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Resident coping strategies in the nursing home: an indicator of the need for dietary services change
Resident Coping Strategies in the Nursing Home: An Indicator of the Need for Dietary Services Change Bronwynne C. Evans, Neva L. Crogan, and Jill Armstrong Shultz
Inadequate food intake leading to malnutrition impacts up to 85% of nursing home residents. Malnutrition can result in compromised quality of life and lead to chronic disability, functional decline, increased health care utilization and costs, and death. This article examines organizational structure (Perrow, 1979) and person-environment fit (Lawton, 1982) as factors in nutritional care of nursing home residents. The strategies used by residents to cope with organizational food and food service issues, competence, and environmental press in the nursing home can alert nurses to the need for changes in dietary services to increase food intake and quality of life. © 2004 Elsevier Inc. All rights reserved.
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NADEQUATE FOOD INTAKE leading to malnutrition impacts up to 85% of nursing home residents (Kayser-Jones, 2000). Malnutrition, defined as insufficient dietary intake among essential nutrients, can result in compromised quality of life and can lead to chronic disability, functional decline, increased health care utilization, increased health care costs, and death (Chen, Schilling, & Lyder, 2001). Antecedents to malnutrition for nursing home residents include loss of optimal body composition, oral health, sensory function, and role function (Chen, Schilling, & Lyder, 2001). Other antecedents are functional dependency, when elders have difficulty with activities of daily living, and loneliness. Social isolation also may result in depression and decreased food intake and chronic illness requiring multiple medications may place residents at risk for drug-induced malnutrition. Poor quality food or food service also can affect food intake as shown by Crogan et al. (2004) and
Bronwynne C. Evans, PhD, RN, CNS, Assistant Professor, Intercollegiate College of Nursing, Washington State University, Spokane, WA; Neva L. Crogan, PhD, APRN, BC, Assistant Professor, College of Nursing, University of Arizona, Tucson, AZ; Jill Armstrong Shultz, PhD, Professor, Food Science and Human Nutrition, Washington State University, Pullman, WA. Address reprint requests to Bronwynne C. Evans, PhD, RN, CNS, Intercollegiate College of Nursing, Washington State University, 2917 Ft. George Wright Drive, Spokane, WA 992245291. E-mail: [email protected] © 2004 Elsevier Inc. All rights reserved. 0897-1897/04/1702-0006$30.00/0 doi:10.1016/j.apnr.2004.02.003 Applied Nursing Research, Vol. 17, No. 2 (May), 2004: pp 109-115
Evans et al. (2003). In these studies, residents sorely missed their own homes and the control over their own diets. Foods that reminded them of their ethnic or cultural identities were often unavailable and residents counted this as a significant loss. Even foods not regarded as “special” were frequently poorly prepared or prepared in an unfamiliar way, increasing the sense of discontinuity and loss. Even foods not regarded as “special” were frequently poorly prepared or prepared in an unfamiliar way, increasing the sense of discontinuity and loss. In these two studies, residents also missed the dining ambiance to which they were accustomed. They wished for attractive meal service and the food rituals and traditions associated with family meals and social occasions. Because they had lost much of their ability to care for themselves, they were at the mercy of nursing home food providers and food service system (partially mandated by federal Omnibus Reconciliation Act regulations). However, they learned to circumvent some of the institutional rigidity by figuring out how to “work with the system” to meet their individual preferences. They cultivated relationships with staff because they realized that staff members were the conduit to choice in food and food service. Staffresident interactions in the context of these relationships occurred on a more personal level and staff members were more likely to individualize nutrition care. Individualized care was an important issue because food service in the nursing home can easily become task-oriented rather than resident-oriented (Sidenvall, 1999). In Sidenvall’s sec109
110
ondary analysis of 20 nursing home residents, meal procedures were not adapted to individual residents’ personalities or preferences or to their specific inabilities or needs. In short, procedures were organized to meet the needs of staff, rather than the individualized needs of residents.
Even foods not regarded as “special” were frequently poorly prepared or prepared in an unfamiliar way, increasing the sense of discontinuity and loss.
Finally, malnutrition is exacerbated by the fact that nationally more than 56% of nursing home residents now need assistance with eating (American Health Care Association, 1998). Additionally, sufficient numbers of staff may not be available to provide even the most basic nutrition care. In fact, inadequate staffing has been called the most significant barrier to sufficient resident food intake (Kayser-Jones, 2000). CONCEPTUAL FRAMEWORK COMPONENT ONE: ORGANIZATIONAL STRUCTURE
The conceptual framework used to guide investigation into food and food service issues from the perspective of nursing home residents had two components. The first component, Perrow’s (1979) theory of complex organizations, posits that (1) the knowledge needed to perform the work of an organization and (2) the materials used to accomplish the tasks determine the structure of an organization. In our study, resources such as staff (knowledge) and equipment (materials) were identified by residents as important influences on food, food service, and resident food intake in the nursing home. Previous work by the authors found that the nursing home organization depended on the knowledge level and efficiency of its workers and the availability of staff to assist residents during the meal (Crogan, Evans, Severtsen, & Shultz, 2004). CONCEPTUAL FRAMEWORK COMPONENT TWO: ENVIRONMENTAL PRESS
Lawton’s (1982) Person-Environment Fit Theory (P-E Fit), the second component of the conceptual framework, was used to explain why resi-
EVANS, CROGAN, AND ARMSTRONG SHULTZ
dents might react differently to the same nursing home environment and services. Lawton (1982) believes that competence (resident abilities) and environmental press (outside stimuli bombarding the resident such as staff behaviors or attitudes, food service policies and procedures, or characteristics of the physical setting) must be balanced for optimal resident function. As an individual’s competence (or abilities) decreases, the environment must become more supportive to compensate. In relation to food intake, compromised competence is reflected in factors such as poor dentition, difficulty swallowing, or inability of an individual to eat independently. Increased environmental press is demonstrated through factors such as regimented mealtimes, lack of staffing, and lack of staff sensitivity to individual preferences (food choice) and functional abilities. As an individual’s competence (ability) decreases, the environment must become more supportive to compensate.
