Dining Culture Change in Long-Term Care Homes: Transitioning to Resident-Centered and Relational Meals

Abstract: In this case study, the authors investigated how a long-term care (LTC) community transformed its culture of dining from traditional, institutional meals to resident-centered meals and relational dining. Christie Gardens is a continuum of care in Toronto, Ontario, Canada. It is home to 320 Independent and Assisted Living residents and 85 Courtyard Community (LTC) residents. Guided by the Life Nourishment Theory, a case study evaluation and qualitative data analysis were employed to synthesize information obtained with the following methods: 27 dining room observations; 38 interviews with leadership, staff, residents, and family members; and review of 45 relevant documents. The authors describe the resident-centered steps that led the home’s dining culture change, the evolution of care and meals in the home, the challenges and resistance to change that were encountered, and suggestions for overcoming these challenges. Strong yet nurturing leadership, visionary thinking, and translation of relational dining throughout a LTC home are essential for causing change to an ingrained culture.

Key words: Applied nutrition, person-centered care, relational care, culture change.

Citation: Annals of Long-Term Care: Clinical Care and Aging. 2015;23(6):28-36.
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A culture change is occurring in long-term care (LTC) homes throughout North America; providers are moving away from care philosophies based on reductionist, biomedical models and towards more holistic, person-centered practices.^1-5 Although research has suggested practical ways for LTC homes to make mealtimes more person-centered,^5-8 there are few descriptions of how homes can transition from providing meals in an institutional dining environment to providing home-like, resident-centered meals. Person-centered dining promotes the health and wellbeing of LTC residents. Medical models of care have led to rigidly structured and task-focused meals with limited opportunity for residents to choose when and what they eat and with whom they dine.^5,9-13 This can negatively affect residents’ food intake and nutritional status as well as impair their quality of life and acceptance of living in the LTC home.^10,11,14 A good quality of life is important for residents, who typically have little autonomy and control over their care and environment,^13,15 and mealtimes are essential to this.^9,10,16 Therefore, practical information about how to implement resident-centered dining practices in LTC homes is greatly needed.

Food and dining have always been a central part of residents’ lives at Christie Gardens, a continuum of care community in Toronto, Ontario, Canada. As noted on the home’s website, staff work toward ensuring that dining is personal and welcoming – “a socially inviting, nutritionally satisfying experience”¹⁷ – so that residents feel Christie Gardens truly is their home. To start the process of making meals more social, in 2010, the home created an open-dining concept for its Independent Living residents, who eat in a central dining area. Due to the success of this transition, the concept was adapted to the LTC setting initially in a single area. Since then, there have been more, rapid transitions from an institutional, medical-based healthcare model to a social model of care for its Courtyard Community (LTC) residents in the home’s former LTC areas. For example, staff members were cross-trained to become culture change agents, such as Care Partners (formerly personal support workers), and Nutritional Partners (formerly food service workers).

The objective of this qualitative case study was to describe how Christie Gardens is changing its culture of dining within its Courtyard Community (LTC) neighborhoods. Elucidating the main activities and processes that have been undertaken is needed to understand how this transition could be repeated in similar environments. Specifically, we sought to document the transition from traditional, institutional meals to home-like, resident-centered dining within the home. This article outlines the key processes, benefits, challenges, and possible solutions to support culture change that were identified in this data collection and analysis.

Methods
Between January and August of 2013, data were collected through the following methods: 27 Courtyard Community dining room observations, mainly during meals plus during a baking activity and during a staff training session; 38 individual and group interviews (15 formal and 23 informal) with senior leadership, management, staff, residents, and family members of residents; and review of 45 relevant documents, such as job descriptions, accreditation standards, meeting notes, and newsletters.¹⁸ All members of the community (eg, residents, family, staff, and volunteers) were made aware of the study through posters and letters regarding the potential for observation and/or participation in informal interviews. No member requested to not be observed; signs were posted before all observations to ensure transparency in data collection. All interviews and observations were conducted by two researchers; formal interviews were conducted with both researchers present.

Participants in interviews included seven members of the home’s senior leadership, six residents, six family members of residents, and 36 staff. Formal interviews were digitally recorded, and extensive notes were written during the interview and afterwards by both researchers; written consent was provided. Informal interviews occurred ‘in the moment’ during activities such as providing assistance with dining, and extensive notes were made afterwards. Verbal consent was provided to record key points made during the interview, but digital recording was not undertaken. Consistent with the case-study methodology that we used,18 digital recordings were reviewed but not transcribed; comprehensive notes were written by the lead author to summarize key details for inclusion in analysis.

