Putting Staffs’ Beliefs About Values of Mealtime Situations for Long-Term Care Residents’ Health and Well-Being Into Practice: A Qualitative Study
Abstract
In the context of long-term care facilities, mealtime situations have been linked to residents’ health and well-being. The optimisation of mealtime situations is dependent on multiple aspects and is complex. To better understand this complexity, this qualitative study aimed to identify staffs’ beliefs about the values of mealtime situations for residents’ health and well-being and to explore the facilitators of, barriers to, and challenges and actions in accomplishing and upholding these values. The results demonstrated that staffs’ belief consisted of achieving social and relational values, vitality values, self-strengthening values and atmospheric values. During mealtimes, participating staff had to constantly balance these values in relation to mealtime situational preconditions and residents’ individual and communal needs. Experienced facilitators, challenges, barriers and actions could be traced to and explained by identified beliefs, implying that knowledge regarding beliefs about values could be helpful for understanding and managing the complexity inherent in the mealtime situation.
1. Introduction
Optimising mealtime situations for residents in long-term care facilities (LTCFs) is of utmost importance, as intervention studies reveal that mealtime situations have both direct and indirect impacts on residents’ health [1, 2], quality of life/health-related quality of life (QoL/HRQoL) [1] and person-centred care [3, 4]. The mealtime situation also impacts residents’ mealtime experiences [5] and their behaviour during mealtimes [6, 7]. The extent of evidence in the aforementioned studies varies, but overall, there is sufficient evidence to acknowledge the mealtime situation as an actor in residents’ health and well-being and quality of care [1–7].
However, optimising mealtime situations is a complex challenge. According to mealtime theory, mealtimes in LTCFs are described as unique, active processes in which optimal mealtime experiences for residents require individualised care, reflecting interdisciplinary and multilevel interventions [8]. Optimisation also involves considering the interactions between material/physical aspects, that is, the room, food and other artefacts, and immaterial/nonphysical aspects, such as the atmosphere, interpersonal interactions [5, 9] and organisational aspects [5, 9, 10], where changes to one aspect impact other aspects [4]. For example, organisational aspects such as staffing levels, proportion of part-time staff and the turnover rates of temporary care workers may interrupt the consistency of care and interpersonal interactions [10, 11]. Additionally, deficient documentation routines may lead to less awareness of individual resident’s mealtime preferences [12]. Furthermore, minimal staffing and additional training may impact relationship-centred care at mealtimes [13].
Adding to the aforementioned challenge, LTCFs are organised to meet not only individual needs but also communal needs. Watkins et al. point at these dual demands in their systematic review, ‘enhancing the mealtime experience for care home residents needs to take account of the complex needs of residents while also creating an environment in which individual care can be provided in a communal setting’ [2]. These dual demands pose a challenge for participating staff when residents with various functional limitations and assistance needs live in the same setting and often share communal mealtimes [14], thereby risking staff-perceived shortcomings in meeting individual needs [15].
In reviewing the literature, previous research has mainly focused on participating staff experiences, views, attitudes and perceptions in optimising mealtime situations and quality of mealtime care. Staff from various older adult care contexts and countries share a common perception that mealtime care practices should be tailored rather than standardised to optimise mealtime situations [11]. Staff assign mealtime value in meeting residents’ nutritional needs [16], describing food as crucial for avoiding malnutrition [17] and for impacting QoL [2]. Staff also perceive that diet adjustments should be based on individual residents’ preferences and needs [2, 11, 17] and that residents should be provided with modest eating assistance to sustain independence [11]. Mealtime is also assigned social value [2, 11, 17], and creating positive social interactions among residents, as well as between staff and residents, is considered important [2, 11]. Such interaction is described as part of creating a social place for conversation and action to fulfil and develop roles and identities [10]. Staff also perceive that creating and maintaining a comfortable physical environment is important to support eating performance, as well as fostering a sociocultural environment to establish connections [11]. Furthermore, training and education related to nutritional care are considered important [11]. Staff rate their attitudes as low when it comes to knowledge and practices for managing meals and for monitoring residents’ nutritional status [18]. Staff also perceive that their mealtime assistance and feeding skills impact residents’ nutritional status and food intake [19], although the strengths of evidence vary due to study designs [20].
