1) Title: Improving the Knowledge and Practice of Resident-Centered Nutrition: Nursing Home Staff and Resident Outcomes
2) What specifically are you looking to find out?
I intend to explore the effect of resident-centered nutrition education on the knowledge levels of the staff and actual nutrition practices as well as resident outcomes. My hypothesis is that staff education will improve knowledge and practices that will also translate to better resident outcomes. The independent variable is staff education while the primary dependent variables are staff knowledge of person-centered nutrition and nutrition practices. Secondary dependent variables or outcomes include the residents’ food intake, nutritional status, satisfaction with nutrition services, and quality of life.
3) Why are you interested in this particular topic?
I chose this topic because nutrition is a very important health issue among older adults. As a recreational therapist, the ability of residents to participate and enjoy recreational activities and continue to do so for the longest possible time depends on their functional capacity and cognitive function that is influenced in part by their nutritional status (Bernstein & Munoz, Academy of Nutrition and Dietetics, 2012). Studies show that up to 37% of older adults in nursing homes are malnourished (John et al., 2013). Around 50-70% consumes 75% or less of their food (Young-Mason, 2011; Hasselkus, 2011). Older adults are at risk for malnutrition because of a variety of factors including poor oral health, depression, loneliness, pain, sensory loss, lack of appetite, and functional and cognitive decline (Ulger et al., 2010; Rasheed & Woods, 2012).
In addition, the conventional practice among nursing home staff wherein the focus is on the completion of the task of feeding and on the fulfillment of medical nutrition interventions rather than what the food and dining experience means to the residents is also associated with nutrition and quality of life (Robinson & Gallagher, 2008). The choice of food, eating time, type of food service, and the physical and social environment of dining affect the residents’ appetite, dining pleasure, and thus their food intake in the same way that it does to other people. As such, educating the staff on person-centered nutrition so that it can be incorporated in nutrition practices in addition to other established interventions can further enhance resident outcomes. It will also highlight the older adults’ need for person-centered nutrition that can influence the practices of those providing nutrition services for seniors in the community setting.
4) Will you have the resources to conduct this study if you choose to do this study?
The study sample will be the staff in my facility consisting of nurses, certified nursing assistants, registered dieticians, and the catering staff. I need to seek institutional permission from the medical director and the dean of nursing to conduct the study at the site. I also need to obtain the informed consent of the target participants. I will be developing, testing, and piloting a survey instrument on knowledge and practices and will conduct an online survey of the staff thereafter. They can respond to the survey at home, and data gathering should be complete within two weeks. Based on the identified learning needs, I will also be developing a curriculum on person-centered nutrition that will involve a literature review and synthesis, creation of a lesson plan, and identification of appropriate learning strategies.
The activity will include workshop sessions to determine strategies in implementing person-centered nutrition within the context of the organization. The learning activity will be implemented and post-activity knowledge will be measured and compared to baseline to determine improvement.
Baseline data on nutrition practices will include information from the staff survey, facility policy and guidelines review, and interviews of key informants per discipline if necessary. A separate follow-up survey for practice changes, policy review, and interviews will be done six months after staff education. Further, I will obtain baseline measures of food intake, nutrition status, resident satisfaction with nutrition services, and quality of life using data from the quality improvement dashboard maintained by the nursing staff and the use of appropriate instruments. The data will be presented to the staff during the educational activity, and will again be measured after six months. I can enlist the help of senior nurses, CNAs, and the dietician in this effort. I will also be looking into improving my skills in data gathering, teaching, etc. through self-education to enhance my capacity in conducting the study. As such, I believe I have the time and resources to do the research, and a maximum budget of $5,000 will suffice.
5) Is your topic relevant to health educators, nutritionists and/or other health professionals?
Explain how so.
The topic is relevant to nurses, nursing assistants, nutritionists, health educators, and even physicians because the risk for malnutrition and actual malnutrition are common health problems among facility residents. However, the prevailing culture has been to focus on task performance and implementing medical nutrition recommendations with decisions on food and dining solely within the control of the facility administration or the staff (Adams, 2012; Carrier, West & Ouellet, 2009). Moreover, while individualized nutrition based on nutritional assessment is recommended by the Academy of Nutrition and Dietetics (2012) and food preferences and the need for assistance are considered, again the traditional culture is to treat food as therapy only. Social interaction and building a positive relationship with the resident may be disregarded in lieu of other priorities.
Resident-centered nutrition includes knowing the food and dining preferences of residents, allowing more choices in these areas, and facilitating socialization in recognition that eating is not just fulfilling a physiologic need but also providing a pleasurable social experience that affirms personhood (Carrier, West & Ouellet, 2009; Hung & Chaudhury, 2011). Resident-centered nutrition is an additional intervention that health professionals can adopt to address the social and psychological factors contributing to malnutrition (Divert et al., 2015; Wylie & Nebauer, 2011; Young & Mason, 2011).
6) Is it original or does it have an angle?
The Centers for Medicare and Medicaid Services (2013) implemented new dining standards supporting resident-centered nutrition based on what evidence is currently available. Many studies recommend a holistic, person-centered approach to providing nutrition in this population but much needs to be known in terms of best practices (Ahmed & Haboubi, 2010; Merrell et al., 2011). As such, the study, though not original, can contribute to the knowledge base on resident-centered nutrition by showing the impact of staff education on practice and resident outcomes in a culturally diverse resident population as well as how change in this area can be successfully initiated.
