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Mealtimes in Nursing Homes: Striving forPerson-Centered CareHolly D. Reimer MSc, RD a & Heather H. Keller PhD, RD, FDC aa Department of Family Relations and Applied Nutrition, MacdonaldInstitute, University of Guelph, Guelph, Ontario, Canada

Version of record first published: 09 Dec 2009.

To cite this article: Holly D. Reimer MSc, RD & Heather H. Keller PhD, RD, FDC (2009): Mealtimes inNursing Homes: Striving for Person-Centered Care, Journal of Nutrition For the Elderly, 28:4, 327-347

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Review

Mealtimes in Nursing Homes: Strivingfor Person-Centered Care

HOLLY D. REIMER, MSc, RD and HEATHER H. KELLER, PhD, RD, FDCDepartment of Family Relations and Applied Nutrition, Macdonald Institute,

University of Guelph, Guelph, Ontario, Canada

Malnutrition is a common and serious problem in nursing homes.Dietary strategies need to be augmented by person-centeredmealtime care practices to address this complex issue. This reviewwill focus on literature from the past two decades on mealtimeexperiences and feeding assistance in nursing homes. The purposeis to examine how mealtime care practices can be made moreperson-centered. It will first look at several issues that appear tounderlie quality of care at mealtimes. Then four themes orelements related to person-centered care principles that emergewithin the mealtime literature will be considered: providing choicesand preferences, supporting independence, showing respect, andpromoting social interactions. A few examples of multifaceted meal-time interventions that illustrate person-centered approaches will bedescribed. Finally, ways to support nursing home staff to provideperson-centered mealtime care will be discussed. Education andtraining interventions for direct care workers should be developedand evaluated to improve implementation of person-centered meal-time care practices. Appropriate staffing levels and supervision arealso needed to support staff, and this may require creative solutionsin the face of current constraints in health care.

KEYWORDS long-term care, mealtimes, person-centered care

Poor nutrition is a common problem in nursing homes, which can lead toincreased infections (1), slower wound healing (2), greater risk of falls and

Address correspondence to Holly D. Reimer, MSc, RD, Department of Family Relationsand Applied Nutrition, Macdonald Institute, University of Guelph, Guelph, ON, N1G 2W1,Canada. E-mail: hreimer@uoguelph.ca

Journal of Nutrition for the Elderly, 28:327–347, 2009Copyright # Taylor & Francis Group, LLCISSN: 0163-9366 print=1540-8566 onlineDOI: 10.1080/01639360903417066

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fractures (3), and lower health-related quality of life (4). According to asystematic review including 32 studies of institutionalized older adults, 5%–71% of residents were malnourished and 27%–70% were at nutrition riskas assessed by the Mini-Nutritional Assessment (MNA) (5). Many factors con-tribute to this persistent problem of malnutrition. Physiological changes withage are known to include reduced appetite and taste alterations that lead todecreased intake (6). Poor dentition, dysphagia, chronic illness, and medica-tion effects also contribute to malnutrition in nursing home residents (7, 8).Concerns have also been raised that regular menus may not meet residents’micronutrient requirements (9), and that pureed diets do not consistentlyprovide adequate protein (10). In addition, neurological problems and cog-nitive impairment often lead to greater dependence on feeding assistance;inadequate staffing to provide the assistance and supervision needed contri-butes to the problem of low food intake (11).

Malnutrition in nursing homes is a complex issue requiring multifacetedsolutions. Nutrition interventions typically include providing snacks, using flavorenhancement, increasing meal energy density, and providing micronutrient ororal liquid nutrition supplements (12, 13). Yet, even with the best nutrition inter-ventions in place, if interest in eating is poor or residents are not skilfully assisted,it is very difficult to improve nutrition status. Therefore, another key to resolvingthe problem of such high rates of malnutrition is to focus on the mealtimeenvironment and ensure that dining experiences are pleasant for residents.

There has been an increasing trend to create a more homelike livingenvironment in nursing homes (14), and this includes changes in diningroom design, decor, and style of meal service. Food can be portioned on resi-dents’ plates in the dining area rather than in a centralized location, with theaim of encouraging eating and socializing (15). Further, creating a smaller,homelike environment can help prevent overstimulation that may occur ina large, busy dining room (16). Yet simply making changes to the designof the dining room and how food is served does not ensure that the diningexperience will be pleasant, or that the social side of eating will be enhanced.Much depends on the way staff interacts with residents and how they facil-itate conversation at the table (17, 18). Pleasant dining experiences are cre-ated when staff value the social aspect of meals and find ways to honorresidents as individuals.