Optimising mealtime situations relies on multidisciplinary team support and opportunities for team members to communicate [11], and the integration of staffs’ different perspectives and views of meal-related situations should be prioritised [17]. Such an integration might not be easily attainable. Multidisciplinary team support meetings for communication and teamwork are described by staff as helpful for mealtime management but are also challenged by professional soloing and isolated communication [11]. Results show that although staff may acknowledge the importance of the mealtime situation for residents’ physical, social and psychological needs, a missing shared perspective of what is important and how to prioritise mealtime-related issues [11, 17] can result in staff experiences of ‘impossible’ mealtime situations [21].
From our review of the literature, we conclude that there is evidence for the significance of mealtime situations for residents’ health and well-being. Also, what stood out is that despite considerable knowledge of impact from various interventions, optimising the mealtime situation is a complex issue. The organisational framework and the mealtime situations themselves challenge health- and social-care professionals’ knowledge, skills and priorities. While staff may view the nutritional and social values as important, there may be circumstances, and conflicting views, attitudes and perceptions that make it more challenging and complex. One possible way to expand our understanding of this complexity that previously has not been studied is to explore staffs’ beliefs about the value of the mealtime situations as an actor in residents’ health and well-being. Since theories about beliefs state that beliefs constitute the ground for what one sees as right or wrong, considers good or bad and that beliefs are the ‘blueprints’ which guide all our perspectives, views and actions [22, 23], they seem well worth studying also in this context. In the context of mealtime situations in LTCFs, staff might hold various individual or shared beliefs about the values for residents’ health and well-being. These beliefs can be considered grounds for their attitudes and a lens from which staffs’ mealtime experiences take form and ground their actions during mealtime situations. Knowledge regarding staffs’ beliefs about values in the mealtime situation for residents’ health and well-being can contribute to our understanding of important aspects when implementing caring mealtime situations in LTCFs. Following, the objective of this study is to gain knowledge about which health-related value professionals assign to mealtime situations and how these values are manifested, accomplished and upheld in a multidimensional and complex mealtime situation. Therefore, this study aimed to identify staffs’ beliefs about the values of mealtime situations in LTCFs for residents’ health and well-being. Further, facilitators, challenges, barriers and actions for accomplishing and upholding these identified values were explored.
2. Materials and Methods
2.1. Design
This study employed a qualitative design [24] based on the ontological multiverse and epistemological inductive grounds which are consistent with the focus and perspective of the study aim. The data collection method with group interviews [25] and a combination of an interpretive and descriptive qualitative analysis [26] are considered appropriate given this design. The study was approved by the Swedish Ethical Review Authority (registration number 2019-05477). All participants gave their written informed consent after receiving verbal and written information about the study.
2.2. Sampling and Setting
Participants with diverse experiences working in various LTCFs in one municipality in southern Sweden were recruited. In line with a qualitative design, a purposeful sampling strategy [27] in two steps was used, aiming at the inclusion of various professional stakeholders. The inclusion criteria were staff with various mealtime situation responsibilities involved at any organisational level having experiences of mealtime situations in LTCFs. In the initial step, nursing staff engaged in mealtime situations on a daily basis were identified as stakeholders and subsequently recruited. The selected participants (n = 4) possessed extensive experience—either collaboratively serving as regular staff members in a specific LTCF or fulfilling ambulatory rotation roles across multiple LTCFs within one of the four designated geographical units in the municipality. In the following step, other stakeholders acknowledged in the interviews were recruited. The selected participants (n = 9) brought experience to the study that included collaborating with residents and staff, assuming leadership positions and engaging in consulting roles. Importantly, each participant carried out distinct responsibilities tailored to their specialisation, particularly in relation to mealtime situations. All participants who were asked to participate agreed to participate. The final sample was comprised of 13 staff members; see Table 1.
