The Impact of Family Visitation on Feeding Assistance Quality in Nursing Homes

Abstract

The purpose of this study was to determine: (a) the frequency of family visitation during mealtime and (b) whether the presence of family during meals had an impact on the quality of feeding assistance care and resident intake. Participants included 74 nursing home residents from two Veterans Affairs (VA) and four community facilities in one geographic region. Mealtime periods in which family was present were compared with mealtime periods when family was not present for the same resident. Results showed that family visitation was infrequent during mealtime; however, feeding assistance time was significantly higher when visitors were present. Despite the increase in assistance time, there was not a significant difference in intake. Strategies that encourage the involvement of family in mealtime assistance may have additional benefits not directly associated with meal consumption, including providing family members with meaningful activity during a visit and enhancing residents’ quality of life and well-being.

Keywords

nursing home family caregiving feeding assistance quality of care

Introduction

For a substantial number of residents in long-term care (LTC), inadequate food and fluid intake is common and related to poor clinical outcomes, such as weight loss and malnutrition (Simmons et al., 2008; Sloane, Ivey, Helton, Barrick, & Cerna, 2008). Several recent studies have demonstrated that an increase in staff attention during meals results in improved intake and related nutritional outcomes (Simmons, Durkin, Shotwell, Erwin, & Schnelle, 2013; Simmons, Sims, et al., 2013; Simmons et al., 2008). However, these studies also showed that optimal feeding assistance during meals requires significant staff time and exceeds the amount that facility staff typically spend on feeding (Dyck, 2007; Simmons et al., 2008; Simmons & Schnelle, 2004), regardless of physical dependency. For example, Simmons and Schnelle (2006) found that residents rated by staff as independent or requiring only supervision/cueing and who eat poorly require just as much staff time during meals to ensure adequate intake as those who are more physically dependent. Suboptimal feeding assistance is, at least partially, due to the limited staffing resources that exist in many LTC facilities. Specifically, numerous studies have shown that most facilities do not have sufficient direct care staff to provide optimal feeding assistance to all residents who need it during meals (Kayser-Jones & Schell, 1997; Schnelle, Simmons, & Cretin, 2001; Schnelle et al., 2004).

One potential resource for augmenting existing staff during mealtime is visiting family. Recent research has focused on the continuation of the caregiving role after nursing home placement (Gaugler, 2005). One consistent finding is that family members who provided direct care prior to placement continue their caregiving role in some capacity after placement (Garity, 2006; Gaugler, 2005; Gaugler, Zarit, & Pearlin, 2003; Gladstone, Dupuis, & Wexler, 2006; Keefe & Fancey, 2000; Yamamoto-Mitani, Aneshensel, & Levy-Storms, 2002). Descriptive studies have demonstrated that family caregivers report relinquishing intensive care tasks to facility staff following LTC placement but express a desire to continue to provide some aspects of care to their loved one, especially care that helps maintain their relationship and the resident’s well-being (Gaugler, 2005). Family caregivers also have reported that they take on new roles after LTC placement, such as interacting with facility staff about their relative’s care and monitoring care quality (Ben Natan, 2009; Davies & Nolan, 2006). Importantly, caregivers report that they continue to provide assistance with activities of daily living (ADLs), including feeding assistance, although the extent of family involvement in specific aspects of daily care is mostly limited to self-report data, which might be biased (Garity, 2006; Gaugler, 2005; Levy-Storms & Miller-Martinez, 2005). Furthermore, research suggests that family involvement is beneficial to both the physical and the mental health of the resident (Ben Natan, 2009).

In qualitative studies, families report a desire to engage in meaningful activity that makes them feel useful when they visit (Gladstone et al., 2006). This may be particularly salient for those who have relatives with dementia when meaningful conversation is no longer possible (Garity, 2006; Maas et al., 2004; Piechniczek-Buczek, Riordan, & Volicer, 2007). For example, in one study, caregivers reported that difficulty with conversation contributes to a decrease in their visitation frequency and/or the length of time they stay when they visit (Gladstone et al., 2006). Research also suggests that family will increase their involvement in care if alerted to a specific health problem or concern (Keefe & Fancey, 2000); thus, it is possible that if family members are made aware of nutritional issues related to food intake, they may visit more regularly and schedule their visits to coincide with mealtime.

