Identifying Mealtime Intervention Priorities for Long-term Care: A Comparison of Resident, Family, Expert, and Health Care Professional Views

Malnutrition is highly prevalent in long-term care (LTC) residents¹ and is associated with decreased quality of life, poor functional status, poor wound healing, and increased mortality risk in older adults.^2,3 Clinicians and researchers bring valuable experience and training into the development of nutrition interventions designed to address malnutrition. As interventions to enhance food and fluid intake are developed, inclusion of the perspectives of end users of research, such as LTC residents, can enhance the relevance of research and can increase the uptake of the interventions.⁴ Policymakers and LTC administrators can use these perspectives to guide priority-setting and focus on what matters most to this population, while clinicians can integrate these perspectives into their day-to-day approach to care planning and activities.

A 2017 systematic review examined the attitudes, perceptions, and experiences of mealtimes among residents and staff of care homes for older adults.⁵ The major themes identified were organizational and staff support, resident agency, mealtime culture, and meal quality and enjoyment. Data were collected from stakeholders such as speech pathologists, care managers, and nursing staff. Of the 15 studies reviewed, only 4 elicited the perspectives of residents. The authors concluded that more studies that gain insight into the resident mealtime experience are needed, as their perspective can help to improve the care provided and can identify factors affecting the feasibility of mealtime interventions.⁵ 

Our project is a component of the Making the Most of Mealtimes (M3) program of research, focused on improving the food and fluid intake of LTC residents. Based on the M3 prevalence study results, interventions to enhance food and fluid intake will be developed to target determinants of poor food and fluid intake in LTC.⁶ The purpose of this quantitative data collection was to provide a voice to the individuals (residents and family members) who will be directly affected by any proposed interventions to improve food and fluid intake. We conducted ranking exercises in discussion groups to identify nutrition priorities of LTC residents and families to improve food and fluid intake. Nutrition priorities to mitigate malnutrition identified by LTC experts and health care professionals have been previously published by the M3 team^7,8 and are contrasted with resident and family rankings in this article. 

 Ethical clearance for this project was received from the University of Alberta Health Research Ethics Board (Pro00050002).

LTC facility staff consisting of a recreational therapist, a dietitian, a nutrition summer student, and a therapeutic services manager who attended presentations of preliminary findings of the M3 study were asked if they would be interested in having a discussion group for family and residents in their LTC facility. Afterward, interested LTC facilities were contacted by the study authors to confirm a discussion date. They were also provided with an outline of the purpose of the discussion group, how it would be conducted, and the number of residents and family members desired for the study. 

Staff members recruited individual residents and family members they believed might be interested in participating and provided them with study information. Site staff coordinated meeting times and spaces. For one group, interested family members from an initial presentation were contacted directly by the discussion facilitator.

Four discussion groups were conducted between May 2016 and August 2016 with 12 LTC residents and 7 family members, drawn from 4 facilities included in 1 province of the M3 prevalence study. Residents with severe cognitive impairment or those who were unable to communicate verbally were excluded from participation.

Discussion groups began with an explanation of the purpose of the discussion. An information statement was read to participants, outlining the objective of the discussion group and its procedures, including confidentiality policies and information explaining that participation was voluntary. Due to a concern about the possibility of the participants being unwilling to speak frankly, the discussions were not audio or video recorded. Further, the purpose of the discussions did not necessitate transcription, as the primary outcome was the ranking of the participants’ priorities. 