At the heart of mealtime care is the need to uphold residents’ person-hood. Defined by Kitwood (19), personhood is ‘‘A standing or status thatis bestowed upon one human being, by others, in the context of relationshipand social being. It implies recognition, respect, and trust’’ (p. 8). Mealtimesthat are focused merely on meeting residents’ physical needs fail to supportall aspects of personhood. Mealtime care should be holistic, meeting resi-dents’ biological, social, psychological, moral, and spiritual needs (20).According to Brooker (21), care that is truly person-centered has four mainqualities: valuing every resident, using an individualized approach, seeing

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things from the resident’s perspective, and creating a supportive socialenvironment that meets psychological needs.

This review will focus on literature from the past two decades on meal-time experiences and feeding assistance in nursing homes. The purpose is toexamine how mealtime care practices can be made more person-centered. Itwill first look at several issues that appear to underlie quality of care at meal-times. Then four themes or elements related to person-centered care princi-ples that emerge within the mealtime literature will be considered: providingchoices and preferences, supporting independence, showing respect, andpromoting social interactions. A few examples of multifaceted mealtimeinterventions that illustrate person-centered approaches will be described.Finally, ways to support nursing home staff to provide person-centeredmealtime care will be discussed.

FACTORS UNDERLYING QUALITY OF CARE

Silent Recipients of Care

Nursing home residents often do not voice their concerns or desires at meal-times. They are silent, not expressing their wishes for specific foods or waysof being presented food. For example, patients in a rehabilitation andlong-term care hospital tended to be quiet and not complain about the foodbecause this was an embedded cultural value of their generation (22). Like-wise, it has been observed that even though staff accommodated requests,residents were hesitant to ask for anything (18). Being a silent recipient ofcare is potentially more pronounced for those that are a minority withinthe institution. Chinese residents in an American nursing home did not wantto complain because of their cultural values of collectivism and saving face(23). These Chinese residents did not expect their cultural food preferencesto be met because they were aware that the nursing home’s chief purposewas to meet everyone’s medical needs. Further, many residents with severecognitive decline are unable to verbalize their needs or preferences. In theface of this silence, it is the responsibility of the staff to try to understandwhat residents are feeling and how to improve the mealtime experiencefor them.

A Need for Reflection

Understanding a resident’s point of view requires staff to stop and reflect onthe way they do things and how they would feel if they were in the resident’splace. Gastmans (20) stated, ‘‘To be open to the resident’s perception is asign of professionalism and reveals a willingness to be critical of one’sown care practice and to adapt it if necessary with an eye to the resident’swell-being’’ (p. 234). It is easy for busy direct care staff to go about their work

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without this reflection taking place. For example, Schell and Kayser-Jones(24) observed ten residents who required complete feeding assistance, andfindings of these observations were interpreted through a lens of symbolicinteractionism in which role-taking (the ability to put oneself in another’sshoes) explained differences in how mealtime care was provided. Carewas marked with compassion when staff seemed to understand and seethe meal from the resident’s perspective. In contrast, when the staff didnot exhibit good role-taking abilities, their manner of caregiving was routineand mechanistic. Similarly, Sidenvall (22) described how ‘‘defective nursing’’occurred at mealtimes when residents kept quiet and nursing assistants wentabout their usual mealtime work routines automatically with little reflectionon things from the residents’ perspectives. It is not easy work to see thingsfrom another’s point of view. Nursing assistants tend to assess and reactto what they observe in the dining room according to their experienceand common sense, but this requires constant attention (25). Without thisvigilance, feeding could become task-focused, rushed, or stopped too soon.

Staff Attitudes and Beliefs about Mealtimes

The way mealtime care is provided is also tied to the attitudes and beliefs thatstaff hold. For example, some nursing assistants have been described as‘‘social feeders’’ who believe that meals are a time to socialize, whereasothers are considered ‘‘technical feeders’’ who believe that ensuring ade-quate intake is the top priority (26). Some of the nursing assistants maynot fall clearly into either group, perhaps equally valuing the nutritionaland social sides of eating. A recent study on staff perspectives of mealtimesin a geriatric-psychiatric hospital ward in Belgium found that staff tried tokeep a balance between the desire for a patient-oriented approach andthe functional or organizational aspects of meals (27). They recognized thatmealtimes provide a place for social interaction and promoting indepen-dence, and are a time for relaxation and enjoyment. Yet, on the functionalside, ensuring things ran smoothly and efficiently required making agree-ments with residents about how, when, and where meals would be served,and following mealtime rituals or routines was important. In some homes,the balance may be lost and the social aspects of meals suffer. For example,Wu and Barker (23) identified how staff practices were narrowly focused onthe goal of treating or managing medical conditions. This was reflected bythe commonly used terms of ‘‘nourishment and hydration’’ rather than ‘‘foodand drink’’ within the home. In this environment, opportunities for interac-tion and community-building among residents at meals were limited.

