Food that reflects our family backgrounds is a source of comfort and can play an important part in recovery from illness or adaptation to the nursing home, especially for older individuals. When ill or lonely, such older adults may seek comfort in foods that are coupled with pleasant memories (Grodner, Anderson, & DeYoung, 2000). Adaptation to the nursing home could be affected by nutritional care that attends to resident food preferences acquired during the course of a lifetime. However, no studies could be found that explored residents' perspectives on how their food and food service preferences are, or are not, met in nursing homes and the meaning residents attach to nutritional care.
Nutritional Status and Quality of Life
From 35% to 85% of U.S. nursing home residents are malnourished (Burger, Kayser-Jones, & Bell, 2001), with 30% to 50% of residents having a substandard body weight. Malnutrition not only affects quality of life, but it can lead to weight loss, functional decline, chronic disability, death, and increased health care costs because of higher levels of health care usage (Callahan, Stump, Stroupe, &Tìerney, 1998; Cederholm, Jagren, & Hellstrom, 1995).
Quality of life is a subjective and objective phenomenon that includes both the conditions and the experience of life (Kane & Kane, 2000). It has been defined as a sense of wellbeing, meaning, and value that incorporates life satisfaction, self-esteem, general health and functional status, socioeconomic conditions, and coping mechanisms (Kane & Kane, 2000; Sarvimaki & Stenbock-Hult, 2000). Nutritional status is strongly positively correlated with quality of life (Vailas, Nizke, Becker, & Gast, 1998). Conversely, nutritional risk, lack of access to food, depression, functional decline, and lack of enjoyment of food are negatively correlated with quality of life.
Nutritional status depends, in part, on enjoyment of food and food service - yet residents often express dissatisfaction with food and food service in nursing homes (Crogan Sc Evans, 2001; Katzman, 1999; Kayser-Jones, 1996). Nursing home residents want a meal situation that is as natural and independent as possible, comparable to eating in one's own home (Sidenvall, Fjellstrom, & Ek, 1994), and they want food quality and food service that accommodate their preferences (Evans, Crogan, & Shultz, 2003). Unfortunately, health care providers rather than consumers have traditionally defined quality of life and providers' perceptions of quality may not coincide with consumers' perspectives (Lanza, 2000; Larrabee, 1995; Larrabee & Bolden, 2001; Oermann, 1999; Rantz et al., 1999).
Exploring the Meaning of Mealtimes
The familiar, distinctive patterns of family life bring comfort and security, especially in stressful situations. People use food to cope with emotions and express feelings, celebrate triumphs, reward hard work, and gain a sense of companionship (Grodner et al., 2000). Traditions surrounding food consumption, learned within families of origin and carried forward into families established as adults, can provide a powerful link to identity. When traditional foods are unavailable, we lose one way to reinforce individual identity as an individual, risking our quality of life.
Exploring the meaning of food and food service to nursing home residents could furnish insights for improving both nutritional status and quality of life. Consequently, the authors initiated a qualitative study to determine the meaning of mealtimes to residents and to connect that meaning with the social world in the nursing home (Miles & Huberman, 1994).
The purposive sample from a local 140-bed nursing facility in eastern Washington state included 20 English-speaking residents, comprised of five males and 15 females. The residents included one male in his twenties, three women in their forties, and one male in his fifties. The remaining 15 informants ranged from ages 61 to 93. The members of the sample had all experienced the topic in question (Brink, 2001). Quality of information per sampling unit was high (Sandelowski, 1995). When one informant provided a poor interview, another resident was added to the sample.
Interviews are widely used for data collection in health sciences research (Sandelowski, 2002). The authors used a "tell me a story about..." semi-structured interview protocol to examine residents' perspectives related to food and food service in the nursing home, accessing both past and current experiences with food and food service during that process.
Residents were asked during one face-to-face session about food and food service, its best and worst aspects, and what it would be like if it was "perfect." The final query, the focus of this article, was "Tell me about a time in your life when food tasted really good and you really enjoyed eating." Contact summary sheets for each participant noted the circumstances of the tape-recorded interview as well as a brief history and clinical profile derived from the resident's medical record (Miles & Huberman, 1994; Sandelowski, 2002).