As an individual’s competence (ability) decreases, the environment must become more supportive to compensate.
Asking residents about their personal perspectives on the nursing home environment to understand their individualized needs could shed light on P-E Fit in the area of food and food service and is key to quality of life in the nursing home. However, little work has been done to examine everyday consumer preferences for care (Kane, et al., 1997). Accordingly, a phenomenological study was initiated to discover the perspectives of nursing home residents on food and food service. The purposes of this article are to (1) describe coping strategies identified in the study that were used as a means of increasing feelings of competence or decreasing environmental press, (2) consider the resident coping strategies as a reflection of the nursing home’s ability (or inability) to promote P-E Fit for its residents, and (3) consider the resident coping strategies as specific indicators of the need for change in food or food service.
RESIDENT COPING STRATEGIES
METHODS
Research Design This preliminary study explored an area that was previously not well described, residents’ perspectives on food and food service in the nursing home, and created a basis for further inquiry (Miles & Huberman, 1994). The study used a “tell me a story” interview about food and food service in the nursing home that accessed the residents’ “insider” perspectives about the organization (Miles & Huberman, 1994). The goal of the study was to understand the meaning of food and food services for each resident through examination of the individual’s interpretation of his/her life experiences. Sample and Setting A purposive sample of 20 residents was selected from a local 140-bed skilled nursing, not-for-profit, free-standing facility in eastern Washington State. Criteria for inclusion in the study included fulltime residence in the nursing home, ability to speak in English, and ability/willingness to attend and respond to questions posed by the interviewer. All residents were able to feed themselves and make their needs known, but not all were ambulatory. Participants included five males and 15 females, including one male in his twenties, three women in their forties, and one male in his fifth decade of life. The remaining 15 informants ranged in age from 61 to 93 years of age. The heterogeneity of the sample was appropriate for the breadth of the phenomenon of interest (Miles & Huberman, 1994). Data Collection Following informed consent, a PhD community nutritionist or a nursing masters student completed single, face-to-face, tape-recorded, semi-structured interviews with each participant, an effective way to understand individual perspectives (Miles & Huberman, 1994). Participants were asked to “Tell me a story about a time when food tasted really good,” “Tell me a story about the best and the worst features of the meals in the nursing home,” and “Tell me what a perfect meal would be like in the nursing home.” The main issues raised by the resident during the interview and a clinical profile were recorded following the interaction on a contact summary sheet (Appendix A), along with the researcher’s reflections. The interview protocol and contact summary were pre-tested, evaluated
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for their ability to capture relevant data, and revised accordingly. After refinement, the contact summary guided planning for subsequent contacts, suggested new codes, facilitated coordination among the researchers, and acted as an adjunct to data analysis (Miles & Huberman, 1994). Data saturation was achieved before the final interview, meaning that all experiences were captured by the existing themes (Miles & Huberman, 1994). Data Analysis Using an approach deemed appropriate by Miles and Huberman (1994), each member of the research team took turns coding interviews according to pre-established procedural rules. This preliminary analysis was then presented to the group for consensus. Codes were organized into conceptual categories, exemplars were extracted from the data, and a computer program designed for qualitative analysis, ATLAS.ti (Scientific Software Development, Berlin, Germany), was used to generate themes and patterns, that is, overarching concepts that tie together bits of data (Miles & Huberman, 1994). Data were then displayed in a role-ordered matrix (Miles & Huberman, 1994) that enabled comparison across all 20 interviews of resident perspectives on their role in the nursing home organization. This matrix systematically sorted data from a set of “role occupants” (in this case, residents in a nursing home) into rows and columns (Miles & Huberman, 1994, p. 123) so that roles and perspectives of participants could be compared across issues of interest such as food history, criteria for good food, reasons for eating and not eating, and coping strategies. The matrix allowed the researchers “to test whether people in the same role do, in fact, see life in similar ways” (Miles & Huberman, 1994, p. 123). By using the compilation of coping strategies from this data display, a thematic conceptual matrix (Miles & Huberman, 1994) extended the analysis through a closer examination of resident responses to food and food service issues. For the purposes of this article, three thematic conceptual categories will be presented: mechanical coping strategies, psychological coping strategies, and relationship-oriented coping strategies. RESULTS
Issues surrounding food and food service in the nursing home organization led to resident coping
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Table 1. Conceptual Categories of Resident Coping Strategies in Response to Food and Food Service Category
Mechanical coping strategies Psychological coping strategies Relationship-oriented coping strategies
Definition of Category
Resident-initiated physical actions aimed at coping with food and food service issues and optimizing P-E Fit Cognitive or emotional coping responses Responses that involved reaching out to others to enhance communication and connection
strategies that fell into three conceptual categories: mechanical coping strategies, psychological coping strategies, and relationship-oriented strategies (Table 1). Mechanical strategies were defined as resident-initiated physical actions aimed at coping with food and food service issues and optimizing P-E fit. Psychological strategies were defined as cognitive or emotional coping responses, and relationship-oriented strategies were defined as responses that involved reaching out to others to enhance communication and connection. Issues surrounding food and food service in the nursing home organization led to resident coping strategies that fell into three conceptual categories: mechanical coping strategies, psychological coping strategies, and relationship-oriented strategies.
Issues surrounding food and food service in the nursing home organization led to resident coping strategies that fell into three conceptual categories: mechanical coping strategies, psychological coping strategies, and relationship-oriented strategies.
Mechanical Coping Strategies As shown in Table 2, mechanical coping involved such physical strategies as eating (or moving) somewhere else, changing menu selections, flushing food down the toilet, and convincing staff that dietary restrictions should not be imposed inappropriately. Residents also ate food that relatives or friends brought, sometimes purchasing a small refrigerator for their rooms, and sampled friends’ food in the dining room. They washed unpalatable food down with liquids, “picked out just enough to get by,” and scraped excess pepper off some foods.