Staff training can help promote appropriate attitudes and beliefs regard-ing mealtimes and feeding assistance. A study evaluating an educationprogram for nursing assistants providing mealtime care for residents withdementia found significant improvements in knowledge, attitudes, and

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behaviors in those who received the training compared with a control group(28). The study, however, was limited by a very small sample size. There is aneed for further research on staff education and other strategies to influencestaff attitudes and beliefs about mealtime care.

Inadequate Staffing

Not having enough staff appears to be at the root of many problems with thequality of care at mealtimes in nursing homes. Marked differences betweenmealtimes during the day and evening shifts have been observed and attrib-uted to differences in staffing levels (29). At lunch, each nursing assistant fedtwo residents and assisted one to two others. There was extra supervisionand assistance at lunch time from other staff, including the social worker,director of nursing, charge nurse, dietitian, and dietary manager. One ofthe nursing assistants during the day shift was also more highly trained thanthe rest, having a background in nursing in another country. This nursingassistant was a good role model when providing feeding assistance. In con-trast, the nursing assistants on the evening shift were responsible for five toseven residents at meals and had no role model and less supervision. Whilelunches were pleasant, supper times were overwhelming for staff, and theylearned to cope by using mechanistic, assembly-line strategies and takingshort cuts. Less attention was given to helping residents stay clean, commu-nication was minimized, and residents were fed quickly and forcefully (29).

In a survey of 99 nursing assistants and 44 nurses from five Americannursing homes, 73% of nursing assistants and 93% of nurses agreed thatwhen the nursing home was short staffed, residents did not get enough assis-tance with eating (30). Chang and Roberts (31) also reported that of the 31nursing assistants they interviewed and observed during meals in aTaiwanese nursing home, 93% felt there wasn’t enough staff and they lackedthe knowledge needed to feed residents well. Further, a study focusing onresidents’ perspectives found that residents felt there were inadequate staffnumbers to cook food properly, assist them during meals, monitor theirintake, and return them to their rooms after eating (32).

Certainly in an environment where health care budgets are tight, a clearunderstanding of minimum staffing requirements at mealtimes is needed.Also needed are creative solutions for assessing a quality experience for resi-dents despite the limitation in resources. Simmons and coworkers conducteda series of studies testing the time required to provide quality mealtime careusing standardized feeding assistance protocols, shedding some importantlight on these issues (33–35). This program of research focused on residentsidentified to have low food intakes. The goal of the feeding assistance inter-ventions in each of these studies was to improve residents’ intakes by at least15%. The feeding assistance protocol in the first study involved one-on-onecontinuous assistance, prompting to promote self-feeding abilities, and social

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interaction (33). Time spent providing assistance increased to almost 40 min-utes per person when this intervention was added. Thirty-nine percent of theresidents improved their intake by more than 15%, and 11% of residentsimproved by 10%–15%. However, half of the residents showed little to nochange in intake with the intervention. Additionally, for those who didrespond well, the helpfulness of providing the feeding assistance in groupsof three was assessed. Eighteen residents participated in the group feedingtrial, and all but four had even better intakes in this setting.

The second study on staffing examined residents’ responsiveness to dif-ferent graduated levels of feeding assistance and the time required to providethis help (34). Levels of assistance included social stimulation and encourage-ment, nonverbal cuing, verbal cuing to eat, physical guidance such as help-ing to hold a cup or utensils, and full physical assistance. To improveresidents’ intake by at least 15%, 35–40 minutes of staff time were neededregardless of the level of feeding assistance. Interestingly, residents weremore likely to have a 15% or more increase in their intake if they were cog-nitively impaired and required full feeding assistance. A third study showedthat providing snacks with assistance was commonly more effective than themealtime feeding assistance protocol (35). Among residents whose intakesincreased by at least 15%, three quarters had the best intakes with the snackintervention. Under usual care, assistance was provided for less than 10 min-utes per person per meal and less than 1 minute per person per snack. Whenthe interventions were added, staff time for feeding assistance increased toapproximately 42 minutes per person per meal and 14 minutes per personper snack.

What does this mean for practice? No single strategy works for all resi-dents. Some will eat best with one-on-one assistance; others do just as well orbetter when feeding assistance is provided in small groups. Offering snackswith extra assistance may be the best strategy of all for some residents. Whenexamining the number of staff needed to help in the dining room, the indi-vidual needs of residents should be taken into account. Where possible, tobest support increased intakes, self-feeding abilities, and social interaction,feeding assistance should be provided over at least a 40-minute period insmall groups with one staff person to two or three residents. If residentsare more responsive to one-on-one assistance, this should be provided,being mindful of the time required. If residents respond to snacks, then staff-ing levels and routines should be reconsidered to allow for extra assistance atsnack times.