A member of the research team coded one interview, attaching preliminary codes to words, phrases, sentence, or paragraphs. The entire team then reviewed the analysis to achieve consensus on resident meanings, identify any additional codes, and pinpoint exemplars and definitions for each code. Codes were brought forward to the analysis of subsequent interviews and refined.
RESIDENTS WHO SAID, "FOOD TASTED GOOD..." BY CATEGORY OF RESPONSE (n = 2O)*
Coded data were then organized by the team into a role-ordered matrix that enabled cross-case comparison of "whether people in the same role [in this case, the role of 'nursing home resident'] do, in fact, see life in similar ways" (Miles & Huberman, 1994, p. 123; 1998). This method of data display brought together codes that were conceptually coherent into categories. Relevant to this article, one of these conceptual categories was "Role of Food in the Resident's History." This category was examined more closely by constructing a second matrix that employed the tactic of clustering codes within the category by conceptual themes (i.e., identifiable topics that occurred with regularity) (Miles & Huberman, 1994). Three patterns, or overarching concepts under which the resultant themes could be organized, emerged from this analysis:
* Remembering Our Roots.
* Relating to Others.
* Giving Life.
In this study, trustworthiness (credibility) of findings rested on such things as the following (Miles & Huberman, 1994):
* Describing the sample.
* Identifying researcher assumptions and biases.
* Creating quality control procedures and an audit trail to assure consistent, stable processes across researchers and methods.
* Recording an audit trail for methods and procedures.
* Achieving consensus on coding and analysis with a veteran team of researchers.
* Using nonparametric statistics to verify and amplify qualitative findings.
* Laying data bare for the reader.
All 20 residents responded to the query concerning "a time when food tasted good." Their responses fell into four categories: during childhood with family, with family, with family and friends, or with friends (Table 1).
Resident food preferences were chiefly connected with childhood and family while relationships with friends were secondary sources, indicating the importance of the family unit in formation of personal preferences involving nutrition. The remainder of this article summarizes the themes and patterns noted during the exploration of meaning behind food preferences.
Remembering Our Roots
The first pattern, Remembering Our Roots, was composed of seven themes concerned with tradition, religion, and personal taste (Table 2).
Distinct patterns of family life in recreation, religion, and customs were demonstrated as residents remarked on the importance of celebrating special occasions with homemade foods, often from recipes handed down through the family, and how they enjoyed food as children (Banks, 1996). One participant said:
PATTERNS DERIVED FROM THEAAATIC CONCEPTUAL AAATRIX OF FOOD HISTORY
Sundays we always had good meals, oh, we had good meals every day! But Sundays we always had company and it seemed like we had something a little better, like homemade pies and potatoes and gravy - real potatoes!
Relating to Others
The second pattern, Relating to Others, contained four themes that addressed developing or maintaining relationships and sharing memories, as shown in the following exemplar:
When I was 15 years old, I went to an Italian Easter dinner, the grandfathers and the grandmothers, the whole family just eating and drinking together.
Giving Life, the final pattern, contained only three themes having to do with comfort, safety, and health. Residents spoke poignantly of the Great Depression and the need for nutritious food. Participants said:
1. When the Depression hit and the drought with it, we were out there in the dustbowl and the pickings were kinda slim. I remember Mama bringing out a kettle of hot beans and cornbread to the field and we ate that. Even out in the hot sun, working, it tasted pretty good.
2. 1929 was the big crash and I remember how hungry we were. My mother would make soup out of just pure bones, and she would say, "Can you stand a little more of my soup?" I told her that I could eat it for breakfast, lunch, and dinner because that's what we had, no matter what.
As shown in Table 2, Remembering Our Roots encompassed 50% of the total themes identified within the study, and Relating to Others contained another 28.6%. This means that only 21.4% of the themes identified within the 20 interview texts were related to the function of Giving Life, involving good nutrition and getting enough to eat for physical health.
Table 3 amplifies the data set forth in Table 2, adding information about the number of residents who identified each theme within their interviews. The fabric of family life is clear in Remembering Our Roots where special recipes, the cooks who prepared them, and family fun and celebrations are intertwined. The first five themes alone account for almost 64% of all the themes identified in 20 interviews, indicating the importance of understanding residents' family roots in quality nutrition care.
