Improving Nutritional Support for Nursing Home Residents: A Two-phase Project

INTERVENTION: This study will use a four‐element blended Intervention, the Evidence‐based Nutrition Strategy (EBNS), comprising four elements known to support improved nutritional intake‐the SIP (Supportive, Informative, Prescriptive) communication protocol; family‐style group dining; high ambiance table presentation; and routine Dietary‐Nutrition Champion supervision. The intervention will be applied over 10 randomly allocated mealtimes per week (excluding weekends) for a total of 8 weeks. The four elements of the intervention are detailed below: ‐ 1. Communication Protocol: Supportive, informative & prescriptive The SIP protocol consists of the systematic reinforcement of subject sitting‐at‐table and eating behaviours by using three dimensions of communication: a) Style, i.e. general conversation about eating (generated by the use of the Supportive, Informative and Prescriptive categories from Six‐Category Intervention)(Heron, 1976); b) Form, i.e. specific elements of social behaviour (smiling, eye contact, nodding, laughing) and c) Content (focus of the conversation) on the meal and providing encouragement to eat. Systematic stopping of table‐leaving behaviour should be injected into the intervention as needed. 2. Family‐style group dining The preservation of homelike environments can be achieved through strategies such as: a) Preparing food close to time eaten to maximize cooking odours as a stimulant b) Keep former rituals as much as possible such as meal blessing c) If food is in a different consistency to which the PwD is familiar then cue the PwD to the item d) Eat in rooms where meals are usually served such as dining room e) Encourage caregiver involvement and engage them in eating some of the meal 3. High ambiance table presentation Physical presentation of meals and the use of very pleasant surroundings (table linen, china, flowers) has been shown to improve intake for PwD over a 6‐week period 4. Dietary‐nutrition champion supervision Constitutes paying particular attention to what is eaten and how it is eaten, including the following: ‐ ‐ Residents should be properly positioned to eat; that is, they should be sitting upright. ‐ Residents should have their dentures, glasses, and hearing aides, if needed. ‐ Resident requests for substitute food and fluid items should be honoured (and substitutes offered by staff if a resident doesn't seem to like the served meal). ‐ If a resident entirely consumes a particular food or beverage, offer a second helping, even if the food is a dessert. ‐ Residents should have access to their trays for up to 1 hour per meal (and no less than 30 minutes). Feeding assistance ends when each resident has refused all food and fluid items on his or her tray multiple times. ‐ An oral nutritional supplement should be offered at the end of the meal only to those residents who refused all other food and fluid items on their tray, consumed less than 75% of their meal, or requested a supplement. ‐ The nurse or nurse aide should follow a graduated prompting protocol to encourage residents to feed themselves. This standardized procedure instructs staff members to try nonverbal and verbal prompts to encourage residents to eat before offering physical guidance or assistance. CONDITION: Cognitive impairment Dementia Under‐nutrition PRIMARY OUTCOME: Mealtime nutritional intake: INCLUSION CRITERIA: Cognitive impairment; independently ambulatory; restraint free; continuous resident on a unit for three months; vision and hearing adequate for normal conversation ; Measured by comparing food weight and fluid volume before and after every meal. Each food item on the plate (e.g. meat, vegetables, starches, fruits, liquids) will be dispensed at the table using the prescribed individual amounts for each person. Discarded or spilled food and fluid will be retrieved from the table, floor and clothing. Pre and post‐meal plate photographs will be taken to enable proportion size and proportion eaten to be calculated, a reliable and valid method of measuring food intake. For this study, inadequate nutritional intake will be defined as less than 75% of the meal consumed and less than 240ml of fluid consumed. SECONDARY OUTCOME: Height, weight and Body Mass Index (BMI) using foot‐to‐foot bioelectrical impedance analysis (BIA) Mealtime agitation using the Cohen‐Mansfield Agitation Inventory (CMAI). Nutritional Status using the Mini Nutritional Assessment (MNA) Table‐leaving behaviour: ; Measured on three dimensions: frequency, duration and stimulus. Duration comprises elapsed time from point of rising from the table to point of sitting down again. Stimulus for table‐leaving will be recorded in brief narrative and explored for emergent themes. RAs will judge if the table‐leaving episode was a) self initiated or b) other‐initiated and note mode of return to the table (by self / other). Time spent at the table will be calculated by subtracting time away from the table from the standard 30 minutes of observation.