Providing adequate assistance may require creative strategies. Onepotential solution to the problem of low staffing is to encourage help fromvolunteers. This was the approach of the Dining with Dignity Program,which aimed to provide greater assistance and create positive mealtimeexperiences for residents (36). A three-hour training session was providedfor interested volunteers and family members on how to provide feeding

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assistance and deal with disruptive behaviors they may encounter. Althoughperspectives of staff and residents were not reported, volunteers found itvery meaningful to assist residents at meals.

ELEMENTS OF PERSON-CENTERED MEALTIME CARE

Valuing residents as individuals and creating a sense of belonging by attend-ing to the social side of eating is at the heart of mealtime care. Although thereare certainly some challenges to overcome, actions to uphold residents’ per-sonhood need to be pursued to improve mealtime experiences and helpaddress ongoing problems of poor food intakes. Four key elements ofperson-centered mealtime care are illustrated in Figure 1 and describedbelow.

Providing Choices and Preferences

Food often carries great significance in residents’ lives. The meaning behindresidents’ food choices is frequently related to traditions, religion, or personaltaste—it is a part of remembering their roots (37). In a study involving inter-views with 20 residents about food and food service in the nursing home,

FIGURE 1 Four main elements of person-centered mealtime care for nursing home residents.

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residents valued having variety and choice in the menu, being able to chooseto eat in the dining room or in their bedroom if desired, and having oppor-tunities to ask for more (38). The same research group also found residentsappreciated opportunities to order alternatives, try new foods, return itemsthey disliked, and bring in food from family members or other places (32).Several questionnaires have been developed in recent years to better under-stand residents’ satisfaction with food services and their preferences (39–41).Obtaining input from residents and family through food committees is onemeans for promoting preferences, and menu-planning typically providesopportunity for this input. However, constraints of cost (both labor and food)and diversity in the resident population impact the ability to incorporatethese stated preferences (42).

In one study, the greatest barrier to good nutrition care recognized bystaff was that residents sometimes did not like the food being served (30).Bryon and coworkers (27) also reported that staff felt key barriers topatient-oriented care were when residents had to follow strict diets andthe food quality did not resemble home-cooked meals. Sometimes effortsto improve menus and food services for residents fall short of their goals.An American nursing home with a large proportion of Chinese residentsworked to provide an Asian diet by offering everyday options of a side dishof rice porridge (juk), rice, and tea or hot water (23). In addition, fourChinese entrees were part of the menu cycle for those on a regular diet.Unfortunately, residents did not see the Asian diet choices as Chinesebecause of the way the food was prepared or served. For example, Chinesetea is traditionally brewed in a pot and poured into small handleless teacups;using tea bags and plastic mugs removed the cultural significance. Despitethe nursing home’s efforts, the only taste of home residents recognizedwas when their families brought foods in for them. An important aspect ofperson-centered mealtime care is providing foods that are personally accep-table and culturally appropriate. This can be a challenge to provide but inno-vative approaches need to be explored, including flexibility to allow forfamily provision of key foods, dining clubs, or other events that providefor food preferences.

For residents who need full physical assistance with eating, great careshould be taken to give them choices as they are being fed. Residents withcognitive impairment may not be able to recognize foods on their plate,and it is helpful when staff orient them to the meal by describing what isbeing served. Schell and Kayser-Jones (24) found that some staff who pro-vided feeding assistance failed to help orient residents to the meal and didnot support their autonomy by offering choices. Instead of giving the resi-dent a choice of what to eat at the meal, nursing assistants may give foodbased on their perception of the nutritional quality of foods, offering themost nutritious first (25, 31). It was observed that for some nursing assistants,this meant the main source of protein, while for others it was the soup or oral

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liquid nutrition supplement. Residents who are being provided suchassistance should be shown how they are honored and valued as individualsby offering opportunities to make choices about what to be fed and in whichorder. Other preferences such as where to eat and with whom one sits, orwhich direction one faces (e.g., looking out the window) have beenneglected in the literature but are other mealtime opportunities for makingdecisions and offering choice. When much of the care that is provided toolder adults in nursing homes is prescribed, every opportunity to makedecisions that are meaningful, such as what and how one eats, need to beprovided to promote satisfaction and quality of life.

