Pathway to Transforming Dining: Steps to Resident Input and Improving the Environment

Put the “I” into Individualizing the Dining Experience

The following is an excerpt from Linda Bump’s paper “The Deep Seated Issue of Choice” from the 2010 Creating Home in the Nursing Home II: A National Online Symposium on Culture Change and the Food and Dining Requirements.

“Simply speaking, it is all about choice. It is as simple as asking, “What does the resident want? How did they do it at home? How can we do it here?” Asking those three simple questions, pushing away “the way things are done,” connecting with the resident and his or her preferences and letting choice rule, you realize the “the way things are done” is certainly not the way you would have done them in your house, and you are on your way to individualized resident directed care. Favorite foods, comfort foods, foods prepared from residents’ favorite recipes, foods they chose to eat in their own home, foods that make them look forward to the day…foods that are good for them, from a therapeutic perspective, or foods that they have enjoyed for their whole life even though they may not be the best choice from a medical perspective…for most elders, these foods will not come wrapped in individual snack packs, but rather from real kitchens, from caring staff. But for some, a candy bar and soda, or chocolate chip cookie and milk may be the “supplement of choice.” Knowing what specific foods tempt specific residents can make the difference between weight loss and gain and between supplement and food first. Knowing the residents, their choices, their preferences and their daily pleasures in dining leads to optimal intake and optimal quality of life in dining”. (Bump)

The key to successful identification of resident preferences is ultimately in the resident participation in the care planning process and the accuracy of documentation of resident wishes and needs. The goals should be geared towards improving the ability of residents to expand food choices. The presumption is that residents will be able to enjoy meals that they like as well as to eat at a time that resident prefers.

Each home will need to determine the amount of risk associated with modifying policies and procedures and practices; however, by reviewing the risks with informed team members, the home can properly prepare for the future. In some cases resident refrigerators may be a simple addition to accommodate personalize choice, and will have to be balanced with food and safety requirements. In other cases, residents may begin to select more items from a menu that has been discussed with resident council members.

One of the best ways to increase resident satisfaction in choices over meals and meal times is by asking each resident what he or she desires.  In order to truly individualize the resident’s care, residents should be able to state their desires.  Once the resident’s desires are know, the staff must be fully aware of the preferences and be able to accommodate them.  This will be a much easier task if staff are consistently assigned to residents in order that they will become innately familiar with resident needs rather that constantly having to reference a care plan.  Identifying resident desires and accurately document them is only the first part of carrying out the resident’s desires.  Staff must be able to help deliver on the promise to give residents maximum flexibility in meals and meal times.

For those residents who cannot express themselves, significant time should be taken with family members, significant others, and by observing resident intake and habits, to help make the best informed choices as possible.  These residents are always at-risk for a loss of dignity in the dining experience and should not be isolated from the deep assessment process that takes place with vocal residents or forums such as resident council.  Staff need to be trained in identifying resident preferences and outcomes for residents who lack communication ability and/or whose needs are not easily identified.  The power of observation, resident history and continual monitoring of resident care is essential for these groups who always experience changes in process without the benefit of easily expressed self-determination.

Person directed care ensures a holistic approach, one that effectively utilizes the interdisciplinary team and incorporates resident choice as well as information from the clinical assessment.  In fact resident choice is not just a part of person directed care, it should drive it.  While these choices may sometimes conflict with recommendations of the clinical team, the label of being “non compliant” should be avoided.  Usually, a careful discussion of risks and benefits with the resident and/or their family/POA will allow for resolution of this conflict and help to create an agreed upon plan of care that can then be monitored for desired outcomes and recommendations.

Use Minimum Data Set (MDS) and Resident Assessment Instruments to identify resident condition and trends in relation to dining program

Review staff education program and determine if staff require any additional training related to dining changes

Meet with resident council and family council, resident advocacy groups, and inform the of the changes that the home is undergoing

Establish a method for identifying the needs of those residents who cannot adequately express themselves in order to find out what their nutritional needs and dining desires may be and how to best accommodate them.

Establish a risk process so that safety issues can be addressed quickly and as a team.

Create the Look and Feel of Home

The process of shifting from an institutional dining model is typically a gradual one for those homes who have not yet begun to expand resident choice beyond one alternate served on a main menu and who have rigidly set meal times. In the beginning there are simple steps that a home can take to become more of a “home”.  It is helpful to define what makes a home feel like a home. Let the residents and staff assist with this effort.  The answers are not so far from what we all want in a dining and meal experience.  At the core of the shift is the sense of developing a community that treasures the meal experience rather than focuses on it as a task.

Some homes call this ‘fine dining’ or ‘enhanced’ dining and these programs may include the use of fine china, pre-set tables, and combine a buffet style, restaurant style experience. Some offer pre-meal breads and salads, while others have expanded choices by using dessert carts at all meals, and involving residents in the menu planning and food ordering. Many already serve meals without the use of meal trays for the most part, and have long since discontinued or never used clothing protectors. Many homes are at least attempting to create a more dignified dining room, using table cloths and some combination of fine or faux china as well as avoiding the use of trays at least at the point of placing the meal before the resident. Some homes use cloth napkins like those in a restaurant, or paper napkins and some residents may wish to have a terrycloth type clothing protector.