However, it is unknown whether family self-reported visitation and involvement in care match their actual behavior. Several studies show that 45% to 60% of family members report visiting residents frequently (at least once a week; Keefe & Fancey, 1997; Port et al., 2001) and that the frequency of visiting stays relatively stable over time (Yamamoto-Mitani et al., 2002); however, there are measurement issues worth considering. For example, self-report of family members related to visitation frequency and involvement in care after placement may be influenced by social desirability or inaccurate recall and staff reports may be biased or inaccurate based on the quality of their relationship with the family member or the frequency of visits during their shift (Gaugler, 2005; Port et al., 2003). There are scant observational studies to document the frequency of family visitation in a systematic fashion. Finally, although it is generally assumed that family involvement leads to better quality of life and quality of care for the resident, few studies have examined whether family involvement influences resident outcomes or effective interventions to incorporate family in institutional life (Gaugler, 2005).

The purpose of this study was twofold: (a) to determine the frequency of family visitation during mealtime based on standardized observations by research staff and; (b) to determine whether family visitation during meals had an impact on the quality of feeding assistance care and residents’ food and fluid intake. The study hypothesis was that family visitation during mealtime would result in better feeding assistance care and higher food and fluid intake of the resident when compared with meals during which the same resident received usual care from LTC staff.

Method

Subjects and Setting

This substudy was conducted as part of two larger studies designed to examine nutritional care quality. As part of these two larger studies, participants were recruited from two Veterans Affairs (VA) and four for-profit community facilities in one geographic region that housed a total of 854 residents (occupancy rates ranged from 78% to 99% across the six sites). Nurse-aide level staff-to-resident ratios, as reported by the Directors-of-Nursing, ranged from 6.27 to 10.56 residents per nurse aide during the day (7:00 a.m. to 3:00 p.m., breakfast and lunch meals), 7.83 to 14.73 in the evening (3:00 p.m. to 11:00 p.m., dinner meal), and 14.54 to 23.75 at night (11:00 p.m. to 7:00 a.m., breakfast meal). Licensed nurse (RN+LPN) staffing ratios ranged from 5.71 to 13.57 residents per licensed staff during the day, 12.31 to 27.63 in the evening, and 13.33 to 27.00 at night across the six study sites.

Figure 1 shows the recruitment and data collection of study participants that resulted in the sample for the current substudy (Figure 1). A total of 504 (59%) residents met the inclusion criteria for the two larger studies, both of which required residents to be long-stay (non-Medicare), free of a feeding tube, not receiving hospice, and not on a planned weight loss diet. Consent was obtained for 356 (71%) eligible residents. All study procedures were approved by the VA and University-Affiliated Institutional Review Boards. Following consent, 33 residents were lost from the study due to transfer out of the facility (13), incomplete data (11), transfer to hospice (5), death (3), or a weight loss order (1) (Figure 1). A total of 323 participants completed the initial 2-month baseline study phase in the two larger studies during which meal observations were conducted for each participant. Data are reported for this substudy only for the baseline phase reflective of usual LTC conditions.

Figure 1.

Study participants.

Of the 323 participants who completed mealtime observations, a family/visitor was present for at least one meal for 74 (23%) of these participants (Figure 1). These 74 participants comprised the sample for this substudy. For this subsample, there were a total of 599 mealtime observations (mode = 6 meals per participant). Of the 599 observations, a visitor was present during 109 (18%) meals. Comparisons were, thus, conducted between these 109 observations when a visitor was present and the remaining 490 observations during which these same participants received usual care from LTC staff on feeding assistance care and oral food and fluid intake (see “Mealtime Observations” and “Data Analysis”).

Measures

Demographics, medical information, and the most recent Minimum Data Set (MDS) assessment were retrieved from each participant’s medical record (Hartmaier et al., 1995; Health Care Financing Administration, 1999; Morris, Fries, & Morris, 1999). The MDS-derived Activities of Daily Living (ADL) Scale score ranges from 0 (rated by staff as independent in each of seven areas) to 28 (rated by staff as completely dependent in all areas) (Morris et al., 1999). Staff ratings of eating dependency (Section G. Physical functioning, Item 1h) also were abstracted separately (score range 0 = completely independent to 4 = total dependence) (Health Care Financing Administration, 1999).