| Gender | n |
| Women | 11 |
| Men | 2 |
| Age | 32–55 years |
| Years of experience | 12–38 years |
| Role | n |
| Assistant nurse | 3 |
| Assistant nurse and mealtime agent | 1 |
| Head of LTCF unit | 1 |
| Registered nurse | 1 |
| Dietician | 1 |
| Occupational therapist | 1 |
| Physical therapist | 1 |
| Sight and hearing consultant | 1 |
| Needs assessment officer | 1 |
| Head chef | 1 |
| Central kitchen assistant | 1 |
LTCFs in this study, and in Sweden in general, house residents with various needs and assistance levels in daily living owing to different chronic diseases (e.g., stroke and dementia), frailty and physical impairment/disability. Access to LTCFs is granted based on extensive care needs based on a formal need assessment. Typically, smaller units accommodate 10–12 residents, with some units specialising in dementia care, although a prevalence of residents with various chronic diseases is common. Every resident has a one-room apartment with a combined bed- and living room equipped with a Trinette kitchen. Lunch and dinner are prepared in the central kitchen and delivered in food carts to the units to be served by nursing staff. Meals are typically served in a communal dining room area. Breakfast, daytime, evening and night-time snacks are prepared and served by nursing staff on site. Mealtimes are structured with two or three dedicated staff members, typically assisting nurses, nurse’s aides or untrained staff members, who primarily operate within a specific unit for the majority of their shifts. However, ambulatory rotation shifts are also incorporated, allowing staff members to work across various units and LTCFs. Moreover, each unit engages in collaborative efforts with specialised professionals responsible for aspects of the mealtime situation. These professionals include dieticians, registered nurses, central kitchen staff and physical therapists. Caring for residents’ health and well-being is regulated in the Social Services Act and the Healthcare Act, emphasising autonomy, participation and integrity as essential caring values.
2.3. Data Collection
Group interviews were used in the study to facilitate the exploration of the phenomenon from diverse perspectives [25]. Various staff were combined in 5 groups of 2–5 persons, and each interview lasted 60–90 min. The allocation of participants to each group predominantly relied on considerations of participant convenience and their availability, with flexibility extended to accommodate last-minute organisational adjustments, such as schedule changes resulting from unforeseen circumstances such as sick leave or pressing work obligations. Specifically, two groups were composed of caring staff providing day-to-day care, while three groups were comprised of staff with diverse specialisations. Interviews were conducted by two of the authors (S.A. and C.P.). To collect participants’ perspectives in a narrative way, a semistructured interview guide [28] was constructed including themes corresponding to the Five Aspect Meal Model (FAMM) [25]. This conceptual model provides a holistic approach for studying mealtimes in long-term care facilities [8], including aspects related to the context, product, meeting, management control system and atmosphere of mealtime situations. The FAMM was developed for planning and serving meals in restaurants but has also been found to be valuable for empirical research in the context of nursing homes [29, 30] and in reviewing empirical research [9, 31].
The opening question in all interviews was as follows: ‘Can you please tell us about a mealtime situation that engaged or affected you?’ The two main questions that then followed were as follows: ‘Can you please describe an ordinary mealtime situation?’ and ‘Can you please tell us about what you think is an optimal mealtime situation?’ Follow-up questions were posed to these two main questions to encourage the participants to clarify, deepen and reflect upon their responses in relation to five aspects of the mealtime situation. Data were collected from March to September 2018 and stopped when no further information was elicited. All interviews were transcribed verbatim before the analysis.
2.4. Analysis
Two authors (S.A. and C.P.) performed the main analysis, and four other authors (A.S., C.W.H., K.H. and E.L.) reviewed the analysis and served as critical discussion partners throughout the process. Initially, the transcribed interviews were read through several times to obtain an overall understanding of the content. Afterwards, the analysis was performed in two major steps.
The first step focused on identifying staffs’ beliefs, and since beliefs are embedded in narratives, the emphasis in the analysis needed to be on latent content. Accordingly, an interpretative qualitative content analysis was applied [26]. Relevant parts of the participants’ narratives conveying information that could be related to beliefs about the values of the mealtime situation for residents’ health and well-being were identified, divided into meaning units and subsequently condensed. Questions were posed to each condensed meaning unit regarding what possible belief the text suggested in relation to the value of the mealtime situation for residents’ health and well-being. This identifying part of the analysis process was performed independently by S.A. and C.P., and the identified beliefs about values were then discussed between researchers, and when agreement was reached, each was assigned a condensed meaning unit. Thereafter, meaning units and interpreted beliefs about values were compared to each other in terms of their similarities and differences, and based on this comparison, they were then clustered into themes, with each theme conveying one value of the mealtime situation for residents’ health and well-being. The clustering of the values into themes was discussed and validated by the authors.