The key to enhancement is to identify what you wish to enhance. Not every home will need to make every change. This is a continual improvement process that starts where you are.

Create a checklist of all the elements of dining that the environment must accommodate and routinely assess and monitor compliance.

Determine how you assess resident input and satisfaction as well as how you identify resident preferences and honor them.

Find out what residents and staff think of food and food and dining.

Seek to establish degrees and milestones for improvement, tackling the basic dignity factors first.

Identify a core group of residents and staff and do a trial in dining and test various processes before expanding to entire resident and staff base.

Create Staff Consistency: Educate and Cross-Train Staff in the Dining Experience

In a more institutional nursing home environment, staff perform duties within a rigid segregation of duties (typically distributed between nursing and dietary staff); however as the dining experience allows for residents to have expanded choices of meals and meal times, the traditional job description likely begins to change.  Traditional job descriptions for both nursing and dietary staff, for example, may include substantial dining related tasks.  The nursing staff tend to be required to serve and monitor meals, and to participate in the dining process from beginning to end.  Other than preparing the meal and, in most cases, cleaning up after it, the institutional model maintains this segmentation.

The theories behind more integrated and cross-trained staff all point towards better interdisciplinary cooperation as a result of shared experience, better operational efficiencies (as staff can all resolve more time oriented tasks in real-time), and a more expanded choice over meals and meal times.  While there may be costs associated with process change, some early studies point to overall costs savings in many measurable areas including staff retention, reduced meal waste, decreased supplement costs, increased resident and representative satisfaction.

Nursing homes that are in the process of changing their meal delivery process will quickly identify, during the assessment phase, that one of the central themes in providing more person-centered care in dining is in the consistency of staff assignments and in the involvement of many departments, a higher level of cross training in dining assistant roles and a different approach to the staffing and roles within the home.

Staff Availability and Accountability – It is essential that staff are fully engaged in making the dining process a successful one. The shift away from highly structured meals and meal times emphasizes the need for all staff to participate at meal times.

Consistent Assignments – Consistent assignments are the key to consistent meal delivery along with all service delivery. While it is challenging to maintain the same staff and consistently assign them to the same residents, consistent assignments should be a constant effort. Quality of care depends upon the degree of staff knowledge of residents over time. (link to consistent assignment tip sheet, etc. in Engaging Staff in Individualizing Care Starter Toolkit).

Cross-Trained Staff – Silos of staff are likely counter productive to any long term success with person-centered care and dining. As a resident’s individual needs become more personalized, operational efficiency, cost-control, and resident satisfaction can best be accommodated by many people understanding and providing for the resident’s needs.

Decentralized Eating – As meals become more personalized, the point-of-service expands. The central kitchen slowly becomes less of the ‘command center’ and meal service moves closer to the resident. In some cases, this may look more like a restaurant operation or small pods of service in various dining areas, or steam tables brought  to nursing units and served ready-to-eat.

Establish a team to review job descriptions wherever they pertain to food and dining. Over time, the team may determine that some new duties should be assigned or changed.

Work directly with staff and begin to assess the key functions of staff and whether more cross-training and departmental integration would benefit employee retention and resident care and satisfaction outcomes.  

Create Person-Centered Dining Education and Competency Standards

In many respects, the education and competency standards pertaining to food and dining are the most important as staff need to understand the standards they are expected to reach as well as how to reach these standards. As staff truly gain a working understanding of the critical importance of providing a dignified dining experience, and they desire to create it, the process will perhaps even be seen as team bonding, and end up improving morale and food service efficiencies and having the tools to create that experience, then the long term success of the program is easier to achieve.

For many homes, job descriptions currently exist for numerous departments who all participate in the food and dining experience. For example the laundry staff job descriptions may tie in to the cleaning of clothing protectors, and a cook and dietary aide job description may contain numerous food and cleaning standards, and the nursing staff job descriptions may all contain various components of monitoring, serving or helping with meals. As staff education and competency is established in dining, some homes may find a need to alter job descriptions.  Additionally some providers may determine benefit in cross-training and integrating staff.  A lot of homes already have adapted a meal program which includes the requirement that many staff from all disciplines, including leadership, participate in serving and creating a dignified and enjoyable meal experience for residents.
Assess how the home is currently serving meals and staff assignments during meals

Review orientation and training programs related to dining standards

Review job descriptions of staff and determine how performance standards might change or how job duties might be blended, resources re-allocated

Consider beginning the process of introducing all staff to the dining experience (department leadership, other members of the staff beyond nursing and dietary departments).

Please visit our Resource Library for a many free resources to guide you in creating a non-institutional dining experience.