Mealtime Observations

Trained research staff used a standardized observation protocol shown to be reliable and valid in previous studies (Simmons, Babineau, Garcia, & Schnelle, 2002; Simmons et al., 2003; Simmons & Reuben, 2000) to conduct observations during regularly scheduled meals under usual LTC conditions. Continuous observations were conducted from the time of meal delivery until the time of meal retrieval per person per meal for 6 to 12 meals per participant (mode = 6). One member of the research staff was assigned to a resident and recorded observations during the regularly scheduled mealtime at each facility on randomly selected weekdays. A trained research staff member was assigned to a small group of residents dining in the same area (e.g., dining room) and observed continuously from the time of meal tray delivery until the time of meal tray pick up for each resident-meal period. Research staff documented the presence or absence of each type of assistance provided during the meal to encourage intake including verbal cueing and encouragement (e.g., “How is your breakfast this morning?” “Try another bite of soup.”), social interaction (e.g., “It’s nice to see you today.”), and physical assistance (e.g., spoon-to-mouth feeding or staff assistance with holding utensils or cup). In addition, research staff also recorded whether an alternative to the served meal was offered and/or whether an oral liquid nutritional supplement was given during the meal. Alternatives included any food or fluid items brought into the facility by family or requested from the facility kitchen. The lengths of all episodes of any type of assistance by either family or facility staff were measured using a stopwatch and summed to yield a total assistance time (minutes: seconds) for each participant and meal. For each meal, research staff visually estimated the total proportion of foods and fluids consumed (all foods and fluids combined). This is the method used by facility staff to document daily meal intake and identify residents who are eating poorly (Health Care Financing Administration, 1999; Simmons et al., 2002; Simmons et al., 2003; Simmons & Reuben, 2000). If a supplement was given, the type of supplement and number of fluid ounces consumed also was recorded to yield an estimate of caloric intake from supplements. Finally, research staff recorded whether a visitor (usually a family member) was present during any part of the meal. The rules and rationale that guided the observational protocol to assess feeding assistance care delivery during meals have been described in more detail in previous studies (Simmons, Durkin, et al., 2013; Simmons, Sims, et al., 2013). The interrater reliability was moderate to excellent for each of the observation-based data elements (n = 899 participant-meals) in the larger study: total assist time (Pearson’s r = .975, p < .001; n = 899), alternative offered (Cohen’s kappa = .736, p < .001; n = 899), supplement given (kappa = .914, p < .001; n = 417), total percent eaten (r = .976, p < .001; n = 899), physical assistance to eat (kappa = .955, p < .001; n = 899), and verbal reminders or social interaction during the meal (kappa = .670, p < .001; n = 899).

Statistical Analysis

The goal of the primary statistical analysis was to assess the effects of outside support (family/visitor) on mealtime feeding assistance care for study participants. For the analysis cohort to serve as its own control, participants who did not have a visitor present for any meal during their 2-month observation period were excluded from analysis (Figure 1, Usual Care: No Family Visitation). However, the analysis cohort (n = 74) was compared with the excluded cohort (n = 249) on demographic and clinical measures shown in Table 1. The two-sided Student t test and the chi-square test for homogeneity were used to evaluate continuous and categorical demographic factors, respectively. Because each participant was observed in a repeated manner (over multiple mealtime periods), a “clustered bootstrap” method (Field & Welch, 2007) was used to compute 95% confidence intervals (CIs) for estimates associated with mealtime feeding assistance care measures. This method accounts for the additional uncertainty associated with an unbalanced design, where some residents contribute more mealtime observations and/or family visits than others. The odds ratio (OR) was used to evaluate dichotomous mealtime feeding assistance care (e.g., presence or absence of types of assistance, alternative offered, supplement given), and the difference in means was used for continuous measures (e.g., total assistance time, total percent eaten, caloric intake from supplements). Differences in means were considered statistically significant if the corresponding 95% CI excluded the value 0. ORs were considered statistically significant if the corresponding 95% CI excluded the value 1.

Table 1.

Characteristics of Study Participants With Family Visits (n = 74) and Those Without Family Visits (n = 249) During Observed Meals.

Measure	Participants with family visits^a (n = 74) M (SD) or % (n)	Participants without family visits^b (n = 249) M (SD) or % (n)
% White	86 (63)	86 (213)
% female**	57 (42)	35 (88)
Age	81.97 (± 9.90)	78.85 (± 9.90)
Length of stay in years	2.90 (± 3.47)	3.39 (± 2.73)
% dementia diagnosis	70 (52)	65 (162)
% depression diagnosis	55 (41)	47 (117)
Physical dependency (MDS-ADL, 0-28)*	17.26 (± 7.17)	14.38 ± 8.63
% with MDS eating dependency rating of required assistance	46 (34)	39 (97)
% with prescribed diet order	60 (44)	64 (160)
% with caloric supplementation order	47 (35)	43 (106)
% with recent weight loss on MDS	13 (9)	11 (26)
Body mass index (BMI) <21	25 (14)	27 (54)
Average percentage of meals consumed**	55 (± 29%)	61 (± 28%)
Average feeding assistance time**	9:51 (± 15:02)	5:50 (± 9:33)