They asked for an alternative food or different amounts of food in the dining room, sometimes scraping the plate with bread to indicate a desire for more, and occasionally sent “raw-looking meat” back to the kitchen. Psychological Coping Strategies Psychological coping included worrying and complaining about the food, trying to get used to it, and “being flexible.” Some residents privately laid plans to go home, and ate in their rooms while pretending they were already there. Others “doctored” the food, imagining they had prepared it in their own kitchens, and “worked the system” to get extra condiments or items to support this effort. Some, who had adjusted positively to nursing home food, reported that, “Everyone gets everything they want . . . [what] fun it is to open the cover on the dish! You just want to dive right in, it looks so appetizing.” By contrast, some grimly expressed disgust at food “that looked like a cat threw up on my plate” and a lack of hope in regard to change. Others simply accepted the situation and refused to try to initiate change, even declining opportunities to complain. Relationship-Oriented Coping Strategies Relationship-oriented coping incorporated overtures to nursing home staff and other residents. Some residents tried to make friends with staff, bringing them treats from their visits home, and trying to get them to understand the residents’ dietary needs. These residents assumed a position of advocacy for both residents and staff, excusing errors and complimenting them on their caring, hard work, and efficiency when the residents’ overtures of friendship were reciprocated. DISCUSSION AND IMPLICATIONS FOR PRACTICE
Malnutrition in nursing homes is a multidimensional issue that calls for nursing leadership. “It is a sad reflection on our society that some of our
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Table 2. Response to Food and Food Service in the Nursing Home that Indicate a Need for Dietary Services Change Coping Strategies Issue
Food
Mechanical
Eat out Scrape pepper off Flush food down toilet Convince staff of ability to eat regular diet Get day-old fritters at store Eat food that friend or family brings
Worry about food Be flexible Plan to go home Decline to complain Complain Love the food
Refrigerator in room for jam and bread Wash food down
Use humor Get used to it Let the situation be or accept it Let people think the food is free
Pick out enough to get by Move to another nursing home Taste spaghetti from tablemate Eat vegetables with meat and milk to solidify stool Food service
Psychological
Change selections on card
Eat in your room
Ask for fresh fruit, vegetables
Pretend to be at home
Ask for alternatives Ask for 1/2 portions, all dessert
“Doctor” the food Work the system Planning for assisted living
Ask for double portion Send food back Scrape plate with bread Ask for more food
elders are malnourished and starved in the midst of plenty” (Chen, Schilling, & Lyder, 2001, p. 139). How, then, can nurses intervene in malnutrition in nursing homes? One important way, spotlighted by this study, is to monitor resident coping strategies in relation to food and food service in the nursing home, to recognize that these strategies are used by residents as a means of dealing with inadequate food or food service, and to advocate for change. For example, nurses can work with dietary departments and administrators to help them understand that when residents use coping mechanisms (such as scraping off pepper) to improve unpalatable food, those coping strategies point directly and emphatically to the need for change in menus, food preparation, or food service in the nursing home. Malnutrition in nursing homes is a multidimensional issue that calls for nursing leadership. Put another way, the residents in nursing homes already function at a low level of competence or they would be in their own homes. They have
Relationship-Oriented
Make friends with staff Have fun while eating with friends Advocate for other residents Bring special food from home Gather together Invite researcher to see food Eat and talk with friends in dining room
Excuse/compliment staff Communicate with RD, NACs, diet tech, maintenance staff Help staff/get different outlook on them
Malnutrition in nursing homes is a multidimensional issue that calls for nursing leadership.
difficulty dealing with environmental press (Lawton, 1982) because of that lowered competence, so they resort to scraping off pepper because they are unable to prepare their own food with the right amount of seasonings. That is, they must depend on the knowledge of the staff and the materials used in food service to provide food that will pique their appetites and result in adequate nutritional intake (Perrow, 1979). Resident Response to Environmental Press Recent work on individualized care underscores the importance of the dining experience in nursing
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home quality of life (Rantz, et al., 2000). To provide individualized care and promote P-E fit (Lawton, 1982), consumer perspectives must be taken into account. Unfortunately, residents sometimes avoid verbal expression of their needs because they believe they should be content with what is offered, and nurses fail to ask questions for fear of “prying” (Sidenvall, 1999). Notably, only 55% of nursing assistants believe that they know the personal tastes of most of the residents under their care Kane et al. (1997). However, we have documented in this study that even though the staff may be unaware of their needs, residents themselves adjust food and food service, if possible, to their own taste and nutritional needs. Residents should have allies in this process, however, and nursing assistants could be empowered by nurses who teach them to become more responsive to resident needs, emphasizing personalized assistance. When caregivers “act to assist the person in meeting their own life goals and preferences and act at the patient’s discretion” (Kane, et al., 1997, p. 1092), the emphasis is placed on choice, privacy, and as normal a lifestyle as possible. Even extremely impaired older people can be cared for in this way, but nursing homes must be willing to provide sufficient numbers of nursing assistants, adequate training in communication and other psychosocial concerns, and effective supervision by nurses are needed. (Nursing home surveys documenting unacceptable levels of resident weight loss and pressure ulcers can provide incentives for administrators to provide needed staff and materials.) People who live in, and people who study, groups and organizations “know that how you see life depends, in part, on your role” (Miles & Huberman, 1994, p. 122), which is a set of expectations and behaviors that define your actions in a particular setting. Elicitation of residents’ perspectives on their role in food and food services in the context of the nursing home is a way to study competence, environmental press, and the “fit” between those factors (Lawton, 1982). Residents can articulate their response to environmental press in descriptions of specific strategies that help them cope with food and food service that is unlike that which they enjoyed in their own homes. In our study, these strategies were aimed at maximizing their own competence or easing the demands of environmental press in the organization through mechanical, psychological, or relationship-ori-