Supporting Independence

Many older adults in care require some level of assistance at the meal. Thiscan vary from orientation to full assistance. However, feelings of indepen-dence, especially with feeding oneself, are essential for dignity. Too often,when full independence is not possible, staff can totally take over this role,disregarding the continuum of assistance that can be provided to promotesome level of independence. Osborn and Marshall (43) stated, ‘‘Maximizingindependence is not the same as giving the least amount of assistance possi-ble. Types of assistance that support self-feeding are more, not less, effortfulthan spoon-feeding’’ (p. 254). Promoting self-feeding requires staff to make acareful and detailed assessment of residents’ abilities and find the best waysto support them. This is not a simple task, and it is important for staff to worktogether and communicate with each other about how to best help each resi-dent. This is especially true during periods of transition, when self-feedingabilities can change from meal to meal. It has been observed that eventhough staff felt that maintaining independence was important, they didnot all judge the residents’ self-feeding abilities the same way (18). Differentnursing assistants provided different amounts and kinds of assistance for thesame resident.

As with other areas of care, staff behaviors may more frequently supportdependence rather than independence at meals (44). This is likely due to thetime restrictions as well as lack of priority given to meals. Six residents weresystematically observed for 3 minutes during 20 mealtimes, and behaviors ofboth residents and staff were coded. Two-thirds of staff behaviors supporteddependence by such actions as encouraging requests for assistance or dis-couraging attempts at self-care. There are many ways that staff can promoteself-feeding abilities, and a lot have to do with setting residents up for themeal and giving ongoing prompts and encouragement. Positioning residentsproperly to eat and also being mindful of times of day when they are at theirbest for self-feeding are important. Conditions of inadequate staffing maycontribute to the problem of residents being positioned poorly and lead tobeing served meals in bed (45). In this study it was observed that a poorly

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positioned tray often led residents to eat with their fingers, and a lot of foodfell down rather than being consumed. Residents may not even be able to seeor reach some items on their trays when eating in bed. Staff could see this asinadequate ability to self-feed, when in reality it was a relatively simple issueof where the person ate that influenced their independence.

Bonnel described an educational program for nursing assistants tosupport independent eating behaviors in a group dining environment (46).The training was based on a metaphor that described eating as work, wherethe right tools and supervision make the job easier for residents. It involved asingle one-hour meeting that covered ways of simplifying the task of eating,using resources and creating an environment to support self-feeding, andproviding supervision. Despite lack of a formal evaluation, site of trainingwas found to be relevant; staff trained in the dining room commented thatthis specific setting made mealtime challenges vivid. Increased staff trainingon supporting independent eating would help create mealtimes that aremore person-centered, and future work needs to develop educationalstrategies that are effective.

Showing Respect

Showing respect stems from viewing mealtimes from the resident’s pers-pective. Evans and coworkers (38) found in their study of 20 nursing homeresidents that they appreciated courteous, experienced, truthful, caring, andresponsive staff. It was important to them to have meals on time, to knowthey would receive enough help, and to be served adequate portions. Resi-dents also appreciated when staff were there to listen to their needs andintervene when mistakes were made (32). Staff should slow down, approach-ing residents in a relaxed way and greeting them courteously (16). Theyneed to understand the residents’ reality and show empathy. Schell andKayser-Jones (24) observed that when nursing assistants were empathetic,they addressed the resident before starting to assist with feeding, andsearched for meaning in patterns of behavior.

Unfortunately, studies on mealtimes have often also described exampleswhere respect is lacking. Sitting down while feeding residents is a small wayto show respect, but some staff may be indifferent about whether they sitdown while providing assistance (18). It would seem that inadequate staffingaffects the level of respect shown and influences personalized care. In atime-restricted environment, the dining room can take on a ‘‘sick room’’atmosphere because residents may be brought to the meal without first beingdressed in day clothes, having their hair done, or receiving oral care (45).Insufficient training can also be a problem. Pelletier (47) observed and inter-viewed 20 nursing assistants from 4 nursing homes and found they lackedtraining on dealing with difficult eating behaviors, and generally learnedstrategies on the job from other nursing assistants. Some of these strategies,

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such as mixing all the solid foods together, compromised the residents’dignity and showed a general lack of respect for the resident. This practicewas also observed in two other studies (31, 45). Residents should be treatedwith the respect that staff would wish to receive if they were in the residents’position; effective education for staff could be a step towards a more respect-ful environment.

Promoting Social Interaction

Mealtimes are about much more than the food provided and consumed. In astudy of residents’ perspectives on the meaning of mealtimes, participantssaw eating with others as a way to develop and maintain relationships(37). Social interaction may also have positive influences on food intake.The communication behaviors of 32 patients in a Canadian geriatric hospitalward were observed, and it was found that energy intake was associated withthe total number of interactions (48). The relationship was only partiallyexplained by meal duration. Regular social interactions, by frequentlymaking comments about the food and the mealtime experience, along withnon-verbal cuing, may also help residents who tend to wander from the tableto sit longer and have better intakes (49). Based on participant observation inretirement homes, a range of social interactions among tablemates wereidentified. These included making conversation, providing assistance, shar-ing, humoring, non-verbal expressions, appreciation, and affection, as wellas negative interactions such as rebuffing, ignoring, or excluding (50).

