of self and ongoing feelings of loss and anger. Findings call for a trauma-informed approach that recognizes the pervasiveness of trauma for family caregivers and the avoidance of re-traumatization.

How are the mealtime experiences of people in residential aged care facilities informed by policy and best practice guidelines? A scoping review

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.

Using meta-ethnography to understand the care transition experience of people with dementia and their caregivers

Older adults living with dementia are at risk for more complex health care transitions than individuals without this condition, non-impaired individuals. Poor quality care transitions have resulted in a growing body of qualitative empirical literature that to date has not been synthesized. We conducted a systematic literature review by applying a meta-ethnography approach to answer the following question: How do older adults with dementia and/or their caregivers experience and perceive healthcare transition: Screening resulted in a total of 18 studies that met inclusion criteria. Our analysis revealed the following three categories associated with the health care transition: (1) Feelings associated with the healthcare transition; (2) processes associated with the healthcare transition; and (3) evaluating the quality of care associated with the health care transition. Each category is represented by several themes that together illustrate an interconnected and layered experience. The health care transition, often triggered by caregivers reaching a "tipping point," is manifested by a variety of feelings, while simultaneously caregivers report managing abrupt transition plans and maintaining vigilance over care being provided to their family member. Future practice and research opportunities should be more inclusive of persons with dementia and should establish ways of better supporting caregivers through needs assessments, addressing feelings of grief, ongoing communication with the care team, and integrating more personalized knowledge at points of transition.

Impact of COVID-19 on Relationship-Centred Residential Dining Practices

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.

The experiences, priorities, and perceptions of informal caregivers of people with dementia in nursing homes: A scoping review

BACKGROUND

Person-centered care has been shown to increase desired outcomes for people with dementia, yet informal caregivers' dissatisfaction with care is often reported. For those living in a nursing home, informal caregivers are uniquely situated to provide key insights into the individual's care. However, little is known of the informal caregivers' perspective, which hinders efforts to improve their satisfaction with person-centered nursing home care. Thus, we examined the comprehensive experiences, priorities, and perceptions of informal caregivers of nursing home residents with dementia.

METHODS

In collaboration with stakeholders, a scoping review of Medline (Ovid), EMBASE.com, CINAHL (EBSCO), the Cochrane Library (Wiley), and PsycINFO (Ovid) databases from January 2000 to July 2020 was conducted. Data were extracted reflecting the experiences, priorities, and preferences of caregivers of people with dementia residing in nursing homes.

RESULTS

We identified 114 articles that revealed nine themes: (1) communication, (2) transition to nursing home, (3) quality of care, (4) quality of life, (5) informal caregiver role, (6) knowledge of dementia, (7) end-of-life preferences, (8) medication use to manage neuropsychiatric behaviors, and (9) finances.

CONCLUSION

Informal caregivers described aspects of care that led to both positive and negative experiences with and perceptions of nursing home care. The shortcomings in communication were discussed most frequently, indicating a high priority area. While researchers define the identified themes individually, informal caregivers perceive them to be interwoven as they relate to person-centered care delivery. Although we did not assess the quality of included articles, by identifying themes relevant to caregivers' perspectives of nursing home care, our findings may help to inform efforts to optimize caregivers' satisfaction with nursing home care for residents with dementia.

Optimizing mealtime care for people with dementia from the perspective of formal caregivers: A systematic review of qualitative research

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, a social worker, a 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.

Stakeholder Engagement in Practice Change: Enabling Person-Centred Mealtime Experiences in Residential Care Homes

Person-centred care is recognized as best practice in dementia care. The purpose of this study was to evaluate the effectiveness of a stakeholder engagement practice change initiative aimed at increasing the provision of person-centred mealtimes in a residential care home (RCH). A single-group, time series design was used to assess the impact of the practice change initiative on mealtime environment across four time periods (pre-intervention, 1-month, 3-month, and 6-month follow-up). Statistically significant improvements were noted in all mealtime environment scales by 6 months, including the physical environment (z = -3.06, p = 0.013), social environment (z = -3.69, p = 0.001), relationship and person-centred scale (z = -3.51, p = 0.003), and overall environment scale (z = -3.60, p = 0.002). This practice change initiative, which focused on enhancing stakeholder engagement, provided a feasible method for increasing the practice of person-centred care during mealtimes in an RCH through the application of supportive leadership, collaborative decision making, and staff engagement.