Nonparticipant observations¹⁸ of mealtimes and other dining-related interactions involved all those potentially present in the observation area. The researcher was in the area before, during, and sometimes after the meal/activity to observe interactions among participants. Researchers typically selected two or three tables to observe in a more focused manner to detail ‘at the table’ interactions, while noting general processes (eg, how staff delivered food to residents) during the meal. Short-form notes were written at the time of observation, and these were filled in with greater detail in the form of an observation note on the same day by the researcher. Researchers reviewed each other’s observation notes immediately upon their completion to guide further observations and interviews. The home’s documents included in the review were either provided to the researchers, made available upon request, or freely available on the home’s website. The lead author reviewed all of these documents to identify key policies or strategies around the change in dining culture. This study was reviewed and approved by the Office of Research Ethics at the University of Waterloo.

The Life Nourishment Theory¹⁹ was used as a means of understanding person and resident-centered mealtimes and the relationships among those involved. The Life Nourishment Theory denotes that mealtimes are a reflection of how people lived prior to moving into a LTC home and how they desire to continue living.^11,20 Its central concepts are being connected with one’s self, family, friends, and community,²¹ honoring identity and personhood,²² and adapting to an evolving life.²⁰

All data were analyzed using the case study evaluation, pattern detection, and triangulation methods,¹⁸ which included analysis of dining room observation notes, interview recordings and notes, and documents. Preliminary findings were presented to the home’s senior leadership in a process known as member checking¹⁸ to confirm whether the researchers’ insights regarding resident-centered and relational meals were accurate; a report was provided to the team with a subsequent in-person two-hour meeting to discuss findings. The final results are being disseminated to residents, staff, and family members interested in learning about them. Feedback acquired during presentations of preliminary data to researchers, policy makers, LTC management, staff, family members, and residents at national and provincial conferences reinforced the relevance of findings.

Results
Data analysis resulted in the identification of three themes for this dining culture change process. Each theme and its subthemes are described below, with additional details listed in tables.

Recipes for Success
Christie Gardens took several resident-centered steps that led to the home’s dining culture changes. The main ‘ingredients’ for success included having strong leadership and a supportive board, developing and communicating the vision, building on successes by investing in dining, and creating culture change agents. See Table 1 for more information about the key facilitators for each of these steps.

The home’s mission, vision, and values are driven by strong leadership and a supportive board, comprised of passionate, determined, and creative individuals who are always striving to do better. The home’s mission is to offer more holistic choices for its residents to live well by using its experience and privilege of delivering distinctive services within a continuum of living. The home trains and retains staff members, who share its vision. Well-chosen, well-trained, and well-treated is the home’s leadership culture. The home has been strategic in allocating resources throughout its continuum of care and ensuring that its independent and assisted living residents have access to the full care Courtyard Community in which they have indirectly invested.

The CEO’s unrelenting vision to provide a social model of care within the residents’ home has been vital to Christie Gardens’ culture change journey, which is a continual process. Developing and communicating this vision of resident-centered care is enabled using the good relationships, collaborations, and open communication between residents, staff, family members, management, and leadership. The home’s focus on dining, food, and healthy living are central to its vision, which it enthusiastically shares. Key to developing the vision was training management and key staff on the Eden Alternative. This initial investment in six to eight managers was sufficient to substantially change care processes. Eden Alternative training modules were used informally with staff in huddles and more formally during on-site training as a way of communicating the vision.

Christie Gardens’ traditional dining experience was institutional, with set meal times in bland rooms and rigid staff routines focused on residents’ physical needs. The home then transitioned to resident-centered care by providing 2-hour windows for residents to attend meals with greater choices to meet their personal needs and preferences. Building on its successes by investing in dining, the home is currently in the process of moving toward relational dining by renovating its LTC areas into neighborhoods with 24-hour meal availability via flexible cross-trained staff who provide the residents’ chosen food and drink in home-like dining rooms. Dining areas are being physically renovated to be fairly consistent in size and with decorations and materials (eg, granite counter top) reminiscent of a kitchen and dining area in one’s home. The neighborhood kitchen is fully equipped and accessible by family and residents any time of the day. More flexibility leads to greater autonomy for residents and a better mealtime experience for all involved. Mealtimes are more relaxed, promoting social interactions; family members feel welcome and ‘at home.’ These visible changes have eased staff’s resistance to the home’s new social model of care.

