Data Collection and Measures

An assessment of the physical environment was conducted using the Dining

Environment Audit Protocol (DEAP) in each dining area by a trained provincial coordinator. This assessment was performed once at the beginning of data collection for the home, when the dining room was empty. The DEAP recorded information on the unit and the dining space, specifically: unit type (dementia care unit or general care unit); number of tables;

number of chairs; number of stools or chairs for staff; number of entry ways and exits; percentage of residents with a clear view of the outside garden/green space; use of adjustable tables; contrast between floor/table/dishes; rounded edges of furniture; presence of a posted menu; detergents/non-edibles secured; stove and other dangerous items secured; presence of a television and/or clock; dining room open between meals; adjacent family kitchen with residential appliances, private family dining area; short distance from most bedrooms and visible from bedrooms; accessible washroom near dining room for residents; accessible beverage services; and accessible main kitchen/servery. Data was also collected on the functionality of the space, including lighting intensity, glare and respecting and responding to resident’s opinions on the physical environment (e.g., light, noise, temperature). Each of these items are categorized as zero, one or two, where zero indicates low functional ability, and two represents high functional ability for each variable. Further safety and security information was subjectively assessed by categorizing the space on the size of the dining room, length of pathways for meal delivery, presence of obstacles/clutter, the ability of staff to view all residents and use of restraints. Ratings for size, pathway and obstacles/clutter were one, two or three and were summed to create a scale from one to nine, where a higher score indicates a more functional dining space. Social potential of the space was noted by the presence of a mixture of seating arrangements, which were categorized as zero, one or two, which signify one option, a few options and multiple options of seating arrangements. A total score for features could be tallied from all of these components (max 56). Once all of these features were recorded, the assessor rated the space overall on two separate scales,

homelikeness and functionality of the environment, where the range was 1(low) to 8 (high) (see Appendix E) (26). Four provincial coordinators were trained to complete all measures, including the DEAP, during an intensive three-day in-person training. For DEAP, in-depth review of each item on the assessment was completed. Assessors then observed four dining spaces to practice; results were qualitatively compared and clarification provided where required to promote consistency among provincial raters (17).

A variety of standardized measures were used to assess construct validity. The Mealtime- Relational Care Checklist (M-RCC) assesses relational and person centered care

(R/PCC) behaviours exhibited by staff during mealtimes with individual residents. This checklist includes a variety of positive and negative staff-resident interactions (see Appendix A). Each interaction was given a score of either 0 (absent) or 1 (present); the positive and negative actions were summed and a positive:negative ratio was created. At the resident level, this checklist was performed three times per resident across three non-consecutive days with one observation for breakfast, lunch and dinner. The mean ratio across the three

observations was created and used for analysis. The M-RCC has demonstrated inter-rater reliability (40).

The staff reported person-directed care (PDC) instrument was developed to assess perceived care practices by classifying them into: personhood, comfort care, autonomy, knowing the person and support for relationships (121). By utilizing Likert scales, this questionnaire quantifies the extent to which staff report performing PCC behaviours. The staff PDC questionnaire is self-reported and has demonstrated face validity and conceptually distinct constructs (Cronbach’s alpha 0.86-0.91) (121). The staff PDC is given a maximum score out of 100. Some examples of items include: the number of residents that the staff member knows their preferred music; the number of residents that staff are able to have personal conversations with; and the number of residents that decide where they want to eat.

The Mealtime Scan (MTS) is an instrument which assesses the physical and psychosocial environments (40) as a meal is being completed. The MTS includes three summary scales (1=low to 8=high) to assess the physical, social and person centered

environments (see Appendix F) and includes an M-RCC checklist; however, this checklist is collected at the unit level rather than the resident level. The MTS has been deemed a reliable tool with good intraclass correlations (0.65-0.85) for the three summary scales (40). This data was collected in each dining area by the trained provincial coordinator and/or research

assistants. This instrument was performed 4-6 times in each unit’s dining room (n=82) with observations at breakfast, lunch and dinner; the mean of M-RCC, person centered, social and physical environment summary scales from these observations was used in analyses.

The Resident Food and Foodservice Satisfaction survey (122) is an instrument that is completed in an interview with residents and consists of 21 questions. There are three

components to the questionnaire: aspects of food, aspects of food service and quality of life (see Appendix B). Each question is asked with responses from 1 (less than half the time) to three (most of the time). This instrument was only conducted in-person with residents that had adequate cognition to complete. This survey is has a total score out of 63.

The interRAI Long Term Care Form is a standardized checklist which assesses the health, mental and quality of life of LTC residents (128). Trained provincial coordinators collected this data by interviewing staff members that are familiar with the resident’s current care and behaviour (17). The items from the interRAI Long Term Care Form that were used in this analysis were the Cognitive Performance Scale (CPS; maximum score of 6) (see Appendix G) and the Depression Rating Scale (DRS; maximum score of 33) (123,128,129) (see Appendix C).

Malnutrition risk was measured using the Mini Nutritional Assessment- Short Form (MNA-SF) which was collected from each participant in the M3 study. This tool was completed by gathering information from resident charts, the residents themselves or from care providers who were familiar with the resident. Information was collected on food intake, weight loss, mobility, psychological stress or acute disease, neuropsychological problems and body mass index (see Appendix D). These responses were summed to create a total score out of 14, where a higher score indicates better nutritional status. The MNA-SF has been deemed as a valid and reliable instrument in assessing nutritional risk (130,131).

Food intake measurements for each resident were performed on three non-

consecutive days, including one weekend day, throughout four weeks. Food intake data was gathered by weighing the items on main plates before and after meals, with fluid and side dish consumption and snacks estimated. The detailed process for collecting food and fluid intake data can be found in the Making Most of Mealtimes protocol (17). Home recipes were gathered and assembled in a program called Food Processor (version 10.14.1) and a nutrient analysis was used to estimate intake for the day for each resident based on the portion of all food and fluid consumed. Estimated average energy and protein intake variables for each resident was created by averaging each of three daily energy and protein intake values. Energy is a proxy for the amount of food consumed, while protein for the quality of food

consumed. Ethics clearance was provided by review boards from the Universities of Waterloo, Alberta, and Manitoba and Université de Moncton. Where required, ethics approval at individual nursing homes was also completed. Informed written consent was provided by residents or in the event of cognitive impairment, their alternative decision maker. Staff provided informed consent for completion of their questionnaire (17).