Attending to difference: enacting individuals in food provision for residents with dementia

In the face of warnings about total institutions and growing concern about the quality of care, healthcare professionals in Western Europe and North America have increasingly been exhorted to tailor their services to individuals in their care. In this article, we invite our readers to become more interested in the kinds of differences care is being tailored to, and with what effects. Focusing on food provision for residents with dementia, we present three repertoires through which care workers attend to, and enact different sets of differences between individuals: providing choice allows residents to express fleeting preferences; knowing residents places emphasis on care providers' familiarity with a person; and catering to identities brings to the fore the tastes which make up part of who someone is. The analysis brings attending to difference to the fore as a practical process and suggests that tailoring care requires sensitivity to the different kinds of individuals enacted when attending to difference.

Reliability Testing of the Team Member Mealtime Experience Questionnaire

Team members influence the mealtime experience of residents. Their perspectives on their ability to provide resident- and relationship-centred care during mealtimes is limited. The aim of this study was to describe the development and determine the factor structure and internal and test-retest reliability of the Team member Mealtime Experience Questionnaire (TMEQ). A 23-item questionnaire was developed through several steps. A Likert scale of strongly disagree (score= 1) to strongly agree (score= 5) was used. A total of 137 team members from five diverse homes participated. Time and task-focused items had lower scores (indicating more negative perceptions), whereas knowledge and capability of how to provide resident- and relationship-centred mealtime care had higher scores. Exploratory factor analysis identified three factors; four items were eliminated based on this analysis. Test-retest reliability was completed with 103 participants. Intraclass correlation (ICC) for the total score and three subscales ranged from 0.72 -0.85 while Chronbach's alpha ranged from 0.81-0.92. The 19-item TMEQ is considered reliable for use in research and practice.

"A Bone of Contention…": Perceived Barriers and Situational Dependencies to Food Preferences of Nursing Home Residents

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.

Development and Inter-Rater Reliability of the Mealtime Scan for Long-Term Care

Background and Objectives

Poor food intake is common in long-term care (LTC). The mealtime experience has been identified as influential, yet, research has been limited by lack of quality, standardized measures. The purpose of this study was to develop and test for inter-rater reliability the Mealtime Scan (MTS), an observational measure.

Research Design and Methods

MTS was derived from the literature on ambiance, mealtime experience, social interactions at mealtimes, and social models of care. Three scales on person-centered care and physical and social environments are used to summarize key aspects observed with MTS. Two raters assessed MTS for reliability at 30 different meals conducted in 10 dining rooms, within three LTC residences. Intraclass correlation coefficient (ICC) was used to assess reliability.

Results

MTS demonstrated good to excellent reliability on the three summative scales (physical ICC = 0.73, social ICC = 0.81, person-centered care ICC = 0.83) and other scalable items had good to excellent reliability (e.g., background noise ICC = 0.65, Mealtime Relational Care checklist: negative interactions ICC = 0.85).

Discussion and Implications

MTS is reliable and face valid for assessing mealtime experience. Future work will explore construct validity of this measure. MTS can be used to support improving the mealtime experience for residents living in LTC.

Inter-Rater Reliability of the Mealtime Scan+

BACKGROUND AND OBJECTIVES

The Mealtime Scan (MTS) was developed to assess the dining environment in Long Term Care (LTC). MTS has been reviewed and updated to ensure its standardization and responsiveness to changes in the dining environment. The objectives of this paper are to provide an overview of the changes made in the new MTS+ tool and to describe its inter-rater reliability.

RESEARCH DESIGN AND METHODS

The observational and scoring methods used to evaluate the physical, social, and relational-centered dining environments in LTC homes were reviewed and updated into MTS+ and an overall quality of dining rating derived. Two trained assessors were evaluated for the inter-rater reliability. Nine dining rooms in three LTC homes at different meals were observed for a total of 45 observations. Interclass Correlation Coefficient (ICC) was used to assess reliability.