Experiences of challenges, barriers and facilitators for accomplishing values held important in the mealtime situations for residents’ health and well-being, as well as what actions were taken to uphold these values were explicit in the transcribed interviews. Therefore, in the second analysis step, the manifest content analysis method [26] was used. The transcribed interviews were read again independently by S.A. and C.P. to identify meaning units that conveyed staffs’ experiences and actions. Identified meaning units were condensed, coded, subcategorised [26], subsequently compared, and finally categorised when consensus was reached among all authors.
3. Results
In the interpretative analysis, beliefs about values of the mealtime situation as contributing to resident’s health and well-being were identified. These values were categorised as follows: social and relational values, vitality values, self-strengthening values and atmospheric values. An overarching theme was found in the analysis: balancing within and between values in relation to mealtime’s situational preconditions and residents’ individual and communal needs. This balancing act was ongoing during mealtimes comprising facilitators, challenges, barriers and actions taken to uphold these values.
3.1. Achieving Social and Relational Values
It feels good to have had come this far, actually sitting together, living and eating together. So we have separated the tables so not all sit at the same big table, I believe there are three tables. One then sits with others who are better matches to communicate with, if they have that ability (Group 4).
Friendship among residents was another facilitator for social and relational values. Thus, choice and possibility for residents to sit together during meals was considered important. Participating staffs’ presence was also seen as a facilitator in accomplishing these values. Participating staff being present in the interaction with residents was a prerequisite for establishing connections and conversations to facilitate good social relationships, for residents to feel included and for conversations to support this value. Accomplishment of social and relational values was also facilitated by engaging residents in social activities, for example, staff preparing meals in collaboration with residents. Other facilitators involved creating activities to enhance everyday luxury and bring flavour to life, such as having afternoon tea, and celebrating the end of the week. On special occasions, mealtimes were thematically organised by the municipality, such as Christmas and Easter dinner and the Nobel Prize festivities; these activities were all experienced by staff as a means of promoting community, togetherness and belonging.
Often one adds one’s own personal values and objective, about residents sitting and eating by themselves in one’s room, but you can’t do that. They might have been widowed, or living alone for twenty years before they moved in. Loneliness might not be a problem for them, but we view it from another perspective before reconciling it with certain aspects. One puts a lot of one’s own values and preferences on it (Group 1).
A similar challenge was described when residents could not or would not eat together with others due to feeling ashamed or stigmatised, for example, due to eating difficulties. Even though residents may prefer to eat alone, and free choice was seen as paramount among staff, it challenged the values of the community, including togetherness and belonging. Barriers experienced in terms of social and relational values included organisational hindrances making mealtime-related social activities difficult to organise on a regular basis due to a shortage in participating staff and tight schedules. Values were also threatened when participating staff were distracted by care duties, for example, answering ward phone calls, responding to visitors, preparing the food trolley and clearing dishes. An action but also a challenge related to these barriers was to prioritise either upholding social and relational values or care duties.
3.2. Achieving Vitality Values
…but that you really, if they’re not eating, really support them to continue their meal. When not wanting anything, you see to that they get something else instead. It’s a lot of pressing and coaxing. You try to make sure that they eat but if they say no, I have to accept that (Group 3).
To cater to residents’ sensory preferences and taste, another facilitator for embodying vitality values involved a rehabilitating mealtime situation approach. This addressed functional limitations through sensory stimulation and adaptations, including the use of contrasting colours in food. Person-centred mealtime care planning to adopt portion sizes and food consistency according to the residents’ needs, appetite and food wishes was also seen as a facilitator.
I: What do you think this long wait means? R: Yes, well perhaps one is tired when about to eat. You are tired. Because it is tiring to eat too. So yes, it felt a bit like storage around the dining table. Coming in from the outside, perhaps I see it in another way than those working daily. Perhaps they don’t think it’s strange, that they (residents) are sitting there 1.5 h before food will be served. I felt that was a bit strange (Group 2).
As it was common that the mealtime area was also used for other activities than meals, anticipative cues that meals were about to happen were vague. Related actions taken by participating staff to uphold the vitality values therefore included enhancing mealtime signals and symbols, such as talking about the menu and setting tables to avoid distractions and as a sign that it is mealtime.