7) Does your topic focus on knowledge, attitudes or behavior (KAB)?
The study will focus on the knowledge and practices/behavior of nursing home staff before and after the implementation of an educational activity. Knowledge will be measured through a survey cum learning needs assessment. Practices/behavior will be measured also using a survey as well as policy reviews and staff interviews.
8) Is your topic not too broad?
The sample includes the staff within one facility. There are two primary outcomes pertaining to the staff and four secondary outcomes pertaining to that facility’s residents. I will be introducing only one intervention – the educational activity targeting the staff. As such, I believe the topic is specific.
9) Is there too much or too little literature already on this topic?
The topic of resident-centered nutrition has been in evolution for the past 15 years. In my literature search, I encountered a study on implementing buffet-style dining to allow residents more food choices that was published in 2001 (Remsburg et al., 2001). However, research interest began to increase beginning in 2008 as awareness of the issue of an aging population peaked in conjunction with the legislative pressure of providing quality care brought on by the Accountable Care Act. There are currently five models developed as frameworks for older adult nutrition services in institutional settings (Adams, 2012). Related interventions have been introduced in Canada (Carrier, West & Ouellet, 2009), France (Divert et al., 2015), U.K. (Kenkmann & Hooper, 2012; Winterburn, 2009) and the U.S. (Bertrand et al., 2011; Remsburg et al., 2001). All are descriptive studies. However, a major limitation in congregating and generalizing available research is the diversity in the conceptualization of person-centered nutrition (Robinson & Gallagher, 2008). Besides the dearth in primary studies, the absence of a standard definition of this concept makes it difficult to develop evidence-based recommendations acceptable across disciplines.
10) What have been the major trends in the literature about your topic in terms of what further research needs to be done?
a. The need for standard conceptual and operational definitions of resident-centered nutrition (Robinson & Gallagher, 2008) given the multiple frameworks available.
b. Studies on older adults’ food and dining preferences have been done, but more research is needed to determine the effect of implementing related interventions on weight loss and other outcomes especially in culturally diverse populations (Adams, 2012; Divert et al., 2015).
c. Much of research on older adult nutrition has been on obesity with the need to also focus on undernutrition (Merrell et al., 2011).
d. The need for staff training in providing person- or resident-centered food or nutrition services is apparent and its impact needs further study (Merrell et al., 2011). The need for nurses to constantly update their knowledge on aging and nutrition is also emphasized in the literature (Bertrand et al., 2011).
e. More research needs to be done in diverse institutional care settings to enable generalization because studies are typically conducted in one site (Merrell et al., 2011).
f. Implementing resident-centered nutrition represents a culture change requiring equal focus on change management to ensure success (Robinson & Gallagher, 2008).
g. Studies on resident-centered nutrition must include tailored interventions to suit persons with intact cognitive functions and those in cognitive decline (Carrier, West & Ouellet, 2009); those at risk and those who are already undernourished (Smoliner et al., 2008); and frail versus relatively functional residents (Dyck & Schumacher, 2013).
h. The degree that organizational culture and work environment hinder the staff from providing care and social interaction or encourage them needs to be known (Hung & Chaudhry, 2011). The leadership of nurses in advocating for culture change is warranted (Dyck & Schumacher, 2013).
i. There is a need to include support personnel such as catering staff in interventions and studies because they can play an important role in the delivery of food services (Walton, 2012; Winterburn, 2009). Specially trained dining assistants can also play a significant role especially when there is a shortage in nursing staff in although there is a need to confirm the findings of the pilot through a larger study (Bertrand et al., 2011).
11) Does your final choice of the research problem truly reflect that you have acquainted yourself thoroughly with peer-review journal articles relating to this subject?
I believe that my choice of research problem represents a gap in the literature based on the trends in the authors’ recommendations in research within the past five years. There is a recognized need for more primary research to generate evidence on the outcomes of frameworks and interventions. Culture change, staff education and training, and the involvement of stakeholders including caterers have also been suggested as the foci of future studies. I will be considering these aspects in the study.
References
Academy of Nutrition and Dietetics (2012). Position of the Academy of Nutrition and Dietetics: Food and nutrition for older adults: Promoting health and wellness. Journal of the Academy of Nutrition and Dietetics, 112, 1255-1277. doi: 10.1016/j.jand.2012.06.015.
Adams, K. (2012). Moving toward culture change: Defining skilled nursing facility residents’ dining style preferences. All Graduate Plan B and Other Reports, Paper 185. Retrieved from http://digitalcommons.usu.edu/gradreports/185
Ahmed, T., & Haboubi, N. (2010). Assessment and management of nutrition in older people and its importance to health. Clinical Interventions in Aging, 5, 207-216. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2920201/
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Centers for Medicare and Medicaid Services (2013). To state survey agency directors: New dining standards of practice resources are available now. Retrieved from http://www.cms.gov/Medicare/Provider-Enrollment-and- Certification/SurveyCertificationGenInfo/Downloads/Survey-and- Cert-Letter-13- 13.pdf
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