RESULTS

MTS+ demonstrated good reliability on the orientation cues, social environment, and relationship-centered activities (orientation cues ICC: 0.75, social ICC: 0.78, relational ICC: 0.78). However, the tool's reliability was poor for the physical environment, ICC: 0.48 and moderate for the overall rating of the quality of the dining environment, ICC: 0.67. Discussion and Implications: Although deemed more effective and practical for use in intervention studies, MTS+ has some limitations with respect to its reliability, particularly in assessing the physical environment. It is hypothesized that more extensive training of the assessors may lead to improvements in the reliability of MTS+. MTS+ can be used in intervention research when one assessor completes repeat observations of a dining area.

Facilitators and barriers to optimizing eating performance among cognitively impaired older adults: A qualitative study of nursing assistants’ perspectives

Background and Objectives

Cognitively impaired individuals are at increased risk for functional and behavioral difficulties at mealtimes, leading to compromised eating performance, low food and fluid intake, and negative functional and nutritional outcomes. Nursing assistants are the most critical front-line care staff and best positioned to manage the personal and environmental factors that influence resident eating performance. Identifying nursing assistants’ perceptions of barriers and facilitators to engaging residents in eating will provide important experientially based foundation for developing and testing evidence-driven interventions to promote mealtime care.

Methods

A qualitative descriptive study was conducted in three sites: two nursing homes and one hospital gero-psychiatric inpatient unit. Six focus groups were conducted with a purposive sample of 23 nursing assistants who regularly provided mealtime care to residents with cognitive impairment. Interview questions addressed barriers and facilitators at resident, caregiver, environmental (facility), and policy levels in optimizing mealtime care. Audio recordings of focus groups were transcribed and analyzed using qualitative descriptive content analysis. Both barriers and facilitators were organized into a hierarchical taxonomy based on similarities and differences framed by the Social Ecological Model.

Results

The majority of barriers and facilitators were at the caregiver level. Caregiver-level barriers included lack of preparation and training, competing work demands, time pressure, and frustration. Caregiver-level facilitators included caregiver preparation and motivational, technical, informational, and instrumental assistance. Environmental-level barriers and facilitators related to the physical, social, and cultural environment and facility practices. Only barriers to optimizing mealtime care were identified at resident and policy levels.

Conclusions

Nursing assistants identified multilevel barriers as well as a wide range of caregiver and environmental facilitators to optimizing dementia mealtime care. Findings can inform the development and implementation of multifaceted innovative mealtime assistance and staff training programs to promote resident eating performance while fostering person-centered individualized mealtime care practice.

Mixed methods developmental evaluation of the CHOICE program: a relationship-centred mealtime intervention for long-term care

Background

Mealtimes are important to quality of life for residents in long-term care (LTC). CHOICE (which stands for Connecting, Honouring dignity, Offering support, supporting Identity, Creating opportunities, and Enjoyment) is a multi-component intervention to improve relationship-centred care (RCC) and overall mealtime experience for residents. The objective of this developmental evaluation was to determine: a) if the dining experience (e.g. physical, social and RCC practices) could be modified with the CHOICE Program, and b) how program components needed to be adapted and/or if new components were required.

Methods

A mixed methods study conducted between April–November 2016 included two home areas (64 residents; 25 care staff/home management) within a single LTC home in Ontario. Mealtime Scan (MTS), which measures mealtime experience at the level of the dining room, was used to evaluate the effectiveness of CHOICE implementation at four time points. Change in physical, social, RCC dining environment ratings and overall quality of the mealtime experience over time was determined with linear mixed-effects analyses (i.e., repeated measures). Semi-structured interviews (n = 9) were conducted with home staff to identify what components of the intervention worked well and what improvements could be made.

Results

Physical and overall mealtime environment ratings showed improvement over time in both areas; one home area also improved social ratings (p < 0.05). Interviews revealed in-depth insights into the program and implementation process: i) Knowing the context and culture to meet staff and resident needs; ii) Getting everyone on board, including management; iii) Keeping communication lines open throughout the process; iv) Sharing responsibility and accountability for mealtime goals and challenges; v) Empowering and supporting staff’s creative mealtime initiatives.

Conclusions

This developmental evaluation demonstrated the potential value of CHOICE. Findings suggest a need to: extend the time to tailor program components; empower home staff in change management; and provide increased coaching.

Electronic supplementary material

The online version of this article (10.1186/s12877-018-0964-3) contains supplementary material, which is available to authorized users.

