Eating involves more than consuming nutrients necessary to sustain life or to increase or decrease weight. For the elderly especially, eating is often a symbolic experience embedded with lifelong patterns and cultural preferences. This experience often changes when elders are admitted to long-term care institutions. Many elders lose some independence in their ability to feed themselves and therefore require various degrees of assistance.
In our long-term care department, recent resident classification surveys indicated that approximately half of the residents require some assistance to either organize themselves to eat or to actually eat their meals. The aim of such assistance should be to help elderly residents maintain existing abilities or recover, as much as possible, lost abilities. Nurses are responsible for providing most of this assistance and therefore need to be comfortable with their ability to feed the elderly in a safe and dignified manner.
On one long-term care unit in our 450-bed extended care faculty, the nursing unit director had concerns about some of the feeding techniques being used by staff members. In general, caregivers were inconsistent in the way they were helping residents maintain independence in eating and in feeding those who required more extensive help. When other professionals with expertise in swallowing disorders and relevant feeding techniques provided specific recommendations that would help the resident, caregivers carried them out inconsistently. These high-risk residents were not always ensured an eating experience that provided optimal safety.
The nursing unit director consulted with other members of the multidisciplinary team, including a clinical nurse specialist, and then generated several ideas for working with the nursing staff to help them enhance their feeding skills. These were discussed with the staff, and as a result the program described in this article was developed to help nurses improve and refine their feeding techniques. The feeding program was planned to include four components: a survey of staff knowledge and attitudes, validation of stated knowledge, inservice education, and a posteducation evaluation. To date, the first two components have been completed and the education component is currently underway. Although recognizing that nurses' feeding skills comprise only one component necessary to optimize the residents' eating experience, we felt that improving feeding skills was a necessary first step to accomplish before addressing other aspects of the resident eating experience.
The literature recognizes the importance of personalizing caregiver-elder interactions during mealtimes and the use of proper techniques to feed elders requiring assistance. Two groups in Sweden addressed the relationship aspect between caregivers and nursing home residents during mealtimes. Backstrom et al studied residents in nursing homes in one region of Sweden who were dependent on others for feeding.1 They recorded a high turnover of the number of caregivers assisting residents to eat; some elders were fed by as many as 16 to 20 nurses over the 4-week period. More than 90% of all meals were completed within 20 minutes. The authors postulated that such a high turnover of caregivers could negatively affect residents' eating ability, eating pleasure, and food intake.
Athlin and Norberg demonstrated an increased understanding on the part of caregivers of patients' behavior when the caregiver assignment at mealtimes was changed to a patient assignment system from a task assignment systern.2 During their study, four caregivers fed their assigned patient during 14 meals. Results indicated that, over time, caregivers began to focus on the relationship with the patient rather than solely on the task aspect of feeding.
Hogstel and Robinson emphasized the need to assess a person's swallowing ability, jaw strength, tongue movements, and cough and gag reflexes before providing food.3 They also reviewed strategies for caregivers to consider, such as the rate of feeding, allowing the resident choices about the order of food items, nurse and resident positioning, and providing a selection of foods that the elderly can manipulate independently. The Rehabilitation Institute of Chicago produced a video aimed at caregivers that demonstrates feeding techniques for individuals with dysphagia, a problem frequently encountered in any long-term care setting.4
In general, the nursing literature related to caregiver feeding techniques focuses on the skills required by caregivers from both a relationship aspect when performing the "intimate activity" of feeding someone and the technical aspect to ensure safe and dignified eating.5 An unstudied area is caregivers1 knowledge of issues and strategies that can contribute to a quality eating experience. We felt that this area of study was necessary before proceeding with further staff education.
The goal of this program was to help nurses on one long-term care unit refine their feeding skills. A secondary goal was to enable residents to maintain or regain as much independence in eating as possible. Staff input was believed to be paramount to the achievement of the stated goals and success of the project. With this as a guiding principle, the nursing unit director introduced the idea of a feeding program and engaged in a dialogue with the staff, seeking input and feedback in relation to the various stages of the program. The staffs input was instrumental in helping to structure and time various program components.
The methods employed reflected the need to validate the authors' perceptions that the staff needed assistance in honing their feeding skills; assist staff in recognizing their need for improved feeding skills; involve the staff in the process; and consider existing resource constraints. Multiple methods were used to meet these needs.
We developed a self-administered questionnaire to objectively assess the level of knowledge and attitudes toward feeding the elderly (Figure 1). The knowledge component comprised 20 multiple choice questions. The content of the questions was derived from clinical practice and relevant literature. The questionnaire addressed age-related changes affecting eating abilities, nursing assessment and preparation of residents prior to eating, positioning and environmental issues, techniques to help residents maintain independence in eating, knowledge of factors affecting swallowing ability, and actual feeding techniques unique to the elderly.
