Outline Show full outline Summary Keywords Introduction Methods Discussion Limitations Conclusion References Get rights and content Collegian Volume 21, Issue 3, September 2014, Pages 171-177 ‘Two dead frankfurts and a blob of sauce’: The serendipity of receiving nutrition and hydration in Australian residential aged care Maree Anne Bernoth PhD, MEd(AdultEd&Training)(HonsClass1), RN , Elaine Dietsch PhD, RN, RM, Carmel Davies RN, RM, BA, MTH Charles Sturt University, School of Nursing, Midwifery and Indigenous Health, Locked Bag 588, Wagga Wagga, NSW 2678, Australia Show more https://doi.org/10.1016/j.colegn.2013.02.001 Summary Background This paper explores the serendipity of residents accessing adequate food and fluids in aged Outline Download PDFDownload Export Search ScienceDirect Advanced Brought to you by: Charles Darwin University care facilities. It draws on the findings of two discrete but interrelated research projects conducted in 2009 and 2011 relating to the experience of living in, or having a friend or family member living in, residential aged care. Methods Participants were recruited through media outlets. Indepth interviews with participants were audiotaped, transcribed verbatim and thematically analysed. Findings This paper discusses a theme that was iterated by participants in both projects that is, the difficulty residents in aged care facilities experienced in receiving adequate and acceptable food and fluids. Unacceptable dining room experiences, poor quality food and excessive food hygiene regulations contributed to iatrogenic malnutrition and dehydration. Implications for staffing, clinical supervision, education of carers and the impact of negative attitudes to older people are discussed. Conclusion The inability of dependent residents in aged care facilities to receive adequate nourishment and hydration impacts on their health and their rights as a resident, and is an ongoing issue in Australian residential aged care. Keywords Nutrition; Hydration; Frail aged; Elderly care; Residential aged care Introduction A theme related to nutrition and accessing adequate food and fluids emerged from the thematic data analyses of two research projects (Bernoth, 2009; Bernoth, Dietsch, & Davies, 2012) which explored access issues in relation to aged care services. In response to this finding, a literature search was conducted using EBSCOhost (Health) and CINAHL databases with the keywords aged care, nutrition, mealtimes, malnutrition, dehydration and starvation. Items published in the preceding decade were accessed. Background literature revealed that the companionship of meal sharing enhances the nutritional status of older people (Vesnaver & Keller, 2011). Furthermore, at a time when our current older Australian-born population was young, their diet was based on bread, dripping (fat left in a cooking utensil from frying meat), lamb and tea, with porridge for breakfast with the oats soaked overnight. Any frying was done with dripping from the dripping tin (adding exponentially to the fat consumed); there were slabs of bread and treacle or bread and dripping. The Sunday lunch was generally roast lamb followed by cold leftovers for most of the week. When visitors arrived it was scones with cream and homemade jam (Symons, 2007). During World War II, to reduce the impact of rationing, food was often grown in the backyard, eggs gathered from the fowl-yard and any excess was shared with neighbours, according to the Australian Women's Weekly of the time (8 April, 1944 as cited in Symons, 2007). Meals were prepared by women who stayed at home. The kitchen was the focal point of activity and the smell of food being prepared and cooked pervaded the home, stimulating appetites. Meals were eaten together, at a set time, around the table (Symons, 2007). The outbreak of war in 1939 found Australia's food industry ‘woefully unprepared’ (Farrer, 2001, p. 246) with the outcome being that, during and for some time after the war, Australians experienced food rationing. They tolerated food restrictions to contribute to the war effort. However, the end of World War II brought with it new food experiences and diversity in the people populating Australia. This meant diversity in the type of food eaten and the means by which it was prepared (Symons, 2007). Increasing affluence and cultural diversity allowed Australians to be more adventurous and they took advantage of the new restaurants, broadening their culinary experiences. It was possible to eat away from the home in affordable restaurants. Coffee and wine consumption increased, oil replaced dripping, garlic and herbs and spices came into common use and terms like stir-fry and pasta became familiar. New migrant cuisines produced exciting dishes (Dyson, 2002). Those who lived this history are now in their seventies, eighties and nineties with some requiring residential aged care (RAC) (Australian Institute of Health and Welfare, 2007). Food has meaning, memories and traditions and these become more significant to those in residential aged care. Mealtimes are one aspect of the day that residents should be able to anticipate. Chisholm, Jensen, and Field (2011) discuss the link between a pleasant milieu and optimal nutrition. It is important that residents, including those from