ABOUT THIS MODULE Included here you will find 10 pages of a 44 page educational module which is intended for use by nursing homes who wish to promote more social, nontraditional models of long-term care. The intent of the PEAK- ED project is to assist organizations in implementing progressive, innovative approaches to care that should make a significant difference in the quality of care and the quality of life for those living and working in long-term care environments. To receive the module in its entirety, please send an email to gerontology@ksu.edu with the following required information: Name of Individual and title Name of Organization/Facility Complete mailing address including zip code Telephone number Email address A CD (or email attachment when possible) will be sent with the module along with forms to complete which will enable our project to track the number of people and hours spent reviewing/implementing these ideas. CD's will be sent free of charge to any nursing home in Kansas, and will be sent to those outside Kansas for a fee of $24.00 to cover costs of materials, postage and handling. For further information on the PEAK-ED project please email gerontology@ksu.edu. Pioneering Change Dining Education Module to Promote Excellent Alternatives in Kansas Nursing Homes Table of Contents Dining Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2 Course Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3 Pretest. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6 Activity: Staff Serving Staff . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7 Dining for Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8 Resident Centered Oral Health Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 A Resident's Perspective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10 Dining for Meaning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11 Case Study: Do you really know me?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12 Dining Customs Activity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13 Little Steps, Big Changes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14 More than Mealtime . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14 Heart of the Home . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16 Food Presentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18 Use the Keys Activity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19 Recommendations for Successful Dining Rooms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20 Atmosphere . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23 Ch-Ch-Changing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24 Buffet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24 Family Style . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26 Restaurant Style . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27 Russian and French . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28 4 or 5 Meal Plans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29 Experiencing Dining Styles Activity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30 Food For Thought . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30 Staff Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31 Case Study: Five Star Dining . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33 Regulations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34 A Recipe for Change . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34 Projects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .35 Post-test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37 Answers to Pretest, Post-test and Other Activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .39 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .40 Clip Art Credits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .43 Appendix A: The Easiest Garnishes Ever . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .44 Acknowledgments We would like to thank Sandra Dickison, Heather Generali, Migette Kaup, and Loretta Seidl for their expertise and guidance during the development of this module. Course Objectives: 1. To develop an appreciation of the impact dining has on both quality of life and physical health. 2. To raise awareness that each person attaches different meanings and customs to the dining experience. 3. To recognize the importance of the dining experience in the overall culture change of the home. 4. To develop a basic understanding of the various dining styles. Dining Introduction "As I sat staring at a tray of what they told me was food, I was sure this must be for a cat or dog because I could not recognize anything on the tray. There was a large blob of brown stuff, a scoop of green, and two tray compartments filled with white. I took a big whiff to see if my nose could provide the information my eyes were not. The smell rising from the plate provoked feelings of nausea and questions of "Why me?" instead of evoking memories and stimulating my appetite. After smelling multiple times, I gave up and realized my senses could not help me. As a spoon heaped with brown stuff came at my mouth, I cringed and tried to find out what the substance was. I asked what was on the spoon, and the girl feeding me replied, "I don't know; just eat it!" At that moment, those were the most terrifying words I could have heard. If only I knew what it was I could prepare myself, after all knowledge is power! If she did not know what was on the spoon and neither did I, why on earth should I open my mouth? As the spoon got closer, I began to feel helpless and found myself praying it was something I could at least swallow. I fought with myself for wanting