Note. MDS-ADL: Minimum Data Set derived Activities of Daily Living total score range 0 (rated by staff as completely independent) to 28 (rated by staff as completely dependent in 7 ADLs). MDS eating dependency item (Section G. Physical Functioning) rated 2 (limited assistance), 3 (extensive assistance), or 4 (totally dependent). Prescribed diet order: Any type of altered diet (no added salt, no concentrated sugars, mechanically altered, ground, puree). Caloric supplementation order: Physician or dietitian order for oral liquid nutrition supplement or the provision of additional foods and fluids between meals. BMI formula = 0.454 × weight in pounds / (0.254 × height in inches) (Simmons et al., 2008).

Included in analysis.

Not included in analysis.

p < .05. **p < .01.

To assess the effect of mealtime visitation for the subset of residents who require significant eating assistance, the analyses above were repeated using only those residents with documented need (MDS Section G. Physical functioning, Item 1h greater than 1).

Results

Participant characteristics for the 74 who had a visitor present during at least one observed meal are presented in Table 1. This subsample of participants was predominantly White (86%) and female (57%). Their average age was 82 and their average length of stay in the facility was approximately 3 years. Seventy percent had a physician-recorded chart diagnosis of dementia and 55% had a diagnosis of depression. Participants were moderately physically impaired based on the MDS-ADL total score (17.26 ± 7.17), and 46% were rated by LTC staff as requiring assistance to eat. Sixty percent had a prescribed diet order and 47% had an order to receive caloric supplementation daily. Thirteen percent had a recent weight loss episode (MDS: ≥ 5% in 30 days or ≥ 10% in 180 days), and 25% had a Body Mass Index (BMI) below 21, which is indicative of undernutrition (Fiatarone Singh & Rosenberg, 1999). The clinical and demographic profile for the subgroup of participants studied in this analysis, that is, those who received an outside visitor for one or more meals during the baseline observation period, was significantly different (Table 1) from those who received no visitor (n = 249). On average, those not included in the analysis were less physically dependent (MDS-ADL 14.38 vs. 17.26, p = .01), consumed a larger proportion of their meals (61% vs. 55%; t = 4.245, p ≤ .001), received less feeding assistance from LTC staff (5:50 vs. 9:51 min; t = −7.913, p ≤ .001), and were predominantly male (65% vs. 35%, p ≤ .001).

Mealtime Feeding Assistance Care Measures

For the 323 participants who completed the baseline phase of the larger studies (Figure 1), research staff recorded a total of 2,713 mealtime observations. Frequency distributions were calculated to determine the proportion of mealtime observations during which a family/visitor was present. Results showed that a family/visitor was present during only 109 (4%) of the total observations. Among the subsample of 74 participants who received a visitor during one or more mealtime observations (Figure 1), the average number of mealtime visits was 1.47 (SD = 0.36; range = 1-4). The average number of meals without a visitor was 6.62 (SD = 3.29).

Comparisons were conducted in the frequency of visitation between the two VA sites and the four community facilities. A higher proportion of community facility participants had at least one mealtime visitor compared with the VA participants (38% vs. 25%; p = .074), although this difference did not attain statistical significance. For the subgroup who had one or more mealtime visits, the frequency of mealtime visitation was comparable between community and VA samples (1.59 vs. 1.38, respectively; p = .255).

Table 2 shows the results for the feeding assistance care and outcome measures during mealtime when a family/visitor was present compared with usual mealtime care provided by facility staff for the 74 subgroup participants (total meal observations = 599). Family/visitors spent significantly more time providing assistance to eat when present during mealtime compared with meals during which this care was provided by LTC staff (19:39 vs. 7:52 min per person per meal). Physical assistance was provided more often when a family/visitor was present (42% vs. 32%); however, this difference was not statistically significant. Verbal cuing and encouragement and/or social interaction during mealtime occurred significantly less often when a visitor was present but was notably high under both conditions (86% vs. 96%).

Table 2.

Mealtime Feeding Assistance Care Measures: Comparisons Between Meals With Outside Support Versus Usual Care Provided by LTC Staff (n = 74).