EVANS, CROGAN, AND ARMSTRONG SHULTZ
ented means. Additional research is needed to determine the relationship between coping strategies and their influence on quality of life and dietary outcomes. Resident Response to Organizational Structure The three conceptual categories of coping strategies described earlier (mechanical, psychological, and relationship-oriented) are resident responses to the nursing home organization in terms of staff knowledge, as well as numbers of staff, food, and equipment availability (materials) (Perrow, 1979). These resident responses should be used as a “wake-up call” for the nursing home, because if the quality of their food and food service were adequate, there would be no need for residents to rely on themselves to “remodel” the unpalatable meals. Individual resident choice is integral to perceived quality of life in the nursing home. Unfortunately, most nursing homes offer very few opportunities for residents to choose the food they want to eat (materials) (Kayser-Jones, 2000; Perrow, 1979). In fact, some nursing home administrators believe that it is not economically possible to have a selective menu, but Kayser-Jones noted that a large amount of food was wasted at mealtime and hypothesized that if residents had more choice, waste would decrease. Residents crave certain foods, including ethnic or cultural specialties served in the family home, and appetites could be stimulated by provision of those foods on a regular basis (Crogan, Evans, Severtsen, & Shultz, 2004). Choice in food service is an issue, as well. Residents want their dining rooms to look like home, and they want a voice in hiring of compatible staff (Perrow, 1979) that will be attentive to resident preferences. They want nursing assistants who possess good communication skills, awareness of cultural differences, and effective feeding skills for staff dining rooms (Crogan, Evans, Severtsen, & Shultz, 2004). Paramount to good food service is adequate dining room supervision and teaching of staff by a licensed nurse (Kayser-Jones, 2000). Family members can also furnish choices for residents with gifts of special food or the placement of a small refrigerator in the resident’s room so that “goodies” can be accessed at will (materials) (Perrow, 1979). These “goodies,” such as bread and milk, may reflect life-long preferences and provide comfort that supersedes medications. Their availability also may decrease the resident’s
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sense of loss and increase opportunities for choice, and do not require the presence of a staff member to access the food, therefore promoting food intake (Evans, Crogan, & Shultz, 2003). These notions about choice, combined with resident responses to lack of choice identified in our study, lead directly to recognition of the need for organizational change with corresponding alterations in food service. Organizational changes can lead to “best practices” in nutrition care for nursing home residents such as the use of a tool to assess the need for food and food service changes (Crogan & Evans, in press; Evans & Crogan, in press). Another “best practice,” a Hot Food Cart (a type of steam table) (Darke, 1998) containing a plate warmer; enables dietary staff to move from table to table describing and then serving the food, resulting in increased satisfaction and fewer complaints from nursing home residents. Moreover, a buffetstyle dining program (supper only for 3 months) for 40 nursing home residents has resulted in stable overall mean weight and standard biochemical indicators of nutritional status along with a 25% increase in resident satisfaction with food and food service (Remsburg, et al., 2001). Recognition of resident coping strategies as an indicator for needed dietary services change—an innovative view of these resident behaviors—
could result in improved nutritional status, decreased nutrition-related morbidity and mortality, improved quality of life, and reduced health care costs for older Americans residing in nursing homes. Inquiry into the use of these strategies addresses an important sociopolitical issue and generates knowledge that contributes to emancipation, empowerment, and change (Berman, FordGilboe, & Campbell, 1998). APPENDIX A. CONTACT SUMMARY SHEET (ADAPTED FROM MILES AND HUBERMAN, 1994)
Interviewer Name Date of Interview Resident’s Name Age Site Medical Diagnoses: Relevant Nursing Assessment Data: 1. What were the main issues/themes that struck you in this interview? 2. What information did you get (or fail to get) from each question (include paraverbal and nonverbal)? ● A time when food tasted good? ● The best and the worst features of the meals in the nursing home? ● A perfect meal in the nursing home? 3. Anything else that was salient, interesting, illuminating, or serendipitous?
REFERENCES American Health Care Association. (1998). Facts and trends, the nursing facility sourcebook. Washington, DC: American Health Care Association. Berman, H., Ford-Gilboe, M., & Campbell, J. (1998). Combining stories and numbers: A methodologic approach for a critical nursing science. Advances in Nursing Science, 21(1), 1-15. Chen, C., Schilling, L., & Lyder, C. (2001). A concept analysis of malnutrition in the elderly. Journal of Advanced Nursing, 36(1), 131-142. Crogan, N., Evans, B., Severtsen, B., & Shultz, J. (2004). Improving nursing home food service: Uncovering the meaning of food through resident’s stories. Journal of Gerontological Nursing 30(2), 29–36. Crogan, N.L., & Evans, B.C. (in press). Measuring nursing home resident satisfaction with food and food service: Uncovering the meaning of food through resident’s stories. Journal of Gerontology: Medical Sciences. Darke, S. (1998). Your turn: What methods do you use to make mealtime a pleasurable but efficient experience in your setting? Journal of Gerontological Nursing, 24(3), 52-55. Evans, B., Crogan, N., & Shultz, J. (2003). Quality dining in the nursing home: The resident’s perspective. Journal of Nutrition in the Elderly, 22(3), 1–17. Evans, B.C., & Crogan, N.L. (in press). The Food Ex-LTC: A measure of resident food and food service satisfaction. Journal of Gerontology: Medical Sciences.