Verbal consent was obtained from participants, after which they were provided with a list of the 10 research agenda priorities (Table 1) to improve food intake in LTC. These research agenda priorities were identified by the International-Dining in Nursing homes Experts (I-DINE).⁷ Since its development by I-DINE, this list has been used in a similar way by the M3 research team with a variety of stakeholders (eg, LTC facility administration, advocates, health care professionals) to confirm and focus the research agenda and to develop feasible interventions to improve the food and fluid intake of LTC residents.⁸  

In our groups, each of the 10 priorities was explained and corresponding examples were provided. Participants were asked if they had additional ideas beyond the 10 listed priorities before being asked to rank them individually on a scale of 1 (most important) to 10 (least important). Residents who had difficulty with the ranking exercise were invited to choose their top 3 priorities rather than prioritizing all 10. Rankings were collected and immediately tallied so that the participants’ top choices could be used as the starting point for a discussion on nutrition intervention research priorities. Participants were asked probing questions about why they had chosen a certain priority while a cofacilitator took detailed field notes on their responses and comments. 

Article continues after Table 1.

 Residents identified “choice and variety in dining experience” and “sensory properties of food” as their top priorities for intervention research and improvement (Table 1). When discussing “choice and variety in dining experience,” some residents were not satisfied with the number of choices they were given, while other residents were. Residents who wanted more choices focused specifically on choice of dishes. They acknowledged that alternative dishes were on the menu, but they noted that these alternatives were sometimes not offered during the actual meal. 

Several residents commented that they would like to see more food that they were familiar with (ie, vegetables, potatoes). Other residents who were happy with the “choice and variety in dining experience” acknowledged that every resident has different preferences and that it is not possible to accommodate all of the residents’ preferences in an LTC facility. 

Residents at one site noted that they appreciated when their families brought them their favorite foods for consumption. The discussion on “sensory properties of food” revealed a wide range of opinions. The topics of taste, texture, temperature, and smell were discussed, with each resident having different priorities for the sensory experience. One resident remarked, “I’m fussy. I’ll be the first one to admit it” (Group 3 Resident).

Family members ranked “dining environment” as their top priority for intervention research and improvement, with many commenting on the institutional-like feeling of dining rooms. Intervention ideas offered by these participants centered on “[making] it more homelike” (Group 1 Family Member). Ideas discussed included having different lighting fixtures and using the fireplace to make it feel like the residents’ previous homes.

The second-highest ranked priority for family members was “staff attitude, knowledge, and skills to food provision, assisting with eating.” Some family members felt that the staff culture had changed, and that the residents’ feelings were no longer considered. For example, family believed that staff wanted to “just get [mealtimes] out of the way” (Group 1 Family Member). Family members felt residents were expected “to just come and eat and go. [They’re] not cattle” (Group 1 Family Member). Having staff recognize that they are serving residents in their home was important to family members. Family and resident intervention ideas to improve mealtimes in LTC are summarized in Table 2. 

Article continues after Table 2.

In this study, residents prioritized choice and variety in the dining experience as well as the sensory properties of food. Family members prioritized dining environment and staff attitude, knowledge, and skills as their top areas for improvement.

Residents’ priorities may reflect their desire for autonomy and agency, which was also a prominent theme identified in the Watkins et al⁵ systematic review. The ability to choose is an opportunity to exercise control; however, individual choice is often compromised to meet the needs of the majority of residents in a home.^5,9 This was recognized by several residents in our discussion groups. Watkins et al⁵ also highlighted that physical aspects of the meal, such as taste and texture preferences, can offer a connection to the resident’s past. Likewise, a few female residents in our discussion groups who had been cooks or homemakers longed for familiar food. 

The perspectives of family members were included in this study, as they are often present at mealtimes and can articulate residents’ mealtime experience on their behalf if they are unable or unwilling.⁵ The family members in our study focused on improving the physical dining environment, which has been associated with improving food intake and enjoyment in institutionalized older adults with dementia.^10,11 Although the physical environment can be influential at mealtimes, it is not independent of staff care practices. Family members in our study emphasized the importance of staff maintaining the dignity of their loved ones. Literature reviews have demonstrated the quality-of-life and nutritional benefits of person-centered care at mealtimes, highlighting the need for more staff training to provide person-centered care.^10,12 Increased use of person-centered care at mealtimes encompasses other I-DINE priorities, such as providing choice, demonstrating respect, and encouraging social interaction. The ranking exercise was conducted in several other groups by the M3 research team. A meeting of I-DINE experts (24 LTC researchers and stakeholders) ranked “social interactions of residents with other residents and staff” and “self-feeding ability” as their top 2 priorities.⁷ Health care professionals (administrators, directors of care, registered nurses, food service managers; n=132), as well as local and provincial policymakers, were also asked to provide their perspectives. These stakeholders ranked “adequate time to eat/availability of staff to provide assistance” and “sensory properties of food” as their top 2 priorities.⁸ 