In order to transform its culture of care from the status quo medical model, led by nurses and based on the physical health of residents, to a social model, one that holistically focuses on residents’ quality of life, Christie Gardens began flattening its hierarchy and enhancing opportunities for staff who work closely with residents and each other. Creating culture change agents was done with the introduction of cross-trained Care Partners (formerly personal support workers) who work with Nutritional Partners (formerly food service workers), Nursing Partners (formerly nursing staff), and Housekeeping Partners (formerly housekeeping staff) and are supported by Neighborhood Advocates (formerly life enrichment staff) who collectively determine what is needed for the individual and groups of residents living in each neighborhood. Nursing Partners took on a more peripheral role than in the prior medical model. A Neighborhood Guide (one of the home’s directors) oversees these endeavors, and the home’s management, senior leadership, and Board nurture their efforts. The amount of staff did not greatly change, but rather the types of staff and their roles changed. The selection of labels for these staff was intentional to demonstrate the flattening of the home’s hierarchy. The evolution of care occurred and continues to progress with staff, management, and leadership having time to form relationships and reflect on what works and what could be improved during in-home and off-site mentoring, neighborhood huddles, meetings, and retreats.

Going Beyond Resident-Centered Dining to Relational Meals
The experience at Christie Gardens demonstrated that resident-centered care must precede relational care. Leadership at the home needed to first envision what resident-centered dining was so that they could move past their traditional, institutionally driven mealtime processes. This began with an understanding from management down to point-of-care staff that the residence is a home for residents and family, and thus their preferences and needs would be identified and met. This enabled resident-centered dining, in which residents are increasingly empowered to choose what to eat and drink and when and where to dine.

Yet, resident-centered care was not enough, especially for residents with dementia. Moving toward relational dining was needed, because resident-centered care did not always translate into residents being psychologically and socially engaged at mealtimes by staff or having their preferences met if their verbal capacities were limited. Only by knowing a resident well and building a rapport based on time, continuity, and observational skill, such as to understand the needs and preferences of those with dementia, could the home truly provide resident-focused care within a mutually beneficial relationship. Thus, the term relational dining, which is termed elsewhere as ‘pleasurable’ and ‘sociable’ dining,^23-27 was created to differentiate this concept. See Table 2 for more details on the key facilitators involved with these transitions.

Threats to Success and Solutions
There have been some challenges and, specifically, resistance to change during Christie Gardens’ dining and care transformations. Within this theme, threats to success are portrayed, and possible solutions are provided regarding translating the vision, resisting the vision, and creating the dining atmosphere in Table 3. In general, Christie Gardens’ staff is quite skilled at providing resident-centered and relational dining to residents with sufficient cognitive and verbal capacity. Yet, as noted earlier, the most vulnerable residents are those who are nonverbal and are the most likely to not receive resident-focused care.

Translating the vision requires leadership and management to continually work with staff, residents, and family members to communicate transitions, improve their skills, and empower them to provide relational care. Christie Gardens found that translation was a continual process, and several forums were required, including written and verbal communications, training, and mentorship. Five days of on-site training of staff was required for the first neighborhood. A specific challenge was the transition for staff to see themselves and their work from a new perspective; some staff clung to their roles as personal support or medical care workers, providing care to residents rather than relational caregivers closely working with residents. An example of resisting the vision was defaulting to task-focused care processes, especially when staff felt time-pressured, rather than attempting relational care in all interactions. This resistance can be ameliorated by enhancing interactions with residents with cognitive impairments, working with resident preferences instead of routines, and resolving issues amicably. Creating the appropriate dining atmosphere can be accomplished by focusing activities solely on the social interactions, pleasure, and eating activities in the dining room, rather than routines and ‘tasks to be done.’ This meant selectively administering medications at mealtimes without being obtrusive, minimizing noise, encouraging conversation, and improving the physical environment. The dining rooms could be noisy with little conversation among residents or staff to residents, but ways of directing the conversation back to residents during meals were identified.

