Theoretical contributions and implications

The research presented in this thesis has advanced understanding of the role of mealtimes in care homes. First and foremost, it has highlighted the

importance of the social and psychological dimensions of mealtimes. For instance, reduced self-efficacy at mealtimes emerged as a key issue in the findings. Yet, mealtimes have previously been investigated in the context of single-component interventions with biomedical or clinical outcomes (see Chapter 2, section 2.3) with little attention placed on psychosocial processes. The experiential aspects of care—relationships with staff and other residents, resident preferences and so on (manifested in perceptions of self-efficacy)— have played little part in the care pathway and have been largely neglected in the research literature.

This is in stark contrast to the wealth of research from other fields showing how, for example, social connections to others critically shapes individuals’ wellbeing and general quality of life—with clear implications for physical health(317). There has been a growing interest in recent years in the social determinants of health, notably in terms of the “social cure” approach(10). This approach to research, building on principles of social identity theory and self-categorization theory, establishes how health and wellbeing is intrinsically tied to individuals’ self-conceptions that are defined in relation to other

people(318). For example, group memberships (and the internalisation of these) have been shown to be positively associated with a range of health and

wellbeing outcomes(22, 277, 319). Several studies are now building on these foundations to design and evaluate group-based interventions(95, 267).

Thus, much of the research to date in care homes has failed to account for the complexity of mealtimes, which are influenced on multiple levels by

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residents, staff, and organisational factors(27). By identifying some of the key components of the mealtime experience, this thesis supports the development of multi-component interventions (e.g., food service, dining environment, staff education) that target multi-level factors (e.g., residents, staff) and measure a variety of outcomes(26). In short, the complexity of mealtimes necessitates the development of complex interventions that take full account of social and

psychological processes. The current research has highlighted the translational value of an approach to care home research which fully accounts for the

psychosocial processes inherent to this context.

Secondly, the empirical findings in this thesis elucidate some of the barriers and facilitators to the provision of optimal mealtimes, which show that a psychosocial focus is relevant to a range of factors beyond those pertaining to residents. In the systematic review (Chapter 4), residents and staff recognised the importance of care provision in setting the tone of the mealtime experience: Organisational factors (including staff attitudes) were associated with levels of resident agency, the mealtime culture, and the meal quality and enjoyment. On the other hand, resident interactions, balancing routines, and the ability of staff to manage competing interests were identified as key influences on the

mealtime experience in the interview study (Chapter 5). Given the pivotal role that staff play in defining residents’ experiences of mealtimes, it is important that interventions are designed that target staff behaviour.

Training for mealtime staff is a recurrent recommendation in the literature(161, 163, 254, 274). In particular, it has been suggested that staff training focus on the importance of the social aspect of meals, and that staff are encouraged to reflect on their mealtime practices: Engendering a culture of reflection and prompting staff to step into the shoes of residents may promote

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empathy and pave the way for improved mealtime care(18, 163). In addition, it is hypothesised that training has the potential to improve staff satisfaction. For example, it has been suggested that staff training programmes that provide ongoing emotional support, perhaps by a support group, may reduce turnover and absenteeism(18, 274).

Training also provides an opportunity for increased engagement with staff. Engagement has been defined as a psychological state associated with a sense of commitment and loyalty to one’s organisation and involvement in one’s work: It follows that certain conditions affect levels of staff engagement, which in turn affect behaviour, and consequently impact overall performance(320). In the healthcare sector, highly engaged staff have been shown to be healthier and happier, with lower sickness absence and lower staff turnover(320). For example, in the NHS, West and Dawson (2012) found that organisations with levels of engagement in the top third had absenteeism of 3.6 percent in

comparison with 4.8 percent for those at the bottom(321). Engaged staff may be more likely to demonstrate empathy and compassion to residents, despite the challenges of working in a pressured environment. In hospital settings, positive correlations have been found between staff engagement and both overall patient experience and whether patients reported being treated with dignity and respect(320).

As well as engaging staff, and equipping them with the knowledge and tools to do their job better, training may convey additional benefits. Having the opportunity to have their voices heard, their grievances aired, and endowing staff with the responsibility for certain decisions, may be motivating and empowering. This has important implications for how staff training and education interventions are conceived of and designed. Front-line mealtime

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staff have a wealth and knowledge and experience and may have ideas that could benefit other staff and the care home in general. However, the potential effectiveness of staff education and training interventions is dependent on managers recognising their importance and supporting their implementation.

Creating the conditions for increased staff engagement and

empowerment relies on good leadership. Care home providers, owners, and managers play a crucial role in supporting, motivating, and even inspiring staff in their organisations. Transformational leadership (referred to in section 6.3.5) is widely referenced in the Healthcare Sector, promoted as a style of leadership that facilitates change, increases job commitment, job satisfaction and staff wellbeing(322). Transformational leaders are described as those who “broaden and elevate the interests of their followers, generate awareness and

commitment of individuals to the purpose and mission of the group, and enable subordinates to transcend their own self-interests for the betterment of the group” (Seltzer et al., 1989, p. 174)(323). The concept of transformational leadership encompasses charisma (the leader as a role model), inspirational motivation, intellectual stimulation (i.e., encouraging staff to make their own decisions and be creative and innovative) and individualised consideration (i.e., coaching and mentoring staff)(324).

It may be argued that transformational leaders have an especially important role in care homes. As care home staff have daily contact with

residents, they are likely to be the first to notice changes in their health and are best placed to address their needs. Thus, leaders who encourage staff to solve problems and take responsibility may facilitate improvements in the provision of care(322). Moreover, transformational or inspirational leaders may positively impact staff wellbeing, which is particularly pertinent given the recognised

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pressures on staff in care homes and in the care sector more widely (section 2.3.4).