Per resident/per meal	Family present M (SD)/% (observations = 109)	Usual care: Family not present M (SD)/% (observations = 490)	Difference or odds ratio	Lower 95% CI, Upper 95% CI
Feeding assistance care
Total assist time^a	19:39 (± 24:09)	7:52 (± 11:04)	11:37	[5:47, 18:35]
% physical assistance	42	32	1.49	[0.73, 2.94]
% verbal/social^a	86	96	0.24	[0.09, 0.65]
% alternative offered	5	5	0.97	[0.21, 2.43]
% supplement given^a	29	18	1.84	[1.07, 3.14]
Total supplement calories	226 (± 206)	248 (± 181)	−20.42	[−124.25, 64.09]
Outcome
% consumed	53 (± 27)	58 (± 30)	−4.57	[−9.89, 0.97]

A statistically significant difference was observed between meals where family members were present versus usual care.

Participants were offered an alternative to the served meal during only 5% of mealtime observations, regardless of visitor presence. Participants received a supplement during a significantly greater proportion of meals when a visitor was present (29% vs. 18%); however, caloric intake from supplements, when given, remained comparable (226 vs. 248 calories per person per meal). Finally, despite the increase in assistance time, visitor presence did not exhibit a significant effect on the average proportion of meal consumed (53% vs. 58%).

Nearly half of the included participants (46%) had a MDS eating dependency rating that indicated a significant need for eating assistance. We repeated the primary statistical analysis using only this subgroup of participants (n = 34). Our findings in this subgroup were largely comparable with those associated with the primary sample. There was no significant difference in the frequency of alternative offers (3.6% vs. 4.8%; OR 95% CI = [0.00, —]), physical assistance (70% vs. 62%; OR 95% CI = [0.35, 3.60]), or percent eaten (55% vs. 56%; difference 95% CI = [−13.7, 3.3]). Average assistance time was greater when visitors were present during mealtimes (25:00 min vs. 13:27 min; difference 95% CI = [0:24, 18:56]). However, the average assistance time was greater, regardless of visitor presence, relative to the larger subgroup. Although the effect of visitation on verbal/social support was significant in the primary subset, the evidence was weak in the smaller subset (89% vs. 97%; OR 95% CI = [0.00, 1.20]).

Discussion

This substudy was conducted as part of two larger studies designed to examine nutritional care quality in a sample of community and VA LTC facilities. The results of this study show that family visitation was infrequent during mealtime for this study sample (4% of total observed meals); however, when family did visit, they spent more time providing assistance to encourage food and fluid intake. The lack of a significant difference in meal intake despite more time spent by families suggests that the LTC residents in this study are consistently poor eaters and may not always eat significantly more given additional time. Although average assistance time was greater for residents with significant eating dependence, the effect of mealtime visitation was similar to that in residents with minimal eating dependence. In fact, the characteristics of these LTC study participants demonstrate that they are a cognitively impaired, eating dependent, and nutritionally at-risk group. This is further supported by the comparison of study participants to nonstudy participants. Study participants were poorer eaters and received more assistance during mealtime compared with residents not included in the analysis. Other studies have shown that only 40% to 50% of LTC residents who eat poorly during meals show significant gains in intake in response to improvements in mealtime feeding assistance care quality (Simmons, Durkin, et al., 2013). However, it also should be recognized that visiting family did not receive any specific training in how to provide optimal feeding assistance care.

Encouraging and supporting family involvement in meal assistance has the potential to increase quality of care during mealtime. Although there were no significant improvements in some care processes and caloric intake outcomes, the significant difference in the time spent providing assistance suggests the potential for quality care improvement with proper training. Furthermore, the significant difference in supplements given may indicate an increased awareness on the part of staff to offer a supplement when family is present or a request by the family member for additional nutrition as a result of low intake at mealtime. Federal regulations allow LTC facilities to train non-nursing staff to assist with feeding; and studies have demonstrated positive benefits of such training programs on feeding assistance care quality (Simmons, Durkin, et al., 2013; Simmons, Sims, et al., 2013). A systematic review on the use of volunteers to improve mealtime care found that the use of volunteers (including family members) can improve mealtime care; however, the evidence is limited due to a lack of well-designed studies (Green, Martin, Roberts, & Sayer, 2011). The authors also state,

It is difficult to demonstrate a difference in nutritional status and intake in patients or residents, because there are many factors other than mealtime care which can influence nutritional intake and status that are difficult to control or make allowances for in a research design. (p. 1820)