to push her hand away. As the food entered my mouth, it seemed as if someone else had already chewed it up for me. I felt like a baby bird getting the worm my mother had already chewed for me. That ritual in nature has always disgusted me, and now I found myself taking part! I suffered through a bite of each color. The taste of each was unrecognizable, not bad but certainly not good. Still hungry, I said I was full just to avoid eating more. After all, I could survive with only a little at this meal. I worried if this is what all of the meals in my future were going to be; did I even want to survive? I felt like I was on Fear Factor, but the prize for bravery and having a stomach of steel in this challenge was not money or fame but the opportunity to partake of another meal just like this one. How could my feelings have begun to change from that of a woman in control to an institutionalized person in one meal? When I did not have the power to determine what I ate, when, and how much, previously pleasures, I felt my sense of self and control fading away. Meals like this daily would quickly erode a person's spirit. I never realized the impact of the institutional meal until I was faced with the experience" (Based on Stephanie Gfeller's CNA class experience). The passage above was a student's reaction to a meal during a CNA course. The students in the class had the opportunity to be fed a meal prepared with the various special diet methods. Think about this for a minute. If one meal has that effect on a person, how powerful must this be multiple times each and every day? "It is tragic that in the last years of their lives, many nursing home residents are denied one of life's greatest pleasures – to sit down to a nice meal of one's liking in pleasant surrounding" (Kayser-Jones, 1996, p. 31). Staff Serving Staff Activity To sensitize staff members to institutional dining, set up a meal and give them the opportunity to try foods and experience being fed. Ask kitchen staff to prepare trays for puree, mechanical soft diets and thickened liquids. Bring out trays of food, but do not let staff members know what they are being served. Have staff members work in pairs. One will be the person eating, and the other will be the person assisting. You may wish to ask a few to do one or all of the following while they are assisting the other staff member: Talk to another person assisting about something that does not pertain to the person being fed and ignore the person you are helping. Bring bites to the person's mouth too quickly, so they have little time to chew and swallow. Season food the way you like it without asking the person eating. For example, add too much salt or pepper to something. Mix foods together instead of giving the person the opportunity to enjoy each separately. Stand up while feeding the person and yell to someone across the room. Have one person feed three individuals at a time (assembly line style). Use the spoon instead of a napkin to wipe excess food debris from the person's mouth. After both parties have been given the opportunity to experience both roles ask them to reflect on the following questions. How did you feel while you were being fed? What was the most difficult part of the meal? Did the behavior exhibited by those feeding you have an impact on your experience? How would you feel about dining this way for the rest of your life? What could you do to make the dining experience more pleasurable for residents? This seems like an appropriate time to suggest scrapping the word feeder. Think about the actual definition of a feeder. When you hear staff members using this terminology ask them to do the same. One suggestion that could be used instead is "residents who need assistance with eating." As a team other ideas could be discussed. Dining for Health Meal times in nursing homes have the power to impact physical and emotional health, well being, and quality of life. "Meals are the single most consistently accessible, manageable, and effective health-promoting activity that we can offer to residents" (Zgola & Bordillon, 2001, p. 3). Malnutrition affects 30-85% of the residents in nursing homes (Morley & Silver, 1995). This may indicate that the current system is not meeting the needs of residents. Why are so many elders residing in nursing homes malnourished? Some of the reasons for poor nutritional status are rooted in biology or illness while others are in the culture and environment of nursing homes. A few reasons for poor intake include: decreased ability to smell and taste, early satiety (feeling full after consuming less food than consumed when younger), depression, medications, constipation, oral health problems, dysphagia (swallowing disorder), dementia, infections, pain, functional challenges (inability to feed self), and unnecessary therapeutic diet restrictions (Asai, 2004). Some reversible factors leading to malnutrition include: food quality, addressing individual needs and preferences, dining environment, and food choices (Remsburg et al., 2001). Dining For Meaning To human beings food has more meaning than just nourishing the body. For some, food can nourish the soul, provide links to family, provide comfort with emotions and help create home. Mealtimes are major events in the lives of residents and may offer many of the limited opportunities for interaction during the day. Dining in nursing homes should provide all of the meanings it did for residents prior to admission. A study by Balstone (1983) identified two different theories for providing meals: functional and domestic. The functional mealtime is a meal that is intended to provide nutrition in an efficient