"Cup of tea...food...cup of tea" Foodservice systems influences on nutritional adequacy in aged care residents.

Evidence suggests malnutrition rates, and its related costs, in aged care facilities are high. Foodservices provide nearly all of the food eaten by residents in aged care facilities, so they are able to influence residents’ nutritional status. It is therefore important to evaluate foodservice systems in aged care to understand how nutritional adequacy is achieved. To date no studies have methodically observed aged care foodservice systems over time to explore how systems influence nutritional adequacy. This study aimed to investigate a foodservice system’s influences on the nutritional adequacy of food provided to rest home residents in a single, urban New Zealand, aged care facility. This facility’s head office was located elsewhere in New Zealand. Qualitative methods typical of ethnography were used to directly observe routine foodservice operations over a six-month period, producing over 100 hours of observation in a single facility. Thematic analysis of field notes, photographs, key informant interviews, and policy documents were managed using MAXQDA software. Menu audits were conducted using the Dietitians New Zealand Menu Audit Tool (2010 and 2013 versions). The foodservice produced well-received food reasonably efficiently, but no one had overall nutritional oversight and there was little feedback in the complex system to identify nutritional shortcomings. Multiple factors influenced food purchases, production and service, and ultimately, the nutritional adequacy of food offered to residents. Five groups (Head Office, facility managers (Nursing and Site Managers), kitchen staff (Cooks and Kitchen Hands), Careworkers and Night Staff were involved in food purchasing, production and service, which contributed to system complexity. The menu, developed by a Dietitian at head office level, was a key planning document for the foodservice, but kitchen staff frequently adapted it for a variety of reasons including insufficient equipment and labour. Menu changes were not fully recorded or monitored. While not all individual menu adaptations affected the nutritional content of the food served, serial adaptations served to undermine the original nutritional integrity of the menu to meet residents’ nutritional needs. Nutritional adequacy was also affected by displacement. For example, residents were offered substantial amounts of energy-dense, nutritionally uniform snacks (e.g. baked products) and mealtime extras (e.g. bread), which appeared to displace their appetite for more nutrient-diverse foods such as meat and vegetables at mealtimes. Meal portion sizes were individualised based on appetite. Routine small portion sizes at main meals resulted in kitchen food waste but minimal plate waste. New Zealand aged care facilities have to meet government standards, which include providing nutritionally adequate foods to residents. When assessing compliance, Dietitians need to audit food purchases, the type and amount of food and beverages served to residents at meals and snacks, and edible food and plate waste. One cannot assume Head Office menus are followed exactly, so food storage areas, adapted menus and at least one main meal service should be observed. Managers who have nutritional oversight need to be informed of nutritional shortcomings within local systems and actions prioritised to maximise nutritional outcomes. Given well-established routines, organisational change may be difficult. Multilevel staff-led interventions that align foodservice practices with approved nutritional policies are recommended. These changes are likely to improve the nutritional status of older adults living in aged care facilities and to reduce healthcare costs associated with malnutrition