Good social interactions can be encouraged by appropriately groupingresidents at tables in the dining room. Seating arrangements were seen bystaff to promote social interaction and increase comfort for the residents(18). Cherry and coworkers (51) proposed a model providing guidelinesfor appropriately grouping residents with dementia according to their socialneeds, but the model has not yet been tested. It is hypothesized that thereshould be four different groupings: (1) residents who are aware of theirsocial environment and usual social boundaries, (2) residents with lessawareness of social boundaries, (3) residents with greater tendencies fordisruptive behavior, and (4) residents who respond to stimuli but have noawareness of their social environment. While it is common practice forresidents to have regular tablemates, the staff who assist them may not beas consistent (25). Having the same person assisting a resident to eat on aregular basis may promote better relationship building at meals, althoughin one study staff expressed that they disliked feeding the same resident allthe time and felt it was unfair to do so as some residents were more difficultto feed than others (18). There should be further research on the benefits ofhaving consistent staff feeding assignments.

Often, however, very little social interaction takes place during meals.The need for further staff action to promote social engagement was clearly

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exemplified in a study involving systematic mealtime observations of sixresidents (44). Only 6.8% of residents’ behaviors showed independent socialengagement such as taking initiative to talk to others or passing food.Further, only 5.7% of staff behaviors were considered supportive of socialengagement, by showing awareness of and responding to residents’ socialneeds. In the case of those requiring total assistance, social interaction mayactually be enhanced, as this provides a face-to-face interaction with a stafffor a dedicated amount of time. Pearson and coworkers (18) found that resi-dents who needed little assistance during the meal had very little conversa-tion with staff compared with those who had full feeding assistance,although it also depended on how responsive individual residents were toparticipate in conversation. Not having enough room for staff to sit downas they provide feeding assistance was a problem observed in one study thatled to little or no interaction with residents (31). This suggests that thephysical mealtime environment needs to be considered if social interactionis to be promoted. Also, with conditions of inadequate staffing, it was foundthat more residents ate in bed where they lacked social interaction (45).

Relatively little research has focused on tablemate interactions. In anobservation study in retirement homes, various factors were found to influ-ence tablemate interactions: tablemate roles (i.e., dominant vs. supportive),resident characteristics (i.e., language, health), staff (speaking to individualsvs. the whole table), and the environment (50). Interaction at the nursinghome level among residents often does not occur unless it is encouragedby staff. Simple ways of facilitating some interaction at the table mightinclude having a general knowledge quiz at lunch time or placing a moretalkative resident with several residents who tend to be quiet (18). Resourceson strategies and techniques should be developed to help staff facilitatesocial interactions among residents at meals.

Switching from regular pre-plated foodservice to family-style meals,where food was served from platters at residents’ tables, was found toincrease participation and communication during mealtimes, and there wasan even greater improvement when nursing assistant training was provided(17). This was a small study, however, including observations of only fiveresidents and one nursing assistant. Yet, it was also observed in a study ofChinese residents that when they were taken out for a meal to a local Chineserestaurant, they had a very different experience compared with mealtimes atthe nursing home (23). There was much more social interaction in the restau-rant as they sat around a large table, poured tea for each other and chatted,and served their food from common platters. Individualization of meals bytray service reduced social opportunities and community-building amongresidents within the nursing home. Another way to promote social interac-tion may be to provide more opportunities for staff to eat with residents orsimply sit down with a cup of coffee or tea as the residents eat. Nursing assis-tants, whose care was marked by empathy and compassion, were observed

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to sometimes share in the mealtime experience by eating with the resident asthey attended to the social side of eating (24). Future research could identifymore effective ways to help improve staff interactions with and amongresidents at meals, especially with those who are cognitively impaired.

Carpiac-Claver and Levy-Storms (52) studied how nursing assistantscommunicated with residents at mealtimes using video observation. Theyidentified different types of affective communication, which helped with rap-port or relationship building. One form was personal conversation, whichincluded not only talking about things like visits from family members, butalso pleasantries, laughter, and singing. Affective communication was alsoshown by addressing the resident by name or using terms of endearment;checking in about the resident’s comfort, hunger, thirst, or preferences;and giving emotional support or praise. In this study, the nursing assistantstended to use more imperative instrumental statements such as ‘‘You drinkit, okay? You gotta finish this’’ (p. 63) than affective ones when assistingcognitively impaired residents who did not speak. Likewise, other researchfound that nursing assistants had good communication skills with residentswho could carry on a conversation, but experienced discomfort when tryingto talk with residents who didn’t or couldn’t talk back—their communicationwas often reduced to commands to eat or drink (47). These direct care pro-viders had little knowledge of how to communicate with these residents.Notably, it was found that this topic was poorly covered in their certificationtraining. There appears to be a great need to better prepare staff to engage insome way in social interactions at meals with all residents so they feel valuedand connected with others.