manner. This is obviously the current mind set for most nursing homes considering that many residents are asked to choose their meals several days or maybe even weeks ahead of time. The domestic meal deals with personal needs and social goals as well as comfort during the meal. This is the type of dining in which residents benefit. Switching to domestic meals may help residents connect with their pasts as well as create a vehicle for current and future relationships and personal development. Every resident brings different experiences, previous roles, values, memories, preferences and customs related to dining to the nursing home. Staff must be aware and sensitive to these individual differences in order to meet more than the physiological needs through dining (Crogan et al., 2004) and to avoid substituting their preferences for those of the resident (Pearson, 2003). This can happen only if staff are given the opportunity to develop relationships with residents through consistent staffing. Using residents' recipes, offering ethnic foods to residents and observing religious and cultural customs related to dining can provide comfort to residents and serve to maintain each person's religious and social identity as well as create home. Each home has to determine its own rituals based on the needs and wants of the residents and staff. Village Shalom in Lenexa, Kansas is home to a Kosher café. The café sells freshly-prepared kosher foods meeting the needs of the Jewish residents and visitors. Medicalodge of Wichita, Kansas recently had a Cinco de Mayo celebration. The festivities were complete with a Mexican feast. Residents and staff enjoyed the day and say the chili relleno was a huge hit. At the Dooley Center in Atchison, Kansas the residents are Monastic Elders from the Benedictine Sisters. Since the sisters place a great deal of emphasis on coming together and sharing meals as a community, the home has large dining areas. The residents enjoy meals in the Monastic Dining Room with the entire monastic community as long as possible. At Meadowlark Hills in Manhattan, Kansas a resident's husband came everyday for breakfast, lunch and supper to assist his wife while eating. He became a family member to the house. At the annual picnic, he would bring his famous baked beans made from his secret recipe. Residents and staff thought they were delicious. After his wife passed away, it was only a few months until he passed away, too. The team in Starkey house contacted their daughter and asked if they could have his recipe. The daughter was thrilled to have her parents' memory continue even if they were no longer there. At this year's annual picnic, the team prepared the recipe, and, as usual, it was a huge success. Case Study: Do you really know me? Each day around 10:30 June would get very anxious. She would begin pacing the hallways. Occasionally she would stop at the nurses' desk and move her hand in a circular motion like she was stirring something. No matter what alternatives staff offered, June would not be diverted. When the noon meal was served June would not sit in a chair. She would stand next to the sink in the kitchenette and watch over the table. Frequently she would try to assist other residents with eating. June would rush over to the table to wipe-up spills and would try to clear the table as soon as residents finished eating. During the meal she would grab a bite off of her plate at the table and eat it as she moved about or stood in observation. However, June would sit peacefully at breakfast and the evening meal. June began losing weight, and staff was sure it was because she was not eating enough for lunch. They decided that June needed to be assisted to eat. This caused her to become very upset and aggressive atlunch time. What might be causing June's behavior at lunch? What are possible solutions for June's behavior? After answering the above questions read the second half of the case study. After speaking with June's son about her behavior, the staff realized that she was acting upon her mealtime behavior when she ran a daycarecenter. She would begin preparing the noon meal during the late morning and would eat while standing at the kitchen counter overseeing the children. At the end of the meal she would hurry to clean up so that she could read stories and the children could nap. Discuss strategies for making meal times meaningful for June. What could be done so June could feel useful at lunch time? Can you think of any residents with unexplained behavioral problems atmealtime? Discuss ideas for getting to know the resident to see if his/her past is influencing current mealtime behavior. Little Steps, Big Changes It may seem small, but giving little items of home back to residents can really impact their feelings of autonomy and satisfaction. Residents at Medicalodge in Wichita wanted condiments. They wanted to have access to a variety of condiments at every meal, and they did not mean packets. Staff purchased items like hot sauce, tabasco sauce, and dijon mustard. Now these are on the tables for residents to use as they see fit. When discussing the newly available options, one resident enthusiastically told a PEAK-Ed staff member, "Everything is better with hot sauce!" According to a staff member the residents' appetites have increased since the addition of the condiments. At Medicalodge in Eureka, Kansas staff members had never realized how difficult the individual serving packets of salt, pepper, and sugar were for residents to use. After putting shakers on the tables, staff saw residents become more independent. Residents enjoy being able to season their own meals without assistance.