3.3. Achieving Self-Strengthening Values
The mealtime situation as an actor for strengthening and supporting residents’ selves was another identified belief. Upholding self-strengthening values during mealtimes was expressed as a foundation in mealtime care situations, especially when caring for residents in cognitive decline. Independence and individuality were seen as key aspects constituting this value. Therefore, it was essential to respond to each resident’s level of functional ability as well as to support individuality by acknowledging the resident as a person with preferences and ability to express their personality and cultural and religious identities. To achieve these values, participating staff expressed that they continuously needed to reflect upon and decide which ways to strengthen residents’ sense of self were optimal in any specific situation.
I: How important is the room for the mealtime? R: For some it is very important, that it’s a place for meals to happen. It’s become a routine. To be able to keep up your independence…When it’s time for breakfast everyone that can walk does so. Keeping the appearance up that you are my equal, it’s so strongly associated (Group 3).
A facilitating action included motivating and modelling eating behaviour, while eating together, to act affirmatory and supportive of residents’ independence: ‘…also, the social pedagogical meal, to sit in and join. In many cases it is very important to see someone eating, to be able to mirror’ (Group 5). Accomplishing these values also meant setting tables in a way to adjust to residents’ cognitive levels and hearing and vision disabilities so as to facilitate independence.
…people that recently arrived from other cultures and never used a knife and fork. Then they become dependent…And if you develop dementia, perhaps had learned to use a knife and fork late, then you don’t have it in you (Group 5).
A facilitator to accomplishing these types of self-strengthening values, especially when residents had difficulties communicating, included participating staff knowing and confirming residents as persons, with personal history and preferences.
…at certain tables it’s okay to pick at your food. At other tables it’s not. One tries to think that the reidents should be as independent as possible. You adjust so that not all are treated the same way, even if some resident at the table can’t [eat] by themselves. You really try to adapt to the individual (Group 2).
We have a resident that eat her meals in her room, all the time. She can’t manage the social aspect, really, and believes all stuff and places belong to her. She feels others are rude and yells. She gets angry and yells at them too. She cannot manage the social situation at all…It raises the anxiety. We have chosen this strategy and she thrives; we think (Group 1).
Participating staffs’ acknowledgement and promotion of choice was expressed as confirming individuality and as an exercise of power. Additionally, the opposite was expressed; when participating staff were nonperceptive not acknowledging residents’ preferences and abilities, there was a risk of evoking force and limiting of choice, thus reducing individuality.
Although promoting choice and independence were important for individuality values, actions for strengthening the self were challenging due to the complexity of adjusting the level of residents’ choice so it did not become a stressful challenge and failure owing to residents’ individual circumstances and cognitive disability. For example, advocating for choice while strengthening the self could be promoted by asking residents to choose between several courses and beverages, asking residents to accept single courses and beverages or not asking residents to choose at all. Choice was also influenced by organisational policies of portion control and lower food wastage for sustainability. A barrier emerged when meals were preordered a week in advance, which essentially limited possibilities for spontaneous daily choice.
3.4. Achieving Atmospheric Values
Finally, another identified belief included the mealtime situation as an actor for upholding atmospheric values, which was seen as ‘home-likeness’ (home-like atmosphere), and ‘calmness and tranquillity’. ‘Home-likeness’ meant having meals in a familial way, characterised as a comfortable, convivial, relaxed and friendly atmosphere.
Home-likeness was also related to creating a homely feel facilitated by furnishing the mealtime area in a home-like way, and serving aromatic and savoury foods and drinks familiar to residents. It also involved presenting food in an appealing and homely way, such as by serving food in serving bowls at the table. ‘Calmness and tranquillity’ meant creating audial and visual harmony that was facilitated by participating staff being present and responsive in the moment focussing on the resident, balancing between being silent and speaking quietly and calmly based on residents’ needs and having meaningful conversations to create such an outcome. It also involved visually screening and controlling the flow of movement in and around the meal situation to limit residents’ stressful and anxious responses due to impaired cognition.
When it comes to food, one would like to…it’s somewhat under time pressure. One has to run along with the canteens and if one starts clanking and emptying then it’s noisy. It’s also a signal for everyone to stand up and leave. If it weren’t for the canteens having to be ready for transport, then it would be calmer (Group 3).
We carry the telephone alarm unit that keeps ringing. Many residents might think the call is for them…They might expect a call in their mind, being at work. As soon as one leaves the mealtime area, three, four residents may just stand up and leave the table. It gets turbulent. We (participating staff) can pick up where we left right away. They (residents) often can’t. Then one has to start all over again, get things to calm down and have them seated. It can affect how food tastes for other residents not on the go (Group 1).
