After a careful review of protein-calorie undernutrition in nursing home residents, it was found that this problem is often associated with insufficient food intake even in the presence of adequate food supply. Estimates ofenergy intake showed that up to 50% of these individuals were underweight with a substandard adipose mass while, at the same time, less than 20% of this group had an intake below the recommended allowance (Rudman & Feller, 1989).
Malnutrition in the elderly can be caused by many factors; among them, the loss of independent eating is of particular significance. As one of the last activities of daily living (ADL) to be lost, loss of independent eating is frequently associated with deficits in cognitive ability (Siebens et al., 1986). Other factors include: impaired mobility, diets altered in consistency, decreased upper-arm control, oral abnormalities, lack of teeth and dentures, and abnormal swallowing, anorexia, depression, anorexigenic drugs, decrease or loss of taste and smell, and/or a general environment not conducive to eating (Rudman & Feller, 1989; Siebens et al., 1986). Loss of independent eating (whether or not caused by physical or cognitive impairment) has been correlated with an increased mortality rate when compared with independent eaters. It often is associated with death within 6 months (Solving dysphagia, 1992).
Figures 1 and 2. Nursing staff should be advised on the preferred feeding position. While the standing position is more often used, the sitting position is preferred.
Providing adequate nutrition to the institutionalized elderly is a critical concern, particularly with the frail elderly who do not have the cognitive ability, manual dexterity, or energy to feed themselves (Hogstel & Robinson, 1989). Although this need to provide nutrition is readily recognizable in the physically impaired, it is more difficult to discern in cognitively handicapped individuals. Approximately one-half of all residents in skilled nursing facilities are dependent on staff assistance for feeding, ranging from verbal directions to total physical assistance (Osborn & Marshall, 1992; 1993). The expense of managing eating dependence is high, amounting to 25% of the total cost of caring for the totally dependent resident (Siebens et al., 1986).
As a rule, nurses and nursing assistants can readily determine, if, and to what degree, a physically impaired individual requires feeding assistance. On the other hand, working with the cognitively impaired elderly often poses difficulties in assessing whether or not such elderly do not eat due to lack of desire or any other impairment, i.e., inability to coordinate the eating process (Barnes, 1990).
Caregivers may forgo such an assessment. They may find it easier and more convenient to feed the cognitively impaired residents rather than allowing them to do it for themselves to the extent that they can do so. Such institutional practices can foster in these residents unnecessary dependence or excess disability. On the other hand, with careful assessment of feeding capability and suitable nursing interventions to foster self-feeding, increased feeding disability can be prevented or reversed. Interventions geared to support feeding independence should be based on a comprehension of the etiology of the self-feeding deficit and involve the person as an active participant (Osborn & Marshall, 1993).
If feeding is required, the physical relationship between the feeder and the resident is important. Sitting, preferably at eye level, is the generally accepted position of choice for the feeder (Kolodny & Malek, 1991; Lipner, Bosler, & Cues, 1990). The authors of this study suggest that in addition to sitting at eye level, actual eye contact is also beneficial. The feeder's sitting position provides a more comfortable and unhurried atmosphere (Hogstel & Robinson, 1989) and may help the resident to relax and may ensure that food is presented to the resident from below the mouth.
Training Program Outline for Nursing Assistants
Assuming sitting as the position of choice, Kolodny and Malek (1991) in their investigation of nurses' feeding practices, found that less than one-third of the respondents identified sitting rather than standing as their choice for feeding. They suggested that this relatively low percentage might be attributable to the staff's belief that sitting could be perceived as an indication of laziness.
As has been shown, the position of the feeder in relation to the person being fed is significant. Of the obvious choices for the feeder, i.e., sitting or standing, oniy the advantages of a sitting position have been researched. No analysis of the standing position and of its possible benefits or disadvantages to residents has been found. The authors of this study have investigated both positions with respect to residents' nutritional intake. In this study, a null hypothesis was postulated: There is no relationship between the position of the feeder and the amount of food and fluid consumed by the nursing home resident.
This study was conducted in a 240-bed nursing home forming part of a 1000-bed medical center located in the northeastern United States. Thirty-nine residents requiring complete assistance with feeding were selected from the Nursing Home Care Unit population. Residents who were fed by other than the designated feeders and residents receiving supplemental enterai feedings were excluded from the study. In this study, a "nursing home resident" was defined as an individual in a longterm care facility with physical and/or cognitive impairments who cannot feed him/herself and who required complete feeding assistance for each meal.