Maintenance of "good" nutrition is a paramount concern for caregivers in nursing homes. Facilities are profoundly concerned about physical parameters that directly or indirectly measure nutritional status, such as the presence of falls and pressure ulcers. Perhaps this is shortsighted. It may be that "good" nutrition for nursing home residents as defined by prescriptions and regulations has a lesser relationship to these parameters, while attending to "good" nutrition as defined by residents in the context of their life experiences is more important than previously thought.
PATTERNS DERIVED FROM THEMATIC CONCEPTUAL MATRIX OF FOOD HISTORY
If a person's patterns of adjustment to life are determined partly by life experiences (Shives, 1998), then personal experiences residents "bring to the table" must affect their adjustment to the social world of the nursing home. These experiences affect one's coping skills and sense of identity (Erikson, 1968), especially when a person is "out of synch" with his environment, as may occur in nursing homes. Sharing the experience of consuming traditional foods with other residents such as a Thanksgiving turkey or "roasting ears" can foster coping and confirm a resident's identity previously formed within the family. One participant said:
It was between 1927 and 1929 that my dad planted two cornfields, one with Indian corn and one with regular corn. We looked forward to Dad roasting those on a fire outside or Mama would boil them and of course we would put homemade butter on them. Nothing was as good as that.
This exemplar from the study offers a rich description of farm life during the Depression, socioeconomic status, and age-appropriate behavior. It touched on sharing patterns within the family, and helped the resident make sense of who she was and where she came from. These remembrances comforted her and made her current situation tenable.
IMPLICATIONS FOR PRACTICE
The connection to family plays a significant role in resident adjustment to the social world of the nursing home and, therefore, in quality of life. Adaptation to the nursing home environment cannot easily be facilitated without understanding the patterns of family life, and those patterns may be best accessed through food history.
With few exceptions (Rantz et al., 1999; Rantz et al., 2000), resident and family perspectives and food consumption patterns have not guided nutrition care in nursing homes. However, studies such as this one that seek to identify overlooked components of nutrition care could lead to the creation of best practices that support personal preferences of nursing home residents.
Best practices could include such things as a food cart or buffet dining program that allows item selection and portion size control, as well as choice of accompaniments, where applicable (Darke, 1998; Remsburg et al., 2001). Inclusion of colorful foods in dining programs (e.g., yellow roasting ears, orange apricots) provides stronger visual cues for appetites in older adults who are less sensitive to flavors (Clydesdale, 1994).
Connecting with family and friends of the resident who can specify long-held traditions and food preferences, and report on meals recently enjoyed by the resident, could provide information to encourage dietary intake. For example, when residents return from a visit home or from eating out, staff might inquire about dietary preferences satisfied during the meal(s) eaten away from the facility. Also, when the dietitian reviews menus, residents could be asked, "Have you eaten somewhere that served food you especially enjoyed? What was that food and how was it prepared?" These actions could reinforce a pleasant past dining experience, demonstrate to residents that staff members recognize the importance of food in quality of life, and furnish specific data that could be added to the nutrition care plan for that resident.
Teaching staff to be proactive in gathering information about preferences also can be important. Recognizing that even residents who have learned to "make do" at family meals (because it would have been considered inappropriate to complain about the food) may not be maximally satisfied at nursing home meals could help staff initiate a discussion of resident preferences, thereby avoiding the tendency of these residents to feel guilty about bringing up their desires first (Sidenvall, Fjellstrom, & Ek, 1996).
In fact, staff training may be the key to nutrition intervention because staff members understand the constraints of the nursing home system, although they may not fully grasp each resident's needs. A focus on the staff-resident relationship, along with a concerted effort to discover the personal preferences of each resident, can bring nutrition care to the forefront of daily activities. An individualized nutrition plan (Christensson, Ek, & Unosson, 2001; Kayser-Jones, 1996) can be devised and implemented through aggressive nutrition screening and intervention, competent supervisors and employees to implement nutrition care plans, accurate monitoring of food intake, and adaptation of menus until optimal nutritional care is achieved within the social world of the nursing home.