4. Discussion
The study’s findings reveal beliefs held in common by staff about the values of mealtime situations for residents’ health and well-being. Findings depict the mealtime situation as an actor in social and relational, vitality, self-strengthening and atmospheric values. Furthermore, our study demonstrates that upholding values in the mealtime situation is a complex balancing act when put into practice, requiring compromising within and between values, considering residents’ individual and communal needs, managing mealtime and organisational preconditions and negotiating participating staffs’ individual and shared beliefs. Our findings indicate a tension between the organisational structure, available resources and the perspectives of residents and staff, which will be addressed in the following discussion.
The beliefs about values can be understood in relation to what previous research and steering documents hold to be ‘good’ mealtime situations in caring contexts. For example, as reported in a review, several values are consistent with the meaning of key therapeutic goals for person-centred mealtime care [3]. In this review, actions to promote self-strengthening values for optimising sensory stimulation and supporting and adjusting to residents’ functional (physical and cognitive) ability are described [3]. In our study, this implied affirming and supporting residents’ independence. In addition, the self-strengthening and social values are similar in meaning with what the authors of the review address as therapeutic goals of social interaction and personal control [3]. Lastly, atmospheric values are similar to the described therapeutic goals of sensing familiarity and home-likeness. In previous aforementioned reviews [3, 11], the authors conclude that in order to achieve such goals, LTCFs not only need to take into consideration the benefits of environmental modifications, but also the changes needed in mealtime practices, staffing or organisations. There are tensions in relation to those aspects as well as from the individual residents. Our study contributes to the literature with in-depth knowledge of facilitators, and barriers that impede such changes to strengthen inherent values for residents’ health and well-being. To achieve identified values, our study also supports the importance of the organisational structure for facilitating a participating staff–resident interaction together with the physical and social mealtime situation. These aspects are interrelated and important elements of person-centred mealtime care [6, 32]. The importance of staff–resident interactions for good mealtime situations in our results is validated by a review [33]. Several values in our study describe interactions which the authors of the review synthesise as social connection: empowering the resident towards autonomy and independence; responding to food refusal and tailoring care, including focussing on the individual rather than on the task. Contrary to what are considered good mealtime situations, our findings exemplify how mealtime care was sometimes performed routinely, was not person-centred, and how ‘tasks’ were delegated to new and less-experienced participating staff who did not know the residents involved. Such actions may be indicative of a nontailored task-orientated view and a view of mealtime care as a simple unqualified task, such as merely setting the table and feeding. Adopting a task-orientated approach does not acknowledge the full potential of the meal situation as an actor in health and well-being.
Our findings—that upholding values for health and well-being during mealtimes is a balancing act—is supported in a review of qualitative studies highlighting attitudes, perceptions and experiences of staff and residents in care homes [2]. Similar to their study, our findings indicate that caring for several residents in communal living implies compromising between resident agency (i.e., individual choice, control and autonomy), communal provision and policy. However, in our study, the balancing act could be within the same value, for example, in relation to self-strengthening values when participating staff must weigh residents’ needs against each other when they appear to be in conflict, owing to residents’ different functional and cognitive abilities. The balancing act could also be between values, such as promoting individuality values by acknowledging a resident’s preference to eat alone versus the social and relational values of having a meal together. Subsequently, balancing residents’ individual needs with communal care provision adds organisational challenges and ethical dilemmas to the mealtime caring process that require the creation of supportive mealtime situations. Our data do not offer a definitive answer regarding whether staff prioritised individual needs or communal care provision or the reasons for such prioritisation. However, it is plausible that promoting both individual and communal needs was perceived as equally important. The central theme of our study can be considered a testament to the contemporary era, wherein care policies increasingly advocate for person-centred care, while care units continue to be organised based on the tradition of collective care, requiring individuals, to varying extents, to forgo personal preferences and needs.
