Relational Mealtimes in Long-Term Care: Understanding the context of care at mealtimes for residents with eating and other mealtime challenges

Background: Mealtimes in long-term care (LTC) are essential to resident health and well-being, as eating with others helps to reinforce relationships between those who live and work in these homes and their relationships to the greater community. The evolution of the culture change movement within the LTC sector promotes the adoption of social models of care, such as relationship-centred care (RCC), to improve the everyday lives of residents, including at mealtimes. Malnutrition is a serious and on- going issue among residents living in LTC homes, where 44% of Canadian residents were found to be malnourished largely due to food access issues (e.g., eating ability, dysphagia). Addressing these issues requires a relational understanding of factors that can impact resident mealtimes, and the conditions under which care is provided. Families continue to play an important role in the lives of residents and provide additional support when needed, though their contributions continue to be overlooked. Informed by relational theory, this dissertation aimed to understand how multi-level interacting factors shape the conditions of care, the mealtime experience, and ultimately the well-nourishment of residents. Methods: All parts that comprise this dissertation use secondary data from the Making the Most of Mealtimes (M3) Study, a cross-sectional study that examined multi-level factors associated with food and fluid intake among 639 residents across 32 Canadian LTC homes in four provinces (AB, MB, ON, NB). Part 1 of this dissertation aimed to explore the multi-level factors at the resident-, dining room-, and LTC home system- levels that may impact mealtime care, specifically associations with staff RCC and task- focused (TF) mealtime practices. Descriptive and association analyses were conducted to determine independent associations between multi-level factors and these RCC and TF mealtime care practices. Recognizing that relationships and how eating assistance is provided may impact food intake, the study in Part 2 aimed to explore the potential impact of a family member providing mealtime eating assistance on resident energy and protein intake, as compared to when staff provided this assistance. Descriptive andassociation analyses were conducted to determine the independent association between energy and protein intake with family eating assistance versus staff assistance in a subset of residents requiring physical eating assistance (n= 147). Mealtime experiences of food intake and social interactions can be influenced by many factors, including the resident’s capacity for verbal communication, including vision and hearing abilities. Challenges in communication may be exhibited as wayfaring during meals. Part 3 of this thesis explored the association between resident sensory impairment, communication capacity, wayfaring during the meal, staff mealtime care practices (RCC and TF), and family food involvement (providing eating assistance, bringing food into the home) with the outcome of nutrition status (malnourished vs. well-nourished). Descriptive and association analyses were conducted to determine which of these resident, staff and family variables had the potential to impact resident nutritional status. Results: Using a standardized mealtime observation tool to determine mealtime practices in Part 1, it was noted that RCC practices (9.6±1.4) were more common than TF practices (5.6±2.1). Almost one quarter of participants required eating assistance (n=634; 23.2%). Mealtime RCC and TF practices were associated with multi-level factors: TF practices were more likely to occur with larger home size, care continuums, more staff involved in assisting, male residents, and residents requiring eating assistance. RCC practices were observed more often in for-profit homes, those with recent renovations, and female residents. Results from Part 2 found that of those residents who required any physical eating assistance (N=147), almost 40% had a family member provide assistance during at least one of nine meal observations. Statistically significant differences in eating challenges (i.e., dysphagia risk) and type of home area (i.e., specialized dementia care units) were found between those residents who received family assistance (n=56) compared to those who did not (n=91). Family assistance was independently associated with a significantly higher consumption of both protein and energy intake when compared to staff assistance for meals in these same participants (n=56). Results from Part 3 found that 44% of the resident sample were malnourished. Vision and hearing deficits (despite use of usual aids) affected almost 20% of participants, while verbal communication challenges affected over a quarter of residents. Wayfaring at meals was observed among almost 4% of residents. Statistically significant differences in characteristics were found between well-nourished and malnourished residents. Vision impairment, communication challenges, wayfaring, family member mealtime presence, and fewer RCC mealtime practices were independently associated with resident malnutrition. Conclusion: This dissertation provides insight into some of the relational aspects of mealtimes within Canadian LTC homes. More specifically how capacity for resident participation in meals (e.g., wayfaring, verbal communication), requirement of physical eating assistance, staff mealtime care practices, and family participation are linked to higher level structures that impact the innermost mealtime interactions resulting in differences in food intake and malnutrition. Findings from this dissertation support a refocusing of efforts in the culture change movement on these most vulnerable residents with eating and other mealtime challenges. Future work should target the conditions of care as they relate to mealtimes and translate into RCC practices, which includes the dining environment, organizational culture, and governing bodies