The study was quasi-experimental in design. It covered the noon meal Monday through Friday over a 4-week period. The participants were randomly assigned during this period to one of three groups. Group I was the control group in which the residents were fed by feeders who determined at each meal which position (sitting or standing) to assume during the feeding process. Members of Group II were fed by feeders taking the standing position for the first 2 weeks and changing to the sitting position for the last 2 weeks. In Group III this process was reversed, i.e., feeders started in the sitting position for the first half and finished in the standing position for the second half of the study period.
Training classes were conducted by the investigators to instruct the nursing assistants designated as feeders on the use of the instrument and to review feeding positions and practices (Figures 1 and 2). In this study, "feeders" were defined as nursing assistants who had successhilly completed a training program (Figure 3). Feeder "position" was defined as the posture maintained by the feeder either in the upright or erect posture (i.e., standing) or in a seated position (i.e., sitting) while feeding the participant.
All participants were fed in their customary environment, i.e., in either one of the two dining rooms or in one of several other eating areas on the unit. The eating location assigned to the resident at the beginning of the study remained the same throughout its duration. On the other hand, each day feeders were given a specific assignment (the location of which could change from day to day) to feed the residents in the position applicable to each resident's group assignment (sitting, standing or variable). The feeders were not assigned to individual residents. Two sittings were used, the first from noon until 12:45 PM, followed by the second until 1:30 PM. Forty nursing assistants participated in the study as feeders; on a daily basis their actual number varied between 10 and 15.
Instrument Used to Measure Food and Fluid Consumption
A food and fluid consumption sheet was designed by the researchers to measure the amount of food and fluid consumed at each meal. In this study, fluid was defined as nourishment that could be consumed through a straw; food was defined as nourishment that could not be consumed through a straw. The feeder was asked to record on a daily basis the percentage of food and fluid consumed during the study period. These sheets were color-coded to identify each resident group with the required feeding position. A Likerttype scale was used to estimate the amounts (Figure 4). In a pilot test of the instrument, an inter-rater reliability co-efficient of .85 was obtained.
Descriptive and inferential statistics were applied to the data. The descriptive findings relative to the sample are listed in Table 1 . The Mann-Whitney U test did reveal differences in the ranks of the scores of the experimental and control groups. Data analysis was used for days 1, 5, 10, 15, and 20 using the Stat Pac statistical software program. Although, statistically, analysis did not consistently demonstrate statistical significance between the mean of the Groups I and II, Groups ? and III, and Groups I and III, there were five occasions where the findings were significant (Table 2). However, despite the occasional significance, the null hypothesis was retained: There is no relationship between the position (sitting vs. standing) of the feeder and the amount of food and fluid consumed by the nursing home resident (Table 2).
In analyzing the findings, the following observations can be made. The percentage of residents (95%) with a primary or secondary diagnosis of dementia was larger than expected. The deterioration in ADL associated with dementia affected the accurate assessment of patients who required complete feeding assistance. Indeed, even the selection process for the sample population was difficult because the feeders, as well as some of the professional nursing staff, differed in their assessment of who should be included as participante in the study. Variations in the residents' mental status and/or physical ability may have contributed to a lack of consistency in the study; even slight changes might have affected the amount of intake.
Other variables may also have significantly interacted in the study. The physical surroundings during mealtime can influence residents' eating behavior. Noise level and lighting in the dining area, general traffic caused by the food delivery, the residents themselves, and the feeders and other personnel may have a significant uncontrolled influence on the amount of food and fluid consumed. Easy distractibility and short attention span in residents were not uncommon throughout the duration of the data collection period. Time is another consideration. Realizing that there are two lunch periods in mis institution, the feeders may have rushed the first feeding. This might have been exacerbated by occasional late delivery of meals. Similarly, the feeders might have hastened the second seating in order to get back to their other assignments. Any such behavior might well have been sensed by the residents, possibly affecting their intake. A sense of urgency among feeders and/or some of the residente in the assigned time period raises the question of whether or not the customarily assigned mealtime hours, e.g., noon to 1:30 PM, are indeed a necessity. Would it be more conducive for eating to allow a longer dining period by starting at an earlier time, e.g., 11 AM? Eating is a complex task, particularly among cognitively impaired individuals. Any change in seating arrangements or daily routine could have increased residente' anxiety to the point where their ability, as limited as it may already be, would further affect nutritional intake.
For the purpose of this study, feeders were assigned to a particular area rather than to specific residente. Following an established practice at this institution, residente were assigned a specific seating and place at a table. Since this may not always have coincided with their wishes, location and seat assignment do not go unnoticed and may affect the residente' demeanor. The random assignment of feeders might have interfered with the residents' ability to focus on the tasks of eating and drinking.