Construct Validity of the Mealtime Scan: A Secondary Data Analysis of the Making Most of Mealtimes (M3) Study

Long-term care (LTC) physical and psychosocial mealtime environments have been inconsistently assessed due to the lack of a standardized measure. The purpose of this study was to examine the construct validity of a new standardized observational measure, the Mealtime Scan (MTS), using the Making Most of Mealtimes data collected on 639 residents in 82 dining rooms in 32 LTC homes. The MTS includes physical, social, and person-centered care summary scales scored from 1 to 8. Mean ratings on these summary scales were moderate for physical (5.6 SD 0.9), social (5.0 SD 0.9), and person-centered care (PCC; 5.5 SD 0.8). Regression analyses determined which items within the MTS were associated with these summary scales: physical - music (B = 0.27, p = 0.04), number of staff passing food (B = -0.11, p = 0.03), number of residents (B = -0.03, p = 0.01); social - social sound (B =  0.31 p < 0.0001), number of residents requiring eating assistance (B = 0.11, p = 0.02); PCC - lighting (B = 0.01 p = 0.04), and total excess noise (B = 0.05, p < 0.0001). The Mealtime Relational Care Checklist (M-RCC) was associated positively with ratings on all three summary scales. Correlations revealed that the MTS summary scales were associated with other constructs: Dining Environment Audit Protocol functionality scale, resident and dining room level M-RCC, Mini Nutritional Assessment- Short Form, and resident Cognitive Performance Scale. These results demonstrate that the MTS summary scales exhibit construct validity, as the ratings were associated with expected observed mealtime characteristics and correlated with dining room and resident level constructs in anticipated directions.

Struggling to maintain individuality - Describing the experience of food in nursing homes for people with dementia

PURPOSE OF THE STUDY

To describe the food and dining experience of people with cognitive impairment and their family members in nursing homes.

DESIGN AND METHODS

Interviews and focus groups with people with cognitive impairment and their family members (n=19). Thematic analysis was undertaken using NVivo10 data analysis software package to determine key themes.

RESULTS

The main themes identified tracked a journey for people with cognitive impairment in nursing homes, where they initially sought to have their individual needs and preferences recognised and heard, expressed frustration as they perceived growing barriers to receiving dietary care which met their preferences, and ultimately described a deterioration of the amount of control and choice available to the individual with loss of self-feeding ability and dysphagia.

IMPLICATIONS

Further consideration of how to incorporate individualised dietary care is needed to fully implement person-centred care and support the quality of life of those receiving nursing home care.

The Effect of Dining Room Physical Environmental Renovations on Person-Centered Care Practice and Residents’ Dining Experiences in Long-Term Care Facilities

This qualitative study evaluated the effect of dining room physical environmental changes on staff practices and residents’ mealtime experiences in two units of a long-term care facility in Edmonton, Canada. Focus groups with staff ( n = 12) and individual interviews with unit managers ( n = 2) were conducted. We also developed and used the Dining Environment Assessment Protocol (DEAP) to conduct a systematic physical environmental evaluation of the dining rooms. Four themes emerged on the key influences of the renovations: (a) supporting independence and autonomy, (b) creating familiarity and enjoyment, (c) providing a place for social experience, and (d) challenges in supporting change. Feedback from the staff and managers provided evidence on the importance of physical environmental features, as well as the integral nature of the role of the physical environment and organizational support to provide person-centered care for residents.

Family Involvement in Nursing Homes: Are Family Caregivers Getting What They Want?

The provision of person-centered care for nursing home residents with dementia suggests the need for family caregiver involvement. In this article, we argue that optimal family involvement differs by family caregiver and therefore depends on the degree to which family caregivers consider their own involvement to be important. In this Canadian study, we compare the importance that 135 family caregivers of residents with dementia place on 20 kinds of involvement with the degree to which they perceive opportunities for involvement. Family Involvement Congruence Scores are calculated in three ways: those for whom involvement is important, those for whom involvement is not important, and an overall congruence score. Congruence scores varied by involvement type. These scores show promise for use in future research on family caregiver involvement and as tools for use by facilities as they endeavor to meet family caregiver expectations for involvement.

Interventions for improving mealtime experiences in long-term care

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.