Kane, R., Caplan, A., Uru-Wong, E., Freeman, I., Aroskar, M., & Finch, M. (1997). Everyday matters in the lives of nursing home residents: Wish for and perception of choice and control. Journal of the American Geriatric Society, 45, 1086-1093. Kayser-Jones, J. (2000). Improving the nutritional care of nursing home residents. Nursing Homes, 49(10), 56-59. Lawton, M.Competence, environmental press, and the adaptation of old people. (1982). Aging and the environment: Theoretical approaches. In Layton M., Windley P., Byerts T. (pp. 33-59). New York: Springer. Miles, M., & Huberman, A. (1994). Qualitative data analysis. (2nd ed.). Thousand Oaks, CA: Sage. Perrow, C. (1979). Complex organizations. New York: Random House. Rantz, M., Mehr, D., Petroski, G., Madsen, R., Popejoy, L., Hicks, L., et al. (2000). Initial field testing of an instrument to measure: Observable indicators of nursing home care quality. Journal of Nursing Care Quality, 14(3), 1-12. Remsburg, R., Luking, A., Baran, P., Radu, C., Pineda, D., & Bennett, R., et al. (2001). Impact of a buffet-style dining program on weight and biochemical indicators of nutritional status in nursing home residents: A pilot study. Journal of the American Dietetic Association, 102(12), 1460-1463. Sidenvall, B. (1999). Meal procedures in institutions for elderly people: A theoretical interpretation. Journal of Advanced Nursing, 30(2), 319-328.
Inadequate food intake leading to malnutrition impacts up to 85% of nursing home residents. Malnutrition can result in compromised quality of life and lead to chronic disability, functional decline, increased health care utilization and costs, and death. This article examines organizational structure (Perrow, 1979) and person-environment fit (Lawton, 1982) as factors in nutritional care of nursing home residents. The strategies used by residents to cope with organizational food and food service issues, competence, and environmental press in the nursing home can alert nurses to the need for changes in dietary services to increase food intake and quality of life. © 2004 Elsevier Inc. All rights reserved.
I
NADEQUATE FOOD INTAKE leading to malnutrition impacts up to 85% of nursing home residents (Kayser-Jones, 2000). Malnutrition, defined as insufficient dietary intake among essential nutrients, can result in compromised quality of life and can lead to chronic disability, functional decline, increased health care utilization, increased health care costs, and death (Chen, Schilling, & Lyder, 2001). Antecedents to malnutrition for nursing home residents include loss of optimal body composition, oral health, sensory function, and role function (Chen, Schilling, & Lyder, 2001). Other antecedents are functional dependency, when elders have difficulty with activities of daily living, and loneliness. Social isolation also may result in depression and decreased food intake and chronic illness requiring multiple medications may place residents at risk for drug-induced malnutrition. Poor quality food or food service also can affect food intake as shown by Crogan et al. (2004) and
Bronwynne C. Evans, PhD, RN, CNS, Assistant Professor, Intercollegiate College of Nursing, Washington State University, Spokane, WA; Neva L. Crogan, PhD, APRN, BC, Assistant Professor, College of Nursing, University of Arizona, Tucson, AZ; Jill Armstrong Shultz, PhD, Professor, Food Science and Human Nutrition, Washington State University, Pullman, WA. Address reprint requests to Bronwynne C. Evans, PhD, RN, CNS, Intercollegiate College of Nursing, Washington State University, 2917 Ft. George Wright Drive, Spokane, WA 992245291. E-mail: [email protected] © 2004 Elsevier Inc. All rights reserved. 0897-1897/04/1702-0006$30.00/0 doi:10.1016/j.apnr.2004.02.003 Applied Nursing Research, Vol. 17, No. 2 (May), 2004: pp 109-115
Evans et al. (2003). In these studies, residents sorely missed their own homes and the control over their own diets. Foods that reminded them of their ethnic or cultural identities were often unavailable and residents counted this as a significant loss. Even foods not regarded as “special” were frequently poorly prepared or prepared in an unfamiliar way, increasing the sense of discontinuity and loss. Even foods not regarded as “special” were frequently poorly prepared or prepared in an unfamiliar way, increasing the sense of discontinuity and loss. In these two studies, residents also missed the dining ambiance to which they were accustomed. They wished for attractive meal service and the food rituals and traditions associated with family meals and social occasions. Because they had lost much of their ability to care for themselves, they were at the mercy of nursing home food providers and food service system (partially mandated by federal Omnibus Reconciliation Act regulations). However, they learned to circumvent some of the institutional rigidity by figuring out how to “work with the system” to meet their individual preferences. They cultivated relationships with staff because they realized that staff members were the conduit to choice in food and food service. Staffresident interactions in the context of these relationships occurred on a more personal level and staff members were more likely to individualize nutrition care. Individualized care was an important issue because food service in the nursing home can easily become task-oriented rather than resident-oriented (Sidenvall, 1999). In Sidenvall’s sec109
110
ondary analysis of 20 nursing home residents, meal procedures were not adapted to individual residents’ personalities or preferences or to their specific inabilities or needs. In short, procedures were organized to meet the needs of staff, rather than the individualized needs of residents.
Even foods not regarded as “special” were frequently poorly prepared or prepared in an unfamiliar way, increasing the sense of discontinuity and loss.
Finally, malnutrition is exacerbated by the fact that nationally more than 56% of nursing home residents now need assistance with eating (American Health Care Association, 1998). Additionally, sufficient numbers of staff may not be available to provide even the most basic nutrition care. In fact, inadequate staffing has been called the most significant barrier to sufficient resident food intake (Kayser-Jones, 2000). CONCEPTUAL FRAMEWORK COMPONENT ONE: ORGANIZATIONAL STRUCTURE
The conceptual framework used to guide investigation into food and food service issues from the perspective of nursing home residents had two components. The first component, Perrow’s (1979) theory of complex organizations, posits that (1) the knowledge needed to perform the work of an organization and (2) the materials used to accomplish the tasks determine the structure of an organization. In our study, resources such as staff (knowledge) and equipment (materials) were identified by residents as important influences on food, food service, and resident food intake in the nursing home. Previous work by the authors found that the nursing home organization depended on the knowledge level and efficiency of its workers and the availability of staff to assist residents during the meal (Crogan, Evans, Severtsen, & Shultz, 2004). CONCEPTUAL FRAMEWORK COMPONENT TWO: ENVIRONMENTAL PRESS
Lawton’s (1982) Person-Environment Fit Theory (P-E Fit), the second component of the conceptual framework, was used to explain why resi-
EVANS, CROGAN, AND ARMSTRONG SHULTZ
dents might react differently to the same nursing home environment and services. Lawton (1982) believes that competence (resident abilities) and environmental press (outside stimuli bombarding the resident such as staff behaviors or attitudes, food service policies and procedures, or characteristics of the physical setting) must be balanced for optimal resident function. As an individual’s competence (or abilities) decreases, the environment must become more supportive to compensate. In relation to food intake, compromised competence is reflected in factors such as poor dentition, difficulty swallowing, or inability of an individual to eat independently. Increased environmental press is demonstrated through factors such as regimented mealtimes, lack of staffing, and lack of staff sensitivity to individual preferences (food choice) and functional abilities. As an individual’s competence (ability) decreases, the environment must become more supportive to compensate.