culturally and linguistically diverse backgrounds, find comfort and familiarity in their traditional food culture (Miller, 2009). The question needs to be asked: to what extent are we respecting food preferences when older Australians enter residential aged care? Food preferences are significant (Miller, 2009) but enabling residents to access adequate nutrition and hydration to avoid malnutrition is of even greater significance. The impact of malnutrition on the older person can have multiple consequences. Age related changes to muscle mass, mobility and circulation render the older person vulnerable to increased morbidity and mortality when they are malnourished (Koch, Hunter, & Nair, 2009). Malnutrition is a risk factor for pressure ulcers and associated pain (Dawson, Nelan, Pace, & Barone, 2012). Banks, Bauer, Graves, and Ash (2010) state that pressure ulcers in 33% of patients in acute hospitals in Queensland are caused by malnutrition, costing the health system more than $12 million dollars per annum. Inadequate nutrition results in prolonged healing and recovery times from acute illness and longer hospital stays (Koch et al., 2009) which then have a declining, spiral effect on functional capacity and quality of life. The World Health Organization (1999) and the Australian government (National Centre for Classification in Health, 2008) utilise definitions of malnutrition focused on body mass index, unintentional loss of weight, subcutaneous fat and moderate muscle wasting. While there is no universally accepted definition of malnutrition, Elia (2000) argues that: ‘… [it is] a state in which a deficiency, excess or imbalance of energy, protein and other nutrients causes measurable adverse effects on tissue/body form (body shape, size and composition), function or clinical outcome’. This definition has been amended by a number of government instrumentalities (National Institute for Health & Clinical Excellence, 2006, p. 20; NSW Health, 2011, p. 2) and is particularly useful in the context of RAC services. Gaskill et al. (2008) found that almost half (49.5%) of the residents in their study of south east Queensland RAC facilities were malnourished. Malnutrition screening tools, which can quickly identify the risk of malnutrition have been developed for residents in Australian aged care settings (Isenring, Bauer, Banks, & Gaskill, 2009). Even though policies and nutritional guidelines are written regarding nutrition, the implementation of these is problematic for many reasons including the skill mix of staff, time constraints and inadequate staffing (Merrell, Philpin, Warring, Hobby, & Gregory, 2012). Methods Research design and ethics approval The purpose of the first research project informing this paper was to explore the perspectives of family and friends who have someone they love in residential aged care (Bernoth, 2009). The second project investigated the impact on family, friends and communities when the older person had to leave rural and remote communities to access aged care services (Bernoth et al., 2012). In both projects, the participants spoke of difficulties their loved ones experienced in accessing adequate food and fluids; receiving nourishment and hydration became a matter of chance rather than a basic human right. The accidental nature of receiving adequate food and fluids in residential aged care was perceived as serendipitous. The word serendipity has connotations of luck, chance and accidental discovery (Hannan, 2006) and best describes in this context access to acceptable and adequate nourishment and hydration in aged care facilities. This was the implicit theme revealed in the two research projects informing this paper (Bernoth, 2009; Bernoth et al., 2012). Both projects were phenomenological in nature and were approved by the Charles Sturt University (CSU) Institutional Ethics Committee (2010/011 and 2010/034 respectively). Legal and ethical principles related to research with vulnerable populations were adhered to at all times, including referral of participants to statutory authorities such as the Complaints Investigation Scheme, when appropriate. Participants Participants were recruited following CSU media releases alerting the public to the opportunity to take part in the projects. Potential participants contacted the first author who explained the nature of the respective research to them, ascertained their level of interest in being interviewed and ensured their informed consent prior to interview. A total of 43 participants (20 from the first project and 23 from the second) from New South Wales, Victoria and the Australian Capital Territory were interviewed. Data collection Interviews for both research projects were indepth and unstructured and lasted between one and two hours. Participants were advised of the purpose of the interviews and invited to share their experiences. Interviews took the form of conversations as the interviewers followed the participants’ lead at all times. All three authors were involved in the interview process. Interviews took place in the participants’ homes with the exception of two, which were conducted in an alternate site chosen by the participants. All interviews were audiorecorded and transcribed verbatim. Data analysis Transcriptions from the two projects