Some findings relate to experiences from mealtime situations with residents experiencing cognitive decline such as dementia. Dementia severely affects parts of self while other parts remain, even in advanced stages of cognitive decline [34]. Based on staffs’ beliefs about values, our findings indicate that creating mealtime situations can potentially strengthen or threaten the self in several ways, thus exacerbating the complexity of the balancing act. Promoting self-strengthening values related to independence and individuality acknowledges the importance of environments, resources, caring strategies and situations for promoting the self, as previously described in the context of dementia care [35]. Based on the theory of the three aspects of self and selfhood, the author synthesises empirical research on ways to promote residents’ sense of self by emphasising ‘that we are who we are, and who we are together with other persons’ [35]. In the mealtime situation, our findings reveal that all three aspects of the self were challenged or promoted by the situation and interactions with participating staff. In line with the aforementioned literature [35], our findings indicate that participating staff can compensate for problems related to dementia by synchronising verbal and nonverbal communication and by imputing or attributing meaning in the situation for the strengthening of self. Based on the theory of selfhood, promoting self-strengthening values during mealtimes, especially in dementia care, is important, since research shows that when the self is violated or not promoted, it can result in suffering [35].
Adding to this complexity, as hypothesised in the introduction section, our findings indicate that the staff held diverse beliefs from which, according to the belief theory [22], assessments, choices and actions regarding how to achieve mealtime values emerge. Theory about beliefs considers beliefs as facilitating or constraining [22], which suggests that if staff beliefs are constrained in relation to a specific mealtime situation, this will significantly limit the possibility of finding ways to improve the situation. One example from our data includes the staff holding a strong belief regarding the social and relational values and that all residents should be included in the community and if possible, eat at the same table. If such a belief about communal dining results in actions undermining resident choice or needs, for example, a desire to eat alone, such a belief would be a constraining belief when it comes to creating a mealtime situation aiming at supporting each resident’s well-being within a communal setting. Another example included cultural meals and festivities, which were, viewed a facilitator for achieving social and relational values among staff. Staff expressed no requirements for organising cultural meals and festivities other than traditional Swedish holidays, e.g., Easter and Christmas. An important question to ask therefore is how staff in multicultural LTCFs manage to handle different traditional meals in relation to culture, ethnic groups, religions and other aspects. It is possible that a value conflict between identity values and communal needs/preferences could arise due to some residents feeling culturally alienated and excluded while others feel confirmed. What might add to this complexity is how participating staffs’ beliefs in mealtime situations might not always be apparent to themselves or to others in the absence of reflection due to beliefs remaining unconscious [22]. When beliefs and decisions on what, when and how values can best be promoted are not reflected upon, even the best mealtime practices can be adversely affected. One example in our findings is when individual participating staff did not follow team decisions agreeable with their own views about what value should be in focus during mealtimes or how to accomplish such a value. Although such actions may be ethically sound, it may further contribute to the complexity if such a disparity is not recognised and reflected upon. According to the person-centred theory, such implications can affect the person-centred agreement process adversely [36]. Furthermore, the perspectives of individual residents and groups of residents also need to be centred in the decision-making process [37]. However, considering the myriad complex needs and voices of residents with diverse functional limitations and assistance requirements while simultaneously fostering an environment conducive to individualised care provision may lead to experiences of care during mealtime situations as trying to do the ‘undoable’ [21]. Therefore, an evidence-based care model should be used to support staff to reflect upon, negotiate and navigate between values, facilitators, challenges, barriers and actions for optimising mealtime situations for residents’ health and well-being.
In our study, the FAMM [29] was used as a framework, allowing staff to approach the known multiaspect complexity of mealtime situations in LTCFs during interviews [30, 38]. Although not regarding mealtime values per se, the five aspects—the room, product, meeting, management control system and atmosphere—helped to address this complexity. According to the literature, there are differences concerning what is in focus within the five aspects of FAMM in relation to its various contexts, categorised as service [29] and caring [30, 38]. Our findings provide new knowledge on the meaning of the five aspects in a caring context. Regarding the product, combining food and beverages into appetising dishes can be an important aspect of the meal experience [29]. Our findings also reveal that the product was related to vitalising and self-strengthening values by stimulating eating, confirmation of individuality and familiarity. The meeting in our study emphasised mealtime caring encounters, such as assertive and affirmative cues between participating staff and residents, which are essential for social and self-strengthening values. These findings indicate the need to establish organisational support to achieve relationship-centred care at mealtimes, such a minimum staffing and additional training [13]. According to FAMM, ‘atmosphere’ is a multidimensional and not uncomplicated aspect [29]. In our findings, atmospheric values indicate that atmosphere comprised one of several interconnected inherent values in mealtime situations for resident’s health and well-being. Outcomes from other aspects and values combine in atmosphere, which has also been described in a review of mealtime interventions and their outcomes [9]. Similar to this review, ‘atmosphere’ in our study was connected to calmness and home-likeness. Calmness related to supportive management and organisational input, adapting the room visually and audibly and improving the meeting socially. Home-likeness was influenced by the mealtime area design, decoration, table settings, smells, enabled discussions and eating together.