An Overview of Multifaceted Mealtime Interventions

Many strategies can be used to promote the four elements of person-centeredmealtime care, and some examples are listed in Figure 2. In addition, thereare good examples in the literature of mealtime interventions that are multi-dimensional or holistic in nature. Although not necessarily described as‘‘person-centered’’ by the authors, each of these interventions incorporatesa number of elements of person-centered care such as those describedabove—providing choices and preferences, supporting independence,showing respect, and promoting social interactions.

Although most studies with these types of multifaceted interventionshave had major limitations in study design and sample size, one has recentlyovercome many of these weaknesses. Family-style meals were evaluated in arelatively large randomized controlled trial in the Netherlands (53). The studyincluded five nursing homes, and in each home one ward was randomizedto the intervention and another to the control group. In all, 94 residentsreceived the family-style meals intervention and 84 continued with usualpre-plated tray service. The intervention involved a number of changes to

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the mealtime ambience through a new protocol. Tables were prepared nicelywith a table cloth and subtle flower arrangements. Regular plates, drinkingglasses, and cutlery were used rather than plastic. Food was placed in servingdishes on the table, and there were choices of two vegetables, meat, andpotatoes. The staff protocol was to sit down and chat with residents at meals,with at least one staff person at each table. There were to be no staff switchesduring the mealtime to prevent disruptions, and staff always asked what eachresident wanted to eat. Medications were given out before the meal started,and meals began only when everyone was seated at the table, following amoment for reflection or prayer. No other activities took place during themealtime and the dining room was closed to visitors and other health careproviders to prevent interruptions. Carts for meals, medications, and residentfiles were kept out of view to create a homelike environment. Dining roomclean up began when the mealtime was finished. Data were collected atbaseline and six months after the intervention began, and comparisons foundsignificant improvements in intakes of energy and macronutrients as well asMini Nutritional Assessment scores. In fact, the percentage of residents clas-sified as malnourished decreased from 17% to 4% in the intervention group,while malnutrition increased from 11% to 23% in the control group (53).

An earlier study also conducted in the Netherlands with a very similarmealtime protocol was performed with measurements taken at baselineand one year after the intervention began (54). One difference was thatrather than providing food in serving dishes on the table, the meal wasserved course by course per table, or ‘‘restaurant style.’’ Another difference

FIGURE 2 Examples of strategies to promote person-centered mealtime care.

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was that there was one staff person for every two residents. Unfortunately,only 22 of the original 60 participants completed the study; three-quartersof the residents who were lost during follow-up had died during theone-year period. However, with the remaining 10 residents in the controlgroup and 12 in the intervention group, a significant difference in weightchange was observed; weight changed little in the control group, butincreased significantly for those receiving the intervention. Hemoglobinlevels were steady for the intervention group but decreased significantly inthe control group. Self-perceived functional status also was stable in theintervention group but declined significantly in the control group (54).

Some study interventions have combined an educational componentfor staff with changes to the dining environment or style of meal service.For example, a controlled trial was conducted that introduced family-stylemeals along with a one-week education component with three months offollow-up support for staff (55). The intervention group had 18 residentsand the control group had 15 residents. The course focused on promotingresident integrity; in other words, promoting wholeness and meaning as anindividual through building trust and autonomy and upholding the resident’sidentity. Meal service was changed to create a calm, homelike environment.Serving bowls were provided to each table from which the residents servedthemselves. Weight change was the primary outcome measure, and it wasfound that four months after the intervention began, greater weight losswas observed in the control group. Staff reported in diaries that the newfamily-style meal service increased interactions between residents and madethe atmosphere more pleasant (55). Unfortunately, further evaluations of staffsatisfaction and knowledge acquisition were not measured.

Another study that involved staff training examined outcomes of abuffet-style meal service program (56). Food was served from a steam table,allowing residents to select what they wanted and they could have secondhelpings. In addition, there were changes to the dining environment includ-ing table cloths, seasonal decor, and background music. Adaptive utensilsand plates were available, and nursing assistants had special training toprovide the right type and amount of assistance residents needed. Attentionwas given to positioning residents well for eating and social engagement.Forty residents who were at nutrition risk were randomized to receive eitherthe buffet-style meals at supper or usual tray service for three months.Measures were taken before and after the intervention, but no significantdifferences were found in biochemical measures or weight change, poten-tially due to the short time frame and=or small sample size.