were thematically analysed. Nagy, Mills, Waters, and Birks (2010) discuss variations of thematic analysis (narrative, content and discourse) used in phenomenology. One single approach to thematic analysis was considered inadequate to reveal the depth of meaning in the stories shared by participants. Therefore, a tiered approach to thematic analysis was adopted. Narrative thematic analysis was used to appreciate how the stories were told; this was as important as the content of those stories and to reveal the implicit themes evident in the experiences the participants shared. Content analysis was used to describe and interpret the experiences shared and finally, discourse analysis was used to enable a critical lens to be applied to the themes derived through narrative and content analysis. This integrated approach to thematic analysis meant that themes could be revealed, described and interpreted in a way that honoured participants telling of their experiences while exposing some of the contestation of power that was evident in RAC experiences shared. It was noticed that there were some common themes in both projects. To enhance the rigour of the study, transcripts were forwarded to participants to check the accuracy of the data. Themes were identified by the first and second authors individually, and then crosschecked. Only those themes agreed to by consensus of the research team members were included. Findings Participants disclosed that multiple factors led to the likelihood of a person becoming malnourished and/or dehydrated in RAC facilities, thereby impacting negatively on the residents’ rights (Aged Care Standards & Accreditation Agency Ltd (ACSAA), 2012). Findings from the studies informing this paper indicate that these factors include staff issues that impact the dining room experience for residents as well as the quality and appropriateness of the food served. The level of attention given to food hygiene to reduce the risk of food-borne diseases restricts the variety of food available to residents while at the same time, other aspects of food hygiene such as dirty crockery and resident cleanliness are ignored. Whether or not a resident has access to food and fluid contributes to the serendipitous nature of actually receiving and ingesting the food that is served. The theme to be discussed in this paper was identified as the serendipity of receiving food and fluids and has four sub-themes: (i) the dining room experience, (ii) quality of the food, (iii) food hygiene, and (iv) the outcome of iatrogenic malnutrition. The dining room experience Even though there may be many residents present in the communal dining room of a residential aged care facility, it can be a lonely place; sitting at the table with no-one to talk to, just waiting. Residents are encouraged to be seated in their place in the dining room up to an hour prior to the meal being served. Families perceive that it is organised this way so that the few staff available can take the residents to the toilet and then prepare those who remain in bed for their meals. It was observed by some participants that when the meal is served: There isn’t anyone in there while they are eating their tea so if anything happened, there's no one around. (Participant 7) …very rare that they [care staff] were seen in the dining room because normally they disappear and you just can’t find a nurse. (Participant 2) In an understaffed dining room, it was easy for resident safety to be neglected. One family reported that their mother's wheelchair was positioned by a staff member at the table but the brakes were not engaged: …I got a phone call saying Mum had a fall out of her wheelchair, sitting at the tea table. One of the residents saw it happen. She [the other resident] said your Mother just pushed the wheelchair back, the brakes weren’t on. She [the other resident] was yelling out to the girls outside, they were smoking. (Participant 3) As a result of falling backwards out of her wheelchair, the resident sustained extensive bruising to her face and skin tears to her legs and arms. Subsequently, the resident's family felt they had no choice but to be present for all meals to ensure their mother's safety. Staffing levels are such that there are insufficient numbers available in the dining room, especially at the evening meal when fewer staff are rostered. Inadequate staffing can result in neglect of resident care. As related by one family member: …they took him to the dining room [in a wheelchair] with a broken hip and he would try to wriggle himself around because there was no one there to help him. (Participant 1) Irrespective of the staffing levels and the independence of the residents, a safe dining room environment is only one aspect of a positive food experience of frail older people in residential aged care. Quality of the food Respecting the culture and food traditions of residents and the quality of food provided could enhance or detract from the nutritional status of the older, dependent person. The quality of food served in residential aged care was a dominant feature in many interviews: What do they get to eat? …soup, watered down soup for tea and a sandwich, but the soup is always cold. I go and feed Mum and I have to heat up the soup. The lunch is alright, they get a hot lunch. (Participant 5) …he's a self-funded retiree who's paid $400,000 bond to be there and they give him two dead frankfurts and a blob of sauce or two party pies for dinner! It's pathetic. (Participant 11) Other aspects of concern included the paucity of culturally appropriate food, the absence of fruit to snack on, the quantity of food and the lack of variety in the food available. When families need to provide or supplement their relative's food there are financial and social implications. There is the expense of purchasing food and then having to be present at mealtimes to ensure their family member is able to access food they enjoy: Like Dad, like, if they brought their food to him, he’d sort of look at it and ‘Oh bloody this again!’ and he wouldn’t eat it. We’d go down and buy takeaway. (Participant 8) The food is shit, shit! One night a week they used to get two little half sausage rolls and a little container of tomato sauce and a small container of orange juice that you had to pull the lid off and that was dinner…but she loved food. It was her only joy left in life, the taste of food. She was still tasting food but there [aged care facility] she tried to eat something but there was never, never anything. She didn’t complain. (Participant 10) While residential aged care facilities are required to have a dietician evaluate the nutritional content of the menus, there is no assessment of the quality or the quantity of the food served. This is one of the paradoxes of standards monitoring in aged care (Bernoth, 2009). Food hygiene Another enigma relating to food is the veracity of attention paid to the prevention of foodborne pathogens but the cleanliness of kitchens and serving implements are not offered the same attention. Participants spoke of organisational concerns about listeriosis, which led to the prohibition of lettuce and preserved meats being served in RAC facilities. This restriction leads to limited food choices, which impact cultural traditions and residents’ food preferences. It was reported that foods such as tomatoes and apples are washed in diluted bleach so that residents are not at risk. However, family members told us that other aspects of food hygiene do not get the same level of attention. One participant even provided photographs illustrating the unhygienic kitchen, crockery, cutlery and ground-in, spilt food on her mother's clothing. The dignity of the older person in care is negated and their family members suffer the trauma of seeing their loved one left dirty and neglected and eating off utensils that would never be considered acceptable in their home environment: And then I noticed that the plates were dirty, always dirty. The tea cups had stains in them that were obviously there for a long time. And I watched them put out the dinners; the dinners were being put out on plates that were dirty with dried food from soup that they had. Sometimes they used the cups for soup and then sometimes they’d be for cups of tea. The morning and afternoon tea trolley would come around with dried soup on the cups. (Participant 9) The outcome of iatrogenic malnutrition The quality and variety of food available may be questionable but there is another challenge for the older resident and that is the serendipity of accessing the food once it is served. Those with co-morbidities are at greatest risk of malnutrition and dehydration and this is compounded if they do not have a family member who can either be at the facility at every mealtime to assist them or act as their advocate. An example would be the resident who is visually impaired and/or experiencing difficulties with mobility and dexterity, which can have serious consequences. One participant, who was at the facility assisting her mother, described the following incidents: Betty was blind, she was sitting in the corner…I never saw anyone go over to Betty. I was ready to go after feeding Mum; it was an hour after tea time. I asked a nurse ‘Has Betty been fed yet?’. ‘Oh my God, I forgot her’. Another night I asked about Betty, they brought a tray, put it on the end of the table and said ‘I’m going on me break’ and left the tray there. While I was there, she did not get her meal. (Participant 1) Facilities comply with the requirement to provide water for residents and bottles are placed on the bedside tables. However, the bottles are often not within reach of the resident and many do not have the manual dexterity to remove the bottle top to access the water: They’d put water bottles on the table near their beds but the residents in bed couldn’t reach them and even if they could, they couldn’t get the tops off… One family was going away for a week…so they came and asked me if I would take the lid off their relative's water bottle for them because they knew they couldn’t rely on the staff to do it. (Participant 9) Palliative care is a significant feature of residential aged care. The following incident describes a participant's belief that her dying mother would not receive food or fluids unless she was physically present to assist her: Everybody's so busy, they didn’t even feed her. Near the end she couldn’t feed herself anymore, she couldn’t see. She was being handed these tubs of fruit, you have to peel off the top piece of plastic; she