As an individual’s competence (ability) decreases, the environment must become more supportive to compensate.
Asking residents about their personal perspectives on the nursing home environment to understand their individualized needs could shed light on P-E Fit in the area of food and food service and is key to quality of life in the nursing home. However, little work has been done to examine everyday consumer preferences for care (Kane, et al., 1997). Accordingly, a phenomenological study was initiated to discover the perspectives of nursing home residents on food and food service. The purposes of this article are to (1) describe coping strategies identified in the study that were used as a means of increasing feelings of competence or decreasing environmental press, (2) consider the resident coping strategies as a reflection of the nursing home’s ability (or inability) to promote P-E Fit for its residents, and (3) consider the resident coping strategies as specific indicators of the need for change in food or food service.
RESIDENT COPING STRATEGIES
METHODS
Research Design This preliminary study explored an area that was previously not well described, residents’ perspectives on food and food service in the nursing home, and created a basis for further inquiry (Miles & Huberman, 1994). The study used a “tell me a story” interview about food and food service in the nursing home that accessed the residents’ “insider” perspectives about the organization (Miles & Huberman, 1994). The goal of the study was to understand the meaning of food and food services for each resident through examination of the individual’s interpretation of his/her life experiences. Sample and Setting A purposive sample of 20 residents was selected from a local 140-bed skilled nursing, not-for-profit, free-standing facility in eastern Washington State. Criteria for inclusion in the study included fulltime residence in the nursing home, ability to speak in English, and ability/willingness to attend and respond to questions posed by the interviewer. All residents were able to feed themselves and make their needs known, but not all were ambulatory. Participants included five males and 15 females, including one male in his twenties, three women in their forties, and one male in his fifth decade of life. The remaining 15 informants ranged in age from 61 to 93 years of age. The heterogeneity of the sample was appropriate for the breadth of the phenomenon of interest (Miles & Huberman, 1994). Data Collection Following informed consent, a PhD community nutritionist or a nursing masters student completed single, face-to-face, tape-recorded, semi-structured interviews with each participant, an effective way to understand individual perspectives (Miles & Huberman, 1994). Participants were asked to “Tell me a story about a time when food tasted really good,” “Tell me a story about the best and the worst features of the meals in the nursing home,” and “Tell me what a perfect meal would be like in the nursing home.” The main issues raised by the resident during the interview and a clinical profile were recorded following the interaction on a contact summary sheet (Appendix A), along with the researcher’s reflections. The interview protocol and contact summary were pre-tested, evaluated
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for their ability to capture relevant data, and revised accordingly. After refinement, the contact summary guided planning for subsequent contacts, suggested new codes, facilitated coordination among the researchers, and acted as an adjunct to data analysis (Miles & Huberman, 1994). Data saturation was achieved before the final interview, meaning that all experiences were captured by the existing themes (Miles & Huberman, 1994). Data Analysis Using an approach deemed appropriate by Miles and Huberman (1994), each member of the research team took turns coding interviews according to pre-established procedural rules. This preliminary analysis was then presented to the group for consensus. Codes were organized into conceptual categories, exemplars were extracted from the data, and a computer program designed for qualitative analysis, ATLAS.ti (Scientific Software Development, Berlin, Germany), was used to generate themes and patterns, that is, overarching concepts that tie together bits of data (Miles & Huberman, 1994). Data were then displayed in a role-ordered matrix (Miles & Huberman, 1994) that enabled comparison across all 20 interviews of resident perspectives on their role in the nursing home organization. This matrix systematically sorted data from a set of “role occupants” (in this case, residents in a nursing home) into rows and columns (Miles & Huberman, 1994, p. 123) so that roles and perspectives of participants could be compared across issues of interest such as food history, criteria for good food, reasons for eating and not eating, and coping strategies. The matrix allowed the researchers “to test whether people in the same role do, in fact, see life in similar ways” (Miles & Huberman, 1994, p. 123). By using the compilation of coping strategies from this data display, a thematic conceptual matrix (Miles & Huberman, 1994) extended the analysis through a closer examination of resident responses to food and food service issues. For the purposes of this article, three thematic conceptual categories will be presented: mechanical coping strategies, psychological coping strategies, and relationship-oriented coping strategies. RESULTS
Issues surrounding food and food service in the nursing home organization led to resident coping
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Table 1. Conceptual Categories of Resident Coping Strategies in Response to Food and Food Service Category
Mechanical coping strategies Psychological coping strategies Relationship-oriented coping strategies
Definition of Category
Resident-initiated physical actions aimed at coping with food and food service issues and optimizing P-E Fit Cognitive or emotional coping responses Responses that involved reaching out to others to enhance communication and connection
strategies that fell into three conceptual categories: mechanical coping strategies, psychological coping strategies, and relationship-oriented strategies (Table 1). Mechanical strategies were defined as resident-initiated physical actions aimed at coping with food and food service issues and optimizing P-E fit. Psychological strategies were defined as cognitive or emotional coping responses, and relationship-oriented strategies were defined as responses that involved reaching out to others to enhance communication and connection. Issues surrounding food and food service in the nursing home organization led to resident coping strategies that fell into three conceptual categories: mechanical coping strategies, psychological coping strategies, and relationship-oriented strategies.