The attitude section consisted of 13 statements related to caring for and feeding the elderly. They were structured on a four-point Likert scale. The questionnaire was reviewed by three members of the multidisciplinary team and another clinicaï nurse specialist; their comments were incorporated into a second draft of the questionnaire. Two staff nurses on another unit then piloted the questionnaire and provided feedback as to the length of the instrument and clarity of the questions; their comments were incorporated into the final draft. The questionnaire was then completed by 22 staff members on the study unit.
We felt it was important to actually observe caregivers assisting residents at mealtimes to evaluate if stated knowledge was translated into clinical practice. To this end, a behavior checklist was developed to structure observations (Figure 2). It was constructed to include clinical dimensions assessed on the questionnaire, emphasizing those dimensions that were answered inaccurately by 25% or more of respondents. Before using the checklist, the nursing unit director and clinical nurse specialist independently rated nurses on another unit as they were helping residents at mealtime and revised several items on the checklist until consensus was reached on the rating of all items.
Prior to commencing with the behavioral audit component, the results obtained on the knowledge questionnaire were summarized and presented to the staff Plans for behavioral observations were presented to them with the assurance that the goal was to identify pertinent areas to include in education sessions. The staff agreed to participate in the observations, which were all conducted by the clinical nurse specialist. The population to be observed was composed of 23 full-time, part-time, and casual staff working a minimum of two shifts per week. A random stratified sample of 14 caregivers was taken. This included six registered nurses and four registered nursing assistants in addition to all three nursing orderlies and the unit aide.
SAMPLE ITEMS FROM KNOWLEDGE QUESTIONNAIRE
The 35 residents on the nursing unit were categorized by the nursing unit director as either independent or dependent in feeding. Residents considered to be independent were those requiring help to set up their trays or those requiring only verbal encouragement to eat their meals independently. Residents categorized as dependent required either partial or total feeding. All residents were also independently classified by each resident's primary nurse or associate caregiver. There was 91% agreement in the two sets of ratings. Each nurse was observed helping or feeding one independent and one dependent resident.
The sample of 22 staff members who completed the 20-item knowledge questionnaire was composed of nine registered nurses, nine registered nursing assistants, three nursing orderlies, and one unit aide. Responses were analyzed using Statistical Analysis System (SAS). The range of scores obtained was 7 to 17 and the mean was 12.6720 (63%). The mean scores among the different categories of staff were significantly different. There was no relationship between mean scores and length of time respondents had worked in nursing or whether they worked fulltime, part-time, or were casual staff For the purposes of this discussion, only those findings that are most critical to the program are highlighted.
Most of the staff were able to identify age-related changes that affect resident eating ability. However, only 72% could accurately recognize those changes that may increase the possibility of choking.
Several questions addressed nursing assessment of the resident's abilities and preferences and the preparation of the resident prior to eating. More than 90% of the respondents correctly identified that they needed to ensure that the resident was awake; alert; received mouth care; and had dentures, hearing aid, and glasses in place prior to eating. However, only 68% understood the importance of assessing residents' ability to swallow, their cultural and food preferences, and their ability to use utensils and communicate verbally. The same number, 68%, accurately identified environmental factors requiring assessment, such as the noise and aesthetics in the environment.
There was little understanding among respondents regarding the impact of dentures on eating ability. Few recognized the increased time required to chew food properly, and only 40% recognized that, with proper assessment, edentulous elders could eat foods other than those that had been pureed.
Positioning during eating was evaluated from the point of view of both staff and resident. Only 29% of respondents correctly identified sitting as the position they should assume when feeding someone. In relation to resident positioning, 62% of caregivers correctly identified the necessity of ensuring that the resident is sitting upright with head slightly flexed forward and shoulders supported.
Although 82% of respondents were able to identify the general rule that a teaspoon provides better control of the amount of food taken and thus reduces die chance of choking, a specific example of this rule was poorly answered Only 50% correctly identified the teaspoon as me most appropriate utensil for providing more control of the amount of soup or cereal a resident is fed. Furthermore, only 60% of respondents were able to recognize techniques that assist residents to maintain their usual ways of eating, such as allowing residents to choose the order of eating different foods, informing them of the next item being presented, and providing pureed foods separately rather than mixing them together. In relation to factors that affect swallowing, only 58% of respondents correctly identified techniques that may be recommended to facilitate swallowing and reduce choking.
The responses to the attitude statements were difficult to interpret as they did not convey strong opinions toward the statements. The most strongly agreed and disagreed upon statements were "food refusal behavior may occur due to a lack of motivation for eating," and "interpreting the resident's eating behavior is important," respectively. Interestingly, these statements reflect quite contradictory attitudes toward the nurse's role in enabling the resident to eat.