couldn’t see it and she didn’t have the dexterity in her fingers. (Participant 10) The fact that the woman was blind and required assistance would have been in her care plan. However, the participants indicated that the staff who give the actual care may not have accessed or read the care plans. Management was not always privy to the decisions made by staff to withhold food and/or fluids from residents as these participants reported: The staff decided that they were too busy to do the afternoon and morning tea trolley [rounds] so they stopped, just stopped. Management wasn’t even aware until we [relatives] spoke up. (Participant 6) They used to take Dad's dinner tray to him and they’d leave it there for him to eat and walk off. They’d come back and he hadn’t eaten so they’d take the tray away. (Participant 7) The inevitable outcome of inadequate fluid and food intake is dehydration and malnutrition. Physiological, aged related changes add exponentially to the vulnerability of the frail, elderly resident to make them especially susceptible to both dehydration and malnutrition. One family was concerned about their father's health because of his unresolved pain and his weight loss. They requested a doctor to review his condition but this did not happen even after a number of requests. Subsequently, they ordered a maxi taxi, wheeled him into it and took him to a general hospital. Their father was dehydrated, had multiple pressure ulcers, a urinary tract infection and an undiagnosed fractured femur. He died a few days later in intensive care. For this family, it meant their father suffered the ultimate insult, the final outcome of iatrogenic malnutrition: ‘How did this man get into this state?’ [queried the admitting doctor]…Well, Dad ended up…part of his death certificate says he died of malnutrition; well, the doctor in intensive care…that's what he wrote, malnutrition. (Participant 1) Discussion In Australia, residential aged care standards are monitored by the Aged Care Standards and Accreditation Agency Ltd with both announced and unannounced visits to facilities every one to three years (ACSAA, 2012). There are forty-four standards but those relevant to this paper include Standard 2.10 ‘Nutrition and hydration’ and Standard 4.8 ‘Catering, cleaning and laundry’. These standards mandate that residents must be nourished and hydrated within a clean environment (ACSAA, 2012). However, findings from this study infer that standards are not being met and this adds to the serendipity of residents in aged care facilities accessing adequate nutrition and hydration. Staff require adequate time to provide the care that residents need (Gaskill et al., 2008). The lonely, unsafe dining room will continue to exist while there are too few staff to assist the residents. Residents are most vulnerable during the evening meal as fewer staff are rostered on duty and informal support such as activity staff, visitors, families and catering staff are less likely to be available. At that time, there is a larger number of residents in bed so care staff are forced to prioritise where their presence is most needed. For some staff, the task of prioritising may be too onerous and, as participants identified, a few choose to escape for a cigarette rather than being with residents. Clinical expertise, supervision and support are required by staff to enable them to provide appropriate care for the resident who is most in need (Kayser-Jones, 2002). Prioritisation of tasks can be complex for staff when older, frail people who have co-morbidities are involved. Semi-skilled staff are responsible for making these complex decisions, often without adequate supervision (Bernoth, 2009; De Bellis, 2006). Age related changes and pathophysiology can predispose the older person to dysphagia and aspiration pneumonia (Miller, 2009) yet there is inadequate staffing to spend the time necessary with these residents to ensure they are positioned correctly and adequate time is allowed for the person to effectively swallow. Findings from this study indicate that the culture in residential aged care facilities mirrors the pervading culture and societal attitudes towards the dependent, older person. Older people are seen as being incapable of making their own choices and decisions, including those about food and fluid intake, and this leads to others making decisions for them. Nearly 40 years ago, Gresham (1976) described this notion as infantalisation whereby the pervading culture of the RAC facility was one where the older person is deemed to be childlike and this impacts staff interactions with residents. In residential aged care, infantalisation often works synergistically with institutionalisation (Walsh & Waldmann, 2008). The outcome is that the residents’ food is served at a time convenient to the institution, the menu is chosen for them and food they may like but which has a degree of risk is eliminated. Chisholm et al. (2011) emphasise the role of compulsory education and express disappointment at the lack of uptake of education related to nutrition by residential aged care staff. Gaskill et al. (2008) also recommend increased staff awareness of the issue of malnutrition. However, while ageist attitudes persist and the older person's humanity is devalued, education