Finally, the Bon Appetit! Program also aimed to improve mealtimeexperiences through staff training and environmental adaptations (57). Theprogram is designed to support residents’ dignity, identity, and connectionswith others. Attention is given to the food to preserve and enhance taste,aroma, and visual appeal. Details of the dining room environment are also

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considered including space, sound, and decor. Procedures such as timing ofmeals, menu selection, and serving methods are also examined. Self-feedingis encouraged by providing various levels of assistance as needed. Staff aretrained to provide high quality care, and this includes how to interact sociallywith residents, assess needs for assistance, and feed residents properly.Despite apparent strengths of this detailed program, its evaluation was notrigorous. A retrospective evaluation was conducted 12 months after its imple-mentation at a Canadian nursing home with questionnaires completed by 45staff members. They reported improvements in meal service and residents’behavior. Staff commented that everyone was more relaxed, residents weremore calm and sociable, the meal experience had improved, and theywanted to continue the program.

SUPPORTING STAFF TO PROVIDE PERSON-CENTEREDMEALTIME CARE

Increased staff training for nursing assistants on providing mealtime care andcommunicating with residents is a recurrent recommendation in the literature(18, 22, 24, 29, 45 52, 58). Schell and Kayser-Jones (24) emphasized educat-ing staff on the importance of the social side of meals and conducting exer-cises to promote empathy. Staff should be taught to step in the residents’shoes and see things from their perspective. Sidenvall (22) likewise recom-mended promoting reflective cultures among nursing staff. Future researchshould engage front-line staff in active reflection on their mealtime care prac-tices, and develop and test strategies to facilitate such reflection. Nursingassistants also need more training on verbal and non-verbal affective, rela-tionship building communication when working with cognitively impairedresidents (52). Pietro (58) reviewed strategies for training nursing assistantsto communicate effectively with cognitively impaired residents and recom-mended that training programs: (1) keep lectures to a minimum, (2) use avariety of active learning experiences, particularly role playing, (3) presentinformation that nursing assistants really need to know, giving them oppor-tunity to suggest topics, (4) provide training on-site, (5) follow up or providetraining in short sessions held over several weeks or months, conducted bysomeone working within the home, and (6) provide emotional support, per-haps by a support group, to help reduce turnover and absenteeism.

Along with increased education and training, researchers have called formore supervision and role modelling by experienced nurses at mealtimes(22, 24, 29). They have also advocated that more staff are needed to provideassistance. One staff person can assist two to three residents at a meal, and itmust be recognized that giving this assistance requires about 40 minutes(29, 33–35, 45). Creative planning needs to be done to ensure adequate meal-time assistance is provided; this might mean having an 11 am to 7 pm shift to

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cover lunch and supper, or recruiting extra help from non-nursing staff,family, or volunteers (29). Having a protected mealtimes policy can also helpto engage more staff in providing feeding assistance and interacting withresidents at meals (59). Such a policy ensures that potentially disruptiveactivities such as answering phones and giving treatments that are notimmediately necessary do not take place during designated mealtimes.Instead, the focus is placed on creating pleasant mealtime environmentsand promoting the social side of eating.

CONCLUSIONS

Person-centered mealtime care practices augment usual dietary strategiesto address the problem of malnutrition in nursing homes. This reviewhas illustrated that there is good understanding of what a person-centeredmealtime looks like, although there have been relatively few stronglydesigned controlled trials in this area demonstrating the benefits of thiscare. In addition to health or nutritional outcomes, resident satisfactionand rigorous methods of measuring social interaction are lacking; poten-tially developing these forms of outcome assessment will demonstratenon-nutritional benefits of these interventions. It is evident that knowledgetranslation interventions to increase implementation of person-centeredmealtime care practices by front-line staff are needed. Staff education isa noted limitation in mealtime care identified in this review and by others.Further, adequate staffing and supervision to improve mealtime care areprerequisite to a person-centered mealtime environment. Future researchneeds to focus on creative ways to overcome potential barriers, and tailorknowledge translation interventions to strive for person-centered mealtimepractices in nursing homes.

TAKE AWAY POINTS

. Residents often do not voice their concerns or wishes at meals, while staffcarry out their tasks without taking time to view their care practices fromthe resident’s perspective. These issues, as well as staffing levels and staffattitudes and beliefs about mealtimes, influence quality of care.

. Person-centered mealtime care means providing choices and preferences,supporting independence, showing respect, and promoting socialinteraction.

. Although limited, research demonstrates benefits of person-centered careat mealtimes on nutritional outcomes; future work should also determineif these activities promote social interaction, satisfaction and quality of lifefor residents.

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. There is a need for development and evaluation of staff training programsfor person-centered mealtime care.

. Creative strategies are needed to ensure adequate staffing levels andsupervision at mealtimes.

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