Practical implications

Whilst this research now needs taking forward to realise its practical implications, it has highlighted the strong potential of mealtime interventions to address the health and wellbeing needs of care home residents. In this section, the possible future work and necessary implications are identified and

recommended. Section 7.5.1 begins by discussing how the thesis findings inform the development of interventions aimed at improving residents’ mealtime experiences. Section 7.5.2 considers the implications of developing a mealtime training programme for staff and how the training programme designed in this thesis may be developed further.

7.5.1. Implications for enhancing residents’ mealtime experience

Mealtimes are one of the few times during the day that a resident is involved in normal social interaction with other residents as well as staff (286, 325). Eating food can help provide comfort and pleasure(286). It can prompt memories of past experiences of mealtimes and sharing food with others, thereby enhancing feelings of wellbeing(326). They are also the ideal opportunity for residents to have an active role in the home. For example, supervised helping with the preparation of food and being involved in planning the menu may help residents feel more engaged in mealtimes(327). The need for practical solutions to promote resident (and staff) connections, as well as self-efficacy, is consistent with the findings from the empirical work carried out as part of this thesis.

Organisational focus on the physical and medical needs of residents may in part be shaped by policy, and recommendations disseminated by regulatory

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bodies. Regulators, such as the CQC in England, are primarily concerned with safeguarding resident welfare, and guidance is largely based on ensuring good quality of care. As the CQC’s mission statement makes clear, the priority is to ensure that care homes “meet fundamental standards of quality and safety”(42). However, whilst quality of care should underpin quality of life, quality of life does not necessarily correlate with quality of care. For example, guidance on

reducing the risk of falls may also reduce resident independence. Similarly, guidance on the administering soft or pureed foods to residents with dysphagia may ease swallowing difficulties, but may also restrict choice. The ability of staff to strike a balance between safeguarding and self-efficacy, and the support of management to enable this, may fundamentally impact resident wellbeing. The clear implication of the current research, then, is that staff need to explore ways of providing a social environment that promotes individual dignity and comfort, and encourages residents to enjoy mealtimes on their own terms.

Mealtime enjoyment is influenced by a complex interplay of physical, mental and psychosocial factors which becomes increasingly complicated with age and morbidity. The process within care homes of sourcing, preparing and presenting food followed by factors impacting on chewing, swallowing and digesting the meal produces many time points that can hamper a resident’s eating experience. Poorly managed, any one of these time points may negatively impact resident health and wellbeing. Furthermore, the dining

environment may have an important influence on the mealtime experience. For example, enhancing lighting during mealtimes (i.e., having the lights turned on and making sure there are no dark or shadowed areas) may increase functional abilities amongst residents with dementia(328). Other studies have found that the sensory-based manipulation of introducing the smell of baking bread or

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coffee in the dining area may increase food intake(329, 330). The broader principle of changing the style of delivery to a more “family-style” service where residents are presented with empty plates and serving bowls from which to take the food may improve both resident participation in mealtimes and

communication among residents and carers(154, 162). Serving meals in this way creates a more normal, homelike environment(154). However, in order to improve mealtime participation, eating behaviour and social interaction, it has been found that staff need to be instructed to interact with residents by

prompting and praising appropriate mealtime behaviours(162).

Staff education, adequate staffing levels and supervision at mealtimes, as well as an appreciation of personal and cultural preferences are integral to ensuring positive mealtime experiences(18). For many residents, their time in the care home is short: 56 percent of all care home residents die within a year of admission to the care home(331). Therefore, with mealtimes being such an important part of the social routine of living in a care home, it is important to educate staff about the possible benefits of improving the whole eating experience for residents, which may improve overall quality of life during this (often limited) time.

7.5.2. Implications for staff mealtime training

Staff have a crucial role in establishing positive social connections and in honoring individual identities (e.g., food preferences) at mealtimes. There is growing evidence that enhancing the mealtime experience for residents in this way will reduce BPSD and promote food intake and quality of life. At the same time, it is acknowledged that staff need to be sufficiently skilled to identify, and act on, issues related to the mealtime. Staff education interventions have showed promising results for improving quality of and amount of assistance,

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food intake, nutritional status, and quality of life of residents(135, 137, 145-148). Yet, feasibility of intensive eating assistance interventions programs

demonstrate that training to improve knowledge(141, 144) and care processes(104, 144, 156, 157, 332) with audit and feedback(304) or

support(104) are also effective, and potentially more sustainable than intensive eating assistance provided by staff. Staff-focussed programmes are needed because staff are front line, supported by management, and recent research has started to recognise this potential(18, 26).

Encouraging residents to eat and assisting them with feeding is time consuming and requires the carer to be empathetic to, and knowledgeable of, the difficulties that the person may be experiencing(325). Thus, training

programmes that raise staff awareness of the mealtime experience and

encourage empathy may help to improve care provision. This may be done by encouraging staff to imagine “being in residents’ shoes”, for example, by role- playing common scenarios or participating in other active learning

experiences(18). At the same time, there is a need to build capacity at

mealtimes so that staff have time to care for residents. Staggering mealtimes, extending the opening times of the dining room, or reprioritising duties in order to “protect” mealtimes may improve the resident experience, but such strategies necessitate some organisational flexibility.

The findings from the empirical work conducted in this thesis suggest that a mealtime training programme for staff is plausible and ready to be piloted and tested for effectiveness. Moreover, an adoption of this intervention may improve care provision by raising awareness of good mealtime practice. It also gives staff the opportunity to make changes relevant to their care home.

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transformational leadership, and may help to engage and retain staff, as well as enabling them to do their job better.