related to nutrition and improving the quality of food is irrelevant as practices are unlikely to change. Ullrich, McCutcheon, and Parker (2011) suggest that staff skills in creating change and problem solving may be more effective than education about nutrition but this can be problematic and dangerous for the staff member who is vulnerable when challenging the dominant culture (Bernoth, 2009). The participants in this study perceived that too much emphasis was placed on food-borne pathogens while inadequate attention was placed on cleanliness of crockery, cutlery, residents and the kitchen/dining room environment. This not only contravenes Standard 4.8 (ACSAA, 2012) but also causes distress to the resident and family as they see their dignity negated. Residents entering a RAC facility are required to be assessed for nutritional needs. This assessment is part of the facility's claim for funds under the Aged Care Funding Instrument and their assessed needs are documented in the care plan for auditors (Department of Health and Ageing, 2010). However, as previously stated, the participants indicated that the staff who give the actual care may not have accessed or read the care plans. This theory/praxis gap is not unique to Australian RAC as research in the UK also indicates the disparity between clinical practice, policy directives and national standards (Merrell et al., 2012), thereby adding to the serendipity of residents actually accessing the food and fluids as documented in their care plans. Furthermore, current methods of food preparation and delivery, including water bottle tops and food seals, add to the precariousness of residents receiving adequate hydration and nourishment. Unacceptable dining room experiences, poor quality of food, inadequate or excessive food hygiene requirements in RAC facilities can occur along a continuum with a potential outcome being iatrogenic malnutrition and dehydration. Events along this continuum can occur in isolation or in combination. Environments that are founded on appropriate skill mix (De Bellis, 2006), focus on resident needs (Nay & Garratt, 2009) and provide quality experiences around nutrition and hydration are more likely to have positive outcomes for residents (Bernoth, 2011; Gaskill et al., 2008; Miller, 2009). The Nutrition Care Policy Directive (NSW Health, 2011) identifies the consequences of malnutrition and dehydration and recognises the potential adverse outcomes for the individual but falls short of mentioning death. For one participant, the ultimate adverse outcome for her father was death by malnutrition and this occurred, despite the family's pleas for him to receive medical assistance. Limitations There are some limitations to this paper and the studies which inform it. Only one participant chose to relay positive experiences and it could be argued that only participants who had negative experiences and who felt strongly enough about them would participate in being interviewed. The nature of the two studies informing this paper means that the experiences described are based on the experiences of the family members and carers ACSAA, 2012 Australian Institute of Health and Welfare, 2007 Banks et al., 2010 Bernoth, 2009 Bernoth, 2011 rather than the aged persons themselves. Conclusion Themes revealed by the participants related to the experience of the resident in the dining room, the quality of the food provided, the impact of both inadequate and excessive food hygiene practices and finally iatrogenic malnutrition and dehydration of the older person in RAC facilities. Nutritional neglect of residents in aged care facilities occurred along a continuum. At the beginning of the continuum is disregard for the food cultures of these elderly residents when they are admitted to residential aged care. Along the continuum are deficits found in the quality of food and the dining room experience. These impact resident safety as well as nourishment and hydration. By implication, this is a violation of residents’ human rights and the rights of residents in aged care. Even when food and fluids are allocated to the resident, they are not always acceptable and accessible to them due to comorbidities relating to vision, manual dexterity and cognitive deficits. Such is the serendipity of receiving adequate nutrition and hydration as a resident of an Australian aged care facility. 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Published by Elsevier Ltd. All rights reserved. Effectiveness of mealtime interventions on nutritional outcomes for the elderly living in residential care: A sy… Ageing Research Reviews, 2013, pp. 967-981 Download PDF View details Observations of mealtimes in hospital aged care rehabilitation wards Appetite, 2013, pp. 16-21 Download PDF View details The Impact of Music on the PACU Patient's Perception of Discomfort Journal of PeriAnesthesia Nursing, 2010, pp. 79-87 Download PDF View details View more articles Recommended articles Citing articles (1) About ScienceDirect Remote access Shopping cart Contact and support Terms and conditions Privacy policy Cookies are used by this site. For more information, visit the cookies page. Copyright © 2017 Elsevier B.V. or its licensors or contributors. ScienceDirect ® is a registered trademark of Elsevier B.V.