Results of the behavior audits highlighted two major themes and confirmed findings obtained on the questionnaire. Only one caregiver assumed a sitting position while feeding and caregivers in general overlooked the aesthetics of feeding. More specifically, they tended to reuse the same feeding utensil for separate courses without rinsing or wiping it, and lids and wrappers were not removed from the tray, thus cluttering the eating environment. Distinct differences were noted in the skills of the different categories of caregivers.
The mean score of 63% obtained on the questionnaire raises some concern regarding the nursing staffs knowledge of feeding principles, thereby validating our initial perceptions that the staff required assistance in honing their feeding skills. Furthermore, when the results were shared with the staff, they admitted that they found the questions difficult and recognized that they had room to improve their knowledge of feeding principles and feeding techniques.
Because years of experience and work status were not related to the mean score, some commonly held beliefs and practices regarding the assignment of nursing staff were challenged. Accordingly, the full-time nurse with the most seniority ought not necessarily be assigned to the resident requiring specialized feeding techniques. Although such an assignment may sometimes be appropriate, consideration should be given to a variety of other pertinent factors. These may include the nursing care delivery system that is in place, established therapeutic relationships among caregivers and residents, and the need to match a specific caregiver's skills with resident feeding requirements.
SAMPLE ITEMS FROM OBSERVATION CHECKLIST
The staff had difficulty with questions that reflected situations in which a nursing assessment of resident abilities, preferences, or the environment was required. This is consistent with their stated opinion, as indicated in the attitude statements, that interpretation of resident eating behavior is unimportant.
The lack of understanding of proper staff and resident positioning during eating was of concern. One questions the nurses' comprehension of the anatomical process of swallowing when resident positioning during feeding is overlooked. The fact that only one staff member sat down while feeding indicates that staff in general do not understand the importance of sitting to ensure food is presented to the resident from below the mouth. Sitting also sends a message to the resident that the caregiver is relaxed; this often serves to relax the resident as well. In addition, the professional mores of nursing warrant consideration. A frequently shared belief among staff is that sitting while feeding a resident would be perceived as indolent.
The findings provided some direction for the development of the content and structure of a staff education program. The education program is composed of a 30-minute session presented by the clinical nurse specialist several times so that all staff members may attend. The content of the session includes an overview of general feeding principles in addition to the previously identified areas of concern. For example, issues such as proper positioning of resident and caregiver prior to eating, techniques to help residents maintain independence in eating, and strategies for effective feeding are included. As a result of the significant differences in scores obtained by the orderlies as well as their observed feeding behaviors, a second component of education for them may include experiential sessions to provide them with the opportunity to practice skills specific to the elder population. In doing so, we hope to provide a learning opportunity not previously available to them.
To evaluate the effectiveness of the education program, the knowledge questionnaire will be readministered to all staff upon completion of the education sessions. A posteducation behavioral audit will be considered based on the results of the posteducation questionnaire. The results of the evaluation components, in addition to feedback from the staff, will provide direction for further program development on several aspects of the eating and feeding experience.
SUMMARYAND NURSING IMPLICATIONS
The implications of this study relate to the need to hone nurses' knowledge and practice of safe feeding techniques that promote resident independence. Specifically, nursing education must be aimed at developing nurses' knowledge of the anatomical and physiological processes of swallowing, as well as their understanding of the sociocultural dimensions of eating. Staff need particular help with skills required to feed residents needing more than the minimum physical or verbal assistance, as well as to understand the feeding behaviors displayed by these residents. These residents who demonstrate a dependence on nurses to meet their nutritional or safe eating needs present the greatest challenge to staff as they require ongoing nursing assessment and appropriate interventions.
To date, the program has successfully served to heighten awareness of feeding techniques among nursing staff on one long-term care unit Nurses on other units will be able to benefit from this pilot project as it is hoped that this study and feedback from it will form the basis for the development of a disciplinespecific eating program. This program should be directed toward both the enhancement of nursing practice and the provision of an improved eating experience for residents in long-term care.
- 1. Baclcstrom A, Norberg A, Norberg B- Feeding difficulties in long-stay patients at nursing homes. Caregiver turnover and caregivers' assessments of duration and difficulty of assisted feeding and amount of food received by the patient. IniJNurs Stud. 1987; 24:69-76.
- 2. Athlin E, Norfaerg A. Caregivers' attitudes to and interprétations of the behaviour of severely demented patients during feeding in a patient assignment care system. Ini J Nurs Stud. 1987; 24:145-153.
- 3. Hogstel M, Robinson N. Feeding the frail elderly. Journal of Gerontological Nursing. 1989; 15(3):16-20.
- 4. Rehabilitation Institute of Chicago. Feeding Techniques for Adult Dysphagic fatients. Video.
- 5. Norberg A, Norberg B, Gippert H, Bexell G. Ethical conflicts in longterm care of the aged: Nutritional problems and the patient-care worker relationship. Br Med J. 1980; February 9:377-378,
SAMPLE ITEMS FROM OBSERVATION CHECKLIST