Many nursing home residents yearn for this personal, individualized attention to their dietary preferences. One way to focus the attention of staff and residents alike is to designate the occupants of one dining room table each week as "hosts" and provide a colorful sign for their table. At intervals during the week, serve everyone in the dining room a favorite food selected by each "host" as a reminder of home. Ask someone from recreational therapy, occupational therapy, or social services to write down a brief story from the resident about the special food, add the resident's name, print in large font and post on an easel at the dining room entrance when that food is to be served. Serve the food first (using a special plate) to the resident who requested it, commenting on how good it looks and making the occasion fun. Both nutrition and socialization are addressed through this simple adaptation of the "Resident of the Month" strategy commonly used to reinforce self-esteem of nursing home residents. Residents will tell stories, such as the following one told by an older gentleman about a pie he made as a 15 year-old state forest lookout:
I was starving and I couldn't cook but I got to thinking. I found a box of butterscotch pudding and I scraped up enough fixings to make a pie shell. My mom had given me a quart of apricots so I made a pie. I ate and I ate and I ate the whole pie. You talk about something that tasted and felt good! When I came down, I made the pie for my family and they liked it. My mom took it to her grange and they put it in their cookbook and called it "Victor's Lookout Pie."
The personalized nutrition care strategies described previously follow the American Dietetic Association's (ADA) recommendation (2000) for liberalized, individualized diets for older adults who are institutionalized to increase their food intake. The creator of "Victor's Lookout Pie" validates the importance of individualization in the ADA recommendation. He said:
That's the time I remember the most when I enjoyed food, not because I cooked it but because it tasted like something that was close to home.
"Something that tastes close to home" requires work on the part of nursing home staff. The innovative practices described above, with the exception of the food cart, increase costs minimally, but may require some reorganization of meal service and additional staff education for dietary, housekeeping, recreational and occupational therapy, social services, and nursing staff. Nursing homes already complete regular nutritional assessments, revise residents' nutritional care, and monitor food intake, but staff may be unaccustomed to the emphasis on individualized dietary preferences.
Some of these nutrition care strategies, such as the adaptation of the Resident of the Month strategy, can be implemented easily by recreational therapy and dining room staff to provide a personalized, meaningful focus for resident activities, and the dietitian can simply include the identification and addition of favorite foods in regular dietary planning. Moreover, most resident councils would appreciate this strategy as an approach to testing new recipes for possible inclusion in future menu cycles. Families would welcome an opportunity to share their recipes in an effort to promote a homelike atmosphere.
Strategies selected for nutrition care in nursing homes must account for the residents' personal food and food service experiences, particularly within the context of the family. This can be difficult in an institutional setting where the mandates of regulatory agencies drive a significant portion of the care. However, dining experiences that recapitulate residents' personal remembrances of home and family, even in small ways, can reconnect residents with their identities as individuals and significantly increase their quality of life.
- American Dietetic Association. (2000). Position of the American Dietetic Association liberalized diets for older adults in longterm care. Journal of the American Dietetic Association, 100, 580-595.
- Banks, J. (1996). Teaching strategies for ethnic studies (6th ed.). Boston: Allyn and Bacon.
- Brink, P. (2001). Representing the population in qualitative research. Western Journal of Nursing Research, 23(7), 661-663.
- Burger, S-, Kayser-Jones, J-, St BeU, J. (2001). Food for thought: Preventing/treating malnutrition and dehydration. Contemporary Long-term Care, 24(4), 24-26.
- Callahan, CM., Stump, T.E., Stroupe, K.T., St Tierney, WM. (1998). Cost of health care for a community of older adults in an urban academic health care system. Journal of the American Society of Geriatrics, 46, 1371-1377.
- Cederholm, T., Jagren, C., Oc Hellstrom, K. (1995). Outcome of protein-energy malnutrition in elderly medical patients. The American Journal of Medicine, 98, 67-74.
- Christensson, L., Ek, A., St Unosson, M. (2001). Individually adjusted meats for older people with protein energy malnutrition: A single case study. Journal of Clinical Nursing, 10(4), 491-502.
- Clydesdale, F. (1994). Changes in color and flavor and their effect on sensory perception in the elderly. Nutrition Re-views, 52(6), S19-S20.
- Crogan, N-, 8c Evans, B. (2001). Guidelines for improving resident dining room experiences in long-term care facilities. Journal for Nurses in Staff Development, 17(5), 256-259.