The priorities identified by the I-DINE experts were ranked much lower by family and residents in our study. Their priorities likely reflect their training and clinical expertise. For example, the ability to safely eat independently has been widely researched by speech language pathologists and dietitians due to the high prevalence of dysphagia and aspiration in LTC.^13,14 These experts contribute a valuable perspective on mealtimes that residents and families may not have.

Similar to the residents in our study, “sensory properties of food” was a high priority for health care professionals on the M3 ranking exercise.⁸ The perspectives of the health care professionals likely reflect changes that LTC personnel may find feasible to implement, such as providing extra assistance at meals or modifying the menu. As identified by Watkins et al,⁵ mealtime interventions are often limited by the constraints of budget, operation logistics, and meeting the collective needs of the residents. Although clinicians may be unable to effect immediate change at the level of policy or budget, they have considerable control over the day-to-day experience of mealtimes for LTC residents. As Watkins et al⁵ emphasized, the perspectives of care home owners, dietitians, and nursing staff, among others, are crucial because these individuals are directly involved in facilitating change. 

The varying perspectives of the researchers, health care professionals, family members, and residents demonstrate a wide variety of priorities and the complexity of designing mealtime interventions. There is little consensus about the most important determinants of food and fluid intake. To complement the understanding of various perspectives, an empirical approach to assess the most salient determinants of food and fluid intake is needed to develop feasible, acceptable, and effective interventions. This evidence is now available, and suggests that the quality of modified texture food, eating challenges, eating assistance, the physical environment, and person-centered care practices are important.^6,15,16 Together, with these priorities identified by diverse groups, food-based mealtime experience and eating assistance appear to be top priorities for interventions to improve food and fluid intake in LTC. 

Our study has limitations. First, the small sample size limits the transferability of our study findings. Nonetheless, the divergent priorities identified in our study highlight the need for seeking resident and family perspectives when developing mealtime interventions. We did not collect participant demographic information such as age, sex, or ethnicity because we wanted to minimize barriers to participation; therefore, to elicit true thoughts and opinions we opted to maintain participant anonymity. 

Active collaboration between researchers, health care professionals, policymakers, residents, and families, while considering empirical data, is needed to identify mealtime research priorities. Researchers, policymakers, LTC administrators, and clinicians need to consider these perspectives when developing relevant interventions to improve food and fluid intake in LTC residents. 

Authors: Charice Chan, BSc, RD ¹; Carla Ickert, MA ²; Susan E Slaughter, PhD, RN, GNC(C) ^2,3; Heather Keller, PhD, RD, FDC, FCAHS ^4,5

Affiliations:
¹ Revera, Edmonton, AB, Canada
² Faculty of Nursing, University of Alberta, Edmonton, AB, Canada
³ Edmonton Clinic Health Academy (ECHA), Edmonton, AB, Canada
⁴ Faculty of Applied Health Sciences, University of Waterloo, Waterloo, ON, Canada
⁵ Schlegel-University of Waterloo Research Institute for Aging, ON, Canada

Disclosures:
This work was supported by a summer studentship from Alberta Innovates Health Solutions.

Acknowledgements:
The authors would like to thank the longterm care residents, family members, and staff who participated in the discussion groups.

Address correspondence to:
Charice Chan
Revera
Edmonton, AB, Canada
Email: charice.chan@reveraliving.com