4.1. Methodological Considerations
The sample might be considered small but within the recommended sample size for a qualitative design [24], which is also supported by the richness of the data in this study. Within the qualitative research approach adhered to in this study, transferability is mainly the responsibility of the reader to consider in relation to the study context and participants’ characteristics [26]. The study context and sample are representative of Swedish LTCFs but may also be transferable to other contexts. The authors would, however, like to point out some context and sample-related characteristics with possible implications for transferability. Participants were recruited from LTCFs within one municipality only. This could be recognised as a study limitation with implications for sampling variation and, consequently, less transferability due to the geographical limited sampling frame and context specific aspects. Qualitative research favours purposeful sampling [27], and in this study, the sampling evolved from what stood out from the previous group interviews as important stakeholders. The authors therefore consider the sampling strategy mainly a strength but with implications for transferability in relation to the professions recruited. Furthermore, and of importance when considering the findings in relation to transferability, most of our participants had experience in dementia care. This has most likely influenced the results according to beliefs about values such as social, relational and self-strengthening values. Barriers, facilitators and actions taken need to be considered in relation to this experience.
Data were collected through group interviews [25]. A larger group interview was initially planned for care staff actively engaged in mealtime situations on a daily basis. However, this arrangement was ultimately divided into two smaller groups, each consisting of only two to three participants, owing to last-minute changes in participants’ work schedules. This had a noticeable impact on participants’ reflections of each other’s narratives. However, more extensive reflections of one’s experiences were noted in these cases. In all the interviews, follow-up questions were asked in relation to the FAMM. This is considered a strength, since the model supported the exploration of experiences of the mealtime situation allowing the complexity to come forward.
The analysis was a combination of interpretive and descriptive qualitative analysis methods [26]. The choice of an interpretative method was based on the theory of beliefs as embedded in narratives and value driven [22]. Therefore, the method was supportive when it came to identifying beliefs, since they were not explicitly expressed but could be traced from what was recognised as good and bad practice. An interpretative method was not necessary for identifying barriers, facilitators and actions, and therefore, descriptive analysis was chosen. Identified beliefs were validated through discussions within the research group but were also validated in the manifest analysis of facilitators, barriers and actions, all of which could be easily linked back to the beliefs found. The authors therefore consider the analysis as trustworthy.
5. Conclusions and Clinical Implications
Findings demonstrate complex interactions within the mealtime situation, balancing between values, mealtime environmental preconditions and residents’ individual needs to promote health and well-being. The authors conclude—in line with the theory—that staffs’ barriers, challenges and actions could be traced to and explained by identified beliefs. Knowledge regarding beliefs could therefore help in understanding and managing the complexity of the mealtime situation in similar contexts.
Findings in this study may be useful for decision-makers and a multidisciplinary group of professionals to discuss the complexity of mealtime situations when deciding, practicing and educating about mealtime situations in LTCFs. Complex person-centred mealtime care requires effective design and planning, including staffs’ reflections about beliefs to identify value conflicts. Specifically, for organisations aiming to uphold the values elucidated in our study, it is imperative to employ methodologies that foster opportunities for reflection and learning among stakeholders. This facilitates the sharing of beliefs and collaborative planning for mealtime care. Such opportunities have the potential to enhance staff awareness regarding the values deemed significant, aid in identifying the underlying beliefs guiding actions and empower informed decision-making in specific mealtime situations. As a tool for addressing the known multiaspect complexity of mealtime situations, the FAMM could be adapted to specific caring contexts and used as a facilitating framework.
Conflicts of Interest
The authors declare no conflicts of interest.
Funding
This work was supported by the Kamprad Family Foundation for Entrepreneurship, Research, and Charity (Grant number 20172014).
Acknowledgements
The authors have nothing to report.
Open Research
Data Availability Statement
The qualitative data used to support the findings of this study have not been made available because of participant confidentiality.