- 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.
- Erikson, E. (1968). Identity: Youth and crisis. New York: WW Norton.
- Evans, B., Crogan, N, 8c Shultz, J. (2003). Quality dining in the nursing home: The resident's perspective. Journal of Nutrition for the Elderly, 22(3), 1-17.
- Grodner, M., Anderson, Sn & DeYoung, S. (2000). Foundations and clinical applications of nutrition: A nursing approach (2nd ed.). St. Louis: Mosby.
- Kane, R.L., St Kane, R.A. (2000). Assessing older persons. New York: Oxford University Press.
- Katzman, C. (1999). Indiana hospital dishes up patient service. Modern Healthcare, 29, 50.
- Kayser-Jones, J. (1996). Mealtime in nursing homes: The importance of individualized care. Journal of Gerontological Nursing, 22(3), 26-31.
- Lanza, M. (2000). Consumer contributions in developing clinical practice guidelines. Journal of Nursing Care Quality, 14(2), 33-40.
- Larrabee, J. (1995). The changing role of the consumer in health care quality. Journal of Nursing Care Quality, 9(2), 8-15.
- Larrabee, J., St Bolden, L. (2001). Defining patient-perceived quality of nursing care. Journal of Nursing Care Quality, 16(1), 34-60.
- Miles, M., St Huberman, A. (1994). Qualitative data analysis (2nd ed.). Thousand Oaks: Sage.
- Miles, M., St Huberman, A. (1998). Data management and analysis methods. In N. Denzin St Y. Lincoln (Eds.), Collecting and interpreting qualitative materials (pp. 179-210). Thousand Oaks: Sage.
- Oermann, M. (1999). Consumers' descriptions of quality health care. Journal of Nursing Care Quality, 14(1), 47-55.
- Rantz, M.J., Mehr, D.R., Petroski, G.F., Madsen, R. W., Popejoy, L., Hicks, L., Conn, VS., Grando, V.T., Wipke-Tevis, D.D., Bostick, J., Porter, R., Zwygart-Stauffacher, M., St Maas, M. (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.
- Rantz, M.J., Zwygart-Stauffacher, M., Popejoy, L., Grando, VT, Mehr, D.R., Hicks, L.L., Conn, VS., Wipke-Tevis, D., Porter, R, Bostick, J.,Maas, M., St Scott, J. (1999). Nursing home care quality: A multidimensional theoretical model integrating the views of consumers and providers. Journal of Nursing Care Quality, 14(1), 16-37.
- Remsburg, R., Luking, A., Baran, P., Radu, C, Pineda, D., Bennett, R., St Tayback, M. (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.
- Sandelowski, M. (1995). Sample size in qualitative research. Research in Nursing & Health, 18, 179-183.
- Sandelowski, M. (2002). Reembodying qualitative research. Qualitative Health Research, 12(1), 104-115.
- Sarvimaki, A., St Stenbock-Hult, B. (2000). Quali ty of life in old age described as a sense of well being, meaning and value. Journal of Advanced Nursing, 32(4), 1025-1033.
- Shives, L. (1998). Basic concepts of psychiatricmental health nursing (5th ed.). Philadelphia: Lippincott Williams and Wilkins.
- Sidenvall, B., Fjellstrom, C-, St Ek, A. (1994). The meal situation in geriatric care - Intentions and experiences. Journal of Advanced Nursing, 20, 613-621.
- Sidenvall, B., Fjellstrom, C-, St Ek, A. (1996). Cultural perspectives of meals expressed by patients in geriatric care. International Journal of Nursing Studies, 33(2), 212222.
- Vailas, L.I., Nitzke, S.A., Becker, M., St Gast, J. (1998). Risk indicators for malnutrition are associated inversely with quality of life for participants in meal programs for older adults. Journal of the American Dietetic Association, 98(5), 548-553.
RESIDENTS WHO SAID, "FOOD TASTED GOOD..." BY CATEGORY OF RESPONSE (n = 2O)*
PATTERNS DERIVED FROM THEAAATIC CONCEPTUAL AAATRIX OF FOOD HISTORY
PATTERNS DERIVED FROM THEMATIC CONCEPTUAL MATRIX OF FOOD HISTORY