Issues surrounding food and food service in the nursing home organization led to resident coping strategies that fell into three conceptual categories: mechanical coping strategies, psychological coping strategies, and relationship-oriented strategies.
Mechanical Coping Strategies As shown in Table 2, mechanical coping involved such physical strategies as eating (or moving) somewhere else, changing menu selections, flushing food down the toilet, and convincing staff that dietary restrictions should not be imposed inappropriately. Residents also ate food that relatives or friends brought, sometimes purchasing a small refrigerator for their rooms, and sampled friends’ food in the dining room. They washed unpalatable food down with liquids, “picked out just enough to get by,” and scraped excess pepper off some foods.
They asked for an alternative food or different amounts of food in the dining room, sometimes scraping the plate with bread to indicate a desire for more, and occasionally sent “raw-looking meat” back to the kitchen. Psychological Coping Strategies Psychological coping included worrying and complaining about the food, trying to get used to it, and “being flexible.” Some residents privately laid plans to go home, and ate in their rooms while pretending they were already there. Others “doctored” the food, imagining they had prepared it in their own kitchens, and “worked the system” to get extra condiments or items to support this effort. Some, who had adjusted positively to nursing home food, reported that, “Everyone gets everything they want . . . [what] fun it is to open the cover on the dish! You just want to dive right in, it looks so appetizing.” By contrast, some grimly expressed disgust at food “that looked like a cat threw up on my plate” and a lack of hope in regard to change. Others simply accepted the situation and refused to try to initiate change, even declining opportunities to complain. Relationship-Oriented Coping Strategies Relationship-oriented coping incorporated overtures to nursing home staff and other residents. Some residents tried to make friends with staff, bringing them treats from their visits home, and trying to get them to understand the residents’ dietary needs. These residents assumed a position of advocacy for both residents and staff, excusing errors and complimenting them on their caring, hard work, and efficiency when the residents’ overtures of friendship were reciprocated. DISCUSSION AND IMPLICATIONS FOR PRACTICE
Malnutrition in nursing homes is a multidimensional issue that calls for nursing leadership. “It is a sad reflection on our society that some of our
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Table 2. Response to Food and Food Service in the Nursing Home that Indicate a Need for Dietary Services Change Coping Strategies Issue
Food
Mechanical
Eat out Scrape pepper off Flush food down toilet Convince staff of ability to eat regular diet Get day-old fritters at store Eat food that friend or family brings
Worry about food Be flexible Plan to go home Decline to complain Complain Love the food
Refrigerator in room for jam and bread Wash food down
Use humor Get used to it Let the situation be or accept it Let people think the food is free
Pick out enough to get by Move to another nursing home Taste spaghetti from tablemate Eat vegetables with meat and milk to solidify stool Food service
Psychological
Change selections on card
Eat in your room
Ask for fresh fruit, vegetables
Pretend to be at home
Ask for alternatives Ask for 1/2 portions, all dessert
“Doctor” the food Work the system Planning for assisted living
Ask for double portion Send food back Scrape plate with bread Ask for more food
elders are malnourished and starved in the midst of plenty” (Chen, Schilling, & Lyder, 2001, p. 139). How, then, can nurses intervene in malnutrition in nursing homes? One important way, spotlighted by this study, is to monitor resident coping strategies in relation to food and food service in the nursing home, to recognize that these strategies are used by residents as a means of dealing with inadequate food or food service, and to advocate for change. For example, nurses can work with dietary departments and administrators to help them understand that when residents use coping mechanisms (such as scraping off pepper) to improve unpalatable food, those coping strategies point directly and emphatically to the need for change in menus, food preparation, or food service in the nursing home. Malnutrition in nursing homes is a multidimensional issue that calls for nursing leadership. Put another way, the residents in nursing homes already function at a low level of competence or they would be in their own homes. They have
Relationship-Oriented
Make friends with staff Have fun while eating with friends Advocate for other residents Bring special food from home Gather together Invite researcher to see food Eat and talk with friends in dining room
Excuse/compliment staff Communicate with RD, NACs, diet tech, maintenance staff Help staff/get different outlook on them
Malnutrition in nursing homes is a multidimensional issue that calls for nursing leadership.