Last, the Food and Fluid Consumption Sheet was designed with interval recording of data to facilitate its use by the feeders. An instrument providing for the recording of continuous data may have provided more accurate and descriptive data.
Many recommendations can be made from this study despite the fact that the null hypothesis was retained. Advancing age affecte the elderly to varying degrees. Older residente may sustain losses, (e.g., sensory changes, impaired cognitive functioning, and deficits caused by chronic diseases) that may have a direct bearing on eating habite and food intake. Therefore, it is important for the nurse to make an early assessment of eating abilities, identifying any difficulties and providing for appropriate and timely intervention. Ongoing evaluation is necessary to determine the most effective ways of supporting and developing individual strengths. Support by other interdisciplinary team members would enhance this process.
When the nurse is developing a plan of care for residents with eating difficulties, it is important to include their self-feeding abilities. These plans, besides recommending type of diet and calories needed, should also have specific guidelines regarding how to feed the patient or to have him/her initiate feeding activities, e.g., feeder stand, sit, touch the resident, verbal cues, etc. The goal of such plans should be either to increase eating independence or to render support for whatever self-feeding abilities may exist. Support measures encouraging self-feeding have been found to correspond with levels of feeding independence in nursing home residents (Osborn & Marshall, 1992).
Type and consistency of diet are important considerations in safe feeding and eating practices, since some foods are easier for residents to deal with than are other types of foods. If at all possible, regular food should be encouraged. Purees and paste are generally the safest textures since they do not require mastication; they hold together well to form a bolus and do not spill into the trachea easily. Finger foods are a good choice if residents can hold any food in their hands. Not only do they allow the residents some independence and choice of what to eat and when, but they also may be timesaving, thus reducing the staff's need for interventions.
In making patient care assignments, nurses should assign feeders to individual residents, not just to specific dining areas. This consistency might encourage feeders to have a more positive attitude toward assigned residents and increased work satisfaction. By working with the same residents at mealtime, feeders will be in a better position to interpret their residents' eating behaviors (Athlin & Norberg, 1987).
As increasing numbers of residents in long-term care facilities require assistance with their meals, it is important for nurses to make certain that the eating environment and the manner of feeding encourages food intake. Research on feeding methods, the position of the feeder and other interventions must continue. The elderly population is growing and the importance of studying nutrition in the elderly is growing with it.
Inferential Findings T-Test Statistics
- Athlin, E., & Norberg, A. (1987). Caregivers' attitudes to and interpretations of the behavior of severely demented patients during feeding in a patient assignment care system, international Journal of Nursing Studies, 24, 145-153.
- Barnes, K.E. (1990). An examination of nurses' feelings about patients with specific feeding needs. Journal of Advanced Nursing, 15, 703-711.
- Hogstel, M., & Robinson, N. (1989). Feeding the frail elderly. Journal of Gerontoîogical Nursing, 15(3), 16-20.
- Kolodny V., & Malek, A. (1991). Improving feeding skills. Journal of Gerontoîogical Nursing, 17(6), 20-24.
- Upner, H., Bosler, J., & Giles, G. (1990). Volunteer participation in feeding residents: Training and supervision in a long-term care facility. Dysphagia, 5, 89-95.
- Melkus, G. (1994). Primary care of nutritional problems. Nurse Practitioner Forum, 5, 10-12.
- Mikulencak, M. (1992). Initiative seeks to combat malnutrition among elderly. American Nurse, 24(10), 9.
- Osborn, C., & Marshall, M. (1992). Promoting mealtime independence. Geriatric Nursing, 13(5), 254-246.
- Osborn, C., & Marshall, M. (1993). Self-feeding performance in nursing home residents. Journal of Gerontoîogical Nursing, 19(3), 7-14.
- Rudman, D., & Feuer, A. (1989). Protein-calorie undemutritìon in the nursing home. Journal of the American Geriatrics Society, 37, 173-83.
- Siebens, H., Trupe, E., Siebens, A., Cook, F., Anshen, S., Hanauer, R., & Oster, G. (1986). Correlates and consequences of eating dependency in institutionalized elderly. Journal of the American Geriatrics Society, 34, 192-198.
- Solving dysphagia problems can help Alzheimer's victims. (1992). Contemporary Senior Health, 3(3), 7.
- Steffi, B. (1984). Handbook of gerontological nursing (pp. 377-393). New York, NY: Van Nostrand Reinhold.
Training Program Outline for Nursing Assistants
Instrument Used to Measure Food and Fluid Consumption
Inferential Findings T-Test Statistics