Discussion
Three themes emerged from this analysis of how one LTC home has changed its culture of LTC dining from traditional, institutional meals to resident-centered meals and relational dining.  Recent evidence suggests that even when a LTC home embraces culture change, mealtime processes are difficult to modify.²⁸ But resident-centered leadership, management, and staff continually advanced Christie Gardens’ dining culture change despite numerous barriers. There was resistance to the change, varied experiences in fully translating the vision, and challenges with continually creating a ‘home-like’ dining atmosphere, and these barriers should be anticipated. This study provides an overview of the systematic steps taken by one home to overcome these obstacles during dining culture change. A board that fully supports leadership on the vision, financial investment in physical space and training, and change agents who can infuse the vision in all, including family members and residents, are needed. Another key finding in this work was the distinction noted between home-like, resident-centered, and relational dining. Figure 1 provides a model of how these three concepts were distinguished in this case study and how the physical environmental changes can stimulate organizational and subsequent social environmental changes as residents, family members, and staff continue to develop and enact their vision of a social model of care. As evidenced in this case study, physical changes of tablecloths and furniture are not enough to achieve resident-centered dining. To truly meet the needs of residents in a social model of care, relational dining needs to be the goal.

The findings in this study echo those reported by Chang and colleagues²⁹ who conducted a retrospective longitudinal study in a nonprofit, urban New York LTC home, in which all staff received Eden Alternative training. Using Minimum Data Set (MDS) version 2.0 data, they found that, after controlling for baseline differences, residents living within the household area had improved self-feeding ability, were more alert, and required less use of restraints than those in the traditional unit.²⁹ Similar positive findings have been noted in other LTC studies in which the dining culture was changed.^30-32 As an effective care philosophy, it is thus important to understand what is needed for a home to shift its culture to more holistic, resident-centered practices.

As noted in this case study, changes in the physical environment, organizational environment, and social environment are needed to support resident-centered and relational mealtimes. Chang and colleagues²⁹ stated the importance of a modified physical environment that enables residents to more easily access the dining room and engage in activities, such as helping staff in the kitchen. Like most traditional LTC homes, residents typically eat in a large, central dining room that requires staff assistance to access, and this was the case for the majority of residents at Christie Gardens prior to their dining culture changes. Further, investing in modifications in the physical environment also signal to staff, residents, and family members the value of a more intimate and home-like mealtime interaction that provides the opportunity for social-environmental changes.

A critical literature review by Chaudhury and colleagues³³ identified that a supportive and flexible physical and social dining environment was essential for LTC residents to be autonomous and use their remaining abilities. Dining rooms with a home-like ambiance, minimal noise, and careful furniture placement contribute to social interactions during meals.³³ Nijs and colleagues³² studied family style dining with small groupings of residents, noting that modest changes to the physical (table dressing), organizational (food in serving bowls, mealtimes more flexible), and social (staff sitting and chatting with residents) environments promoted improved quality of life, physical functioning, and body weight of LTC residents without dementia. This confirmation of the benefit of the processes undertaken by Christie Gardens to change not only the physical and organizational environments within the social model of care, but also social-environmental change, lends further support to the goal of relational dining.

Although this case study provides a roadmap for others to consider when embarking on dining culture change, there were time and budgetary restrictions limiting further tracking of outcomes associated with the progression from institutional to relational care in all of Christie Gardens’ neighborhoods. For example, staff trust was not measured, but future work should examine the context for change as well as staff trust as change is proceeding. Furthermore, this experience of a single home may not be fully translatable to other LTC situations. Yet, lessons from this process can potentially stimulate a greater understanding of the complexity and perseverance that is required to make changes in dining culture. Interviews with senior leadership, management, staff, residents, and family members provided a comprehensive understanding of the past circumstances, present situation, and future plans in the home, which was verified by the requested and freely available documentation and dining room observations. Although only a few residents participated in formal interviews, potentially due to capacity for consent procedures, this limitation was ameliorated by conversationally speaking with several residents shortly before, during, or right after meals. Dining room observations also provided detailed insights into the mealtime experiences of residents and their interactions with others throughout the changes in the home.

Conclusion
Culture change is a long but determined process, and it is happening at a fast pace at Christie Gardens due to its supportive leadership and Board, inspired staff, and mutually beneficial relationships. This study revealed the key ingredients for a ‘recipe for success’ needed to make dining changes in LTC when a home is developing a social model of care. It is evident that strong yet nurturing leadership, visionary thinking, and translation of this philosophy throughout the organization are needed to truly effect culture change. However, change is not without its challenges, especially with respect to translating improved practices to all involved in dining, as well as upholding these practices on a daily basis so that task-oriented routines do not prevail. The most vulnerable, noncommunicative residents are the greatest challenge but are also those most in need of resident-centered and relational care. The key activities and processes gleaned from this case study can be used in other LTC homes to improve the health and quality of life of persons living, working, and visiting by enhancing the mealtime experience.

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