difficulty dealing with environmental press (Lawton, 1982) because of that lowered competence, so they resort to scraping off pepper because they are unable to prepare their own food with the right amount of seasonings. That is, they must depend on the knowledge of the staff and the materials used in food service to provide food that will pique their appetites and result in adequate nutritional intake (Perrow, 1979). Resident Response to Environmental Press Recent work on individualized care underscores the importance of the dining experience in nursing
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home quality of life (Rantz, et al., 2000). To provide individualized care and promote P-E fit (Lawton, 1982), consumer perspectives must be taken into account. Unfortunately, residents sometimes avoid verbal expression of their needs because they believe they should be content with what is offered, and nurses fail to ask questions for fear of “prying” (Sidenvall, 1999). Notably, only 55% of nursing assistants believe that they know the personal tastes of most of the residents under their care Kane et al. (1997). However, we have documented in this study that even though the staff may be unaware of their needs, residents themselves adjust food and food service, if possible, to their own taste and nutritional needs. Residents should have allies in this process, however, and nursing assistants could be empowered by nurses who teach them to become more responsive to resident needs, emphasizing personalized assistance. When caregivers “act to assist the person in meeting their own life goals and preferences and act at the patient’s discretion” (Kane, et al., 1997, p. 1092), the emphasis is placed on choice, privacy, and as normal a lifestyle as possible. Even extremely impaired older people can be cared for in this way, but nursing homes must be willing to provide sufficient numbers of nursing assistants, adequate training in communication and other psychosocial concerns, and effective supervision by nurses are needed. (Nursing home surveys documenting unacceptable levels of resident weight loss and pressure ulcers can provide incentives for administrators to provide needed staff and materials.) People who live in, and people who study, groups and organizations “know that how you see life depends, in part, on your role” (Miles & Huberman, 1994, p. 122), which is a set of expectations and behaviors that define your actions in a particular setting. Elicitation of residents’ perspectives on their role in food and food services in the context of the nursing home is a way to study competence, environmental press, and the “fit” between those factors (Lawton, 1982). Residents can articulate their response to environmental press in descriptions of specific strategies that help them cope with food and food service that is unlike that which they enjoyed in their own homes. In our study, these strategies were aimed at maximizing their own competence or easing the demands of environmental press in the organization through mechanical, psychological, or relationship-ori-
EVANS, CROGAN, AND ARMSTRONG SHULTZ
ented means. Additional research is needed to determine the relationship between coping strategies and their influence on quality of life and dietary outcomes. Resident Response to Organizational Structure The three conceptual categories of coping strategies described earlier (mechanical, psychological, and relationship-oriented) are resident responses to the nursing home organization in terms of staff knowledge, as well as numbers of staff, food, and equipment availability (materials) (Perrow, 1979). These resident responses should be used as a “wake-up call” for the nursing home, because if the quality of their food and food service were adequate, there would be no need for residents to rely on themselves to “remodel” the unpalatable meals. Individual resident choice is integral to perceived quality of life in the nursing home. Unfortunately, most nursing homes offer very few opportunities for residents to choose the food they want to eat (materials) (Kayser-Jones, 2000; Perrow, 1979). In fact, some nursing home administrators believe that it is not economically possible to have a selective menu, but Kayser-Jones noted that a large amount of food was wasted at mealtime and hypothesized that if residents had more choice, waste would decrease. Residents crave certain foods, including ethnic or cultural specialties served in the family home, and appetites could be stimulated by provision of those foods on a regular basis (Crogan, Evans, Severtsen, & Shultz, 2004). Choice in food service is an issue, as well. Residents want their dining rooms to look like home, and they want a voice in hiring of compatible staff (Perrow, 1979) that will be attentive to resident preferences. They want nursing assistants who possess good communication skills, awareness of cultural differences, and effective feeding skills for staff dining rooms (Crogan, Evans, Severtsen, & Shultz, 2004). Paramount to good food service is adequate dining room supervision and teaching of staff by a licensed nurse (Kayser-Jones, 2000). Family members can also furnish choices for residents with gifts of special food or the placement of a small refrigerator in the resident’s room so that “goodies” can be accessed at will (materials) (Perrow, 1979). These “goodies,” such as bread and milk, may reflect life-long preferences and provide comfort that supersedes medications. Their availability also may decrease the resident’s
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sense of loss and increase opportunities for choice, and do not require the presence of a staff member to access the food, therefore promoting food intake (Evans, Crogan, & Shultz, 2003). These notions about choice, combined with resident responses to lack of choice identified in our study, lead directly to recognition of the need for organizational change with corresponding alterations in food service. Organizational changes can lead to “best practices” in nutrition care for nursing home residents such as the use of a tool to assess the need for food and food service changes (Crogan & Evans, in press; Evans & Crogan, in press). Another “best practice,” a Hot Food Cart (a type of steam table) (Darke, 1998) containing a plate warmer; enables dietary staff to move from table to table describing and then serving the food, resulting in increased satisfaction and fewer complaints from nursing home residents. Moreover, a buffetstyle dining program (supper only for 3 months) for 40 nursing home residents has resulted in stable overall mean weight and standard biochemical indicators of nutritional status along with a 25% increase in resident satisfaction with food and food service (Remsburg, et al., 2001). Recognition of resident coping strategies as an indicator for needed dietary services change—an innovative view of these resident behaviors—
could result in improved nutritional status, decreased nutrition-related morbidity and mortality, improved quality of life, and reduced health care costs for older Americans residing in nursing homes. Inquiry into the use of these strategies addresses an important sociopolitical issue and generates knowledge that contributes to emancipation, empowerment, and change (Berman, FordGilboe, & Campbell, 1998). APPENDIX A. CONTACT SUMMARY SHEET (ADAPTED FROM MILES AND HUBERMAN, 1994)
Interviewer Name Date of Interview Resident’s Name Age Site Medical Diagnoses: Relevant Nursing Assessment Data: 1. What were the main issues/themes that struck you in this interview? 2. What information did you get (or fail to get) from each question (include paraverbal and nonverbal)? ● A time when food tasted good? ● The best and the worst features of the meals in the nursing home? ● A perfect meal in the nursing home? 3. Anything else that was salient, interesting, illuminating, or serendipitous?
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Kane, R., Caplan, A., Uru-Wong, E., Freeman, I., Aroskar, M., & Finch, M. (1997). Everyday matters in the lives of nursing home residents: Wish for and perception of choice and control. Journal of the American Geriatric Society, 45, 1086-1093. Kayser-Jones, J. (2000). Improving the nutritional care of nursing home residents. Nursing Homes, 49(10), 56-59. Lawton, M.Competence, environmental press, and the adaptation of old people. (1982). Aging and the environment: Theoretical approaches. In Layton M., Windley P., Byerts T. (pp. 33-59). New York: Springer. Miles, M., & Huberman, A. (1994). Qualitative data analysis. (2nd ed.). Thousand Oaks, CA: Sage. Perrow, C. (1979). Complex organizations. New York: Random House. Rantz, M., Mehr, D., Petroski, G., Madsen, R., Popejoy, L., Hicks, L., et al. (2000). Initial field testing of an instrument to measure: Observable indicators of nursing home care quality. Journal of Nursing Care Quality, 14(3), 1-12. Remsburg, R., Luking, A., Baran, P., Radu, C., Pineda, D., & Bennett, R., et al. (2001). Impact of a buffet-style dining program on weight and biochemical indicators of nutritional status in nursing home residents: A pilot study. Journal of the American Dietetic Association, 102(12), 1460-1463. Sidenvall, B. (1999). Meal procedures in institutions for elderly people: A theoretical interpretation. Journal of Advanced Nursing, 30(2), 319-328.