Despite the lack of significant effects on meal intake, involvement of the family member in a meaningful role, such as feeding, during their visit may be beneficial to the family member as well as the resident. Redefining the caregiver role may be an important task following placement, and family members have reported difficulty in adjusting to this role (Davies & Nolan, 2006; Maas et al., 2004); however, staff may not be aware of the need for the family member to continue involvement in a modified role (Davies & Nolan, 2006). Studies also suggest that families are more likely to visit if they perceive their visits as useful. For example, families in one study reported satisfaction with a visit when they felt useful and that their visits “made a difference” (Gladstone et al., 2006). In another study, family members discussed the importance of organizing visits around tasks such as providing assistance during mealtime (Piechniczek-Buczek et al., 2007). In contrast, family members report a lack of anything to do with their relative as a reason for decreased involvement (Keefe & Fancey, 2000). According to families, having a concrete purpose helped to ease anxiety and increase gratification (Piechniczek-Buczek et al., 2007).

Future research should examine whether interventions that increase family involvement are beneficial for both the resident and the family member during and outside of mealtimes. This includes not only such aspects as the quality of feeding assistance during mealtimes addressed in this study but also psychosocial benefits and constructs related to life satisfaction and quality of life that go beyond mealtime care. Evaluating how families stay involved post-placement may help inform interventions to support family involvement (Gaugler et al., 2003).

Continuing care may provide the family member with an opportunity for more frequent visits and to monitor care quality (Garity, 2006). In one study, families sought ways to remain involved, especially in the first year after placement (Gladstone et al., 2006). Davies and Nolen (2006) suggested that most caregivers want to remain active in the life of their loved one following placement; however, there is often little effort on the part of care staff to facilitate this involvement. One reason is that staff may view family as visitors who should not be involved in direct care (Maas et al., 2004). Interventions that aim to improve communication and cooperation between family and staff may be beneficial to the resident, family member, and staff. For example, one study suggests that families may want to provide needed care, especially if the facility is short-staffed (Gladstone et al., 2006). The fact that residents included in the study sample are poor eaters and receive more visitors than those not included in the sample suggests that family members may already be responding to increased need by visiting more often. Alerting family to staff concerns about meal intake may increase visitation during mealtime. As Levy-Storms and Miller-Martinez (2005) noted, “If long-term-care institutions were more proactive about how to integrate informal and formal caregivers to provide optimal care for elders, involved family caregivers might be more satisfied, because the quality of care might be better with their help” (p. 172).

There are several limitations of this study. First, observations of family visitation and involvement in mealtime care were limited to only a sample of meals during a 2-month time period and weekdays only. It is quite possible that family visitation is more frequent and reflective of more involvement in other aspects of care throughout the day (evening) and weekend hours (e.g., social activities, walking assistance). Second, this study did not include additional information related to the family member (e.g., relationship to the resident, prior role as a caregiver, frequency of visitation, satisfaction with care, concern about their relative’s nutritional status) that might shed light on their desire to be more involved in some aspects of care.

Finally, assistance was measured based on presence or absence of each type (e.g., physical, verbal, social) and the total duration of all types combined throughout the meal period but did not include specific recording of content or the specific duration of that content. For example, the verbal/social variable is recorded as the presence or absence of any single episode of social interaction between the residents and any staff member at any point during the duration of the meal. However, only the occurrence of social interaction was recorded and not the specific duration of the episode. Therefore, a brief exchange of just a few words (e.g., “Good morning—How are you today?”) was counted as “present” just as a prolonged conversation also was counted as “present.” Because there was a significant difference in total assistance time, it is likely that when verbal cueing and social interaction were present, it occurred for a longer duration when family/visitors were present. In addition, it is also possible that the content of the socialization was more meaningful for the resident when family was present. Thus, these more subtle aspects of the resident’s enjoyment of the meal and associated quality of life were not captured in this study. Despite these limitations, one strength of this study is the use of observational data rather than caregiver self-report or staff report, which may be influenced by social desirability, inaccurate recall, and other measurement issues.

Conclusion

Inadequate staffing is a common problem in LTC facilities that often results in suboptimal mealtime assistance. The use of family/volunteers could be an effective way to augment LTC staff to improve mealtime assistance. However, we have limited knowledge about how often family members visit during mealtime and what types of assistance they provide when present. The results of this study show that although family visitation was infrequent during mealtime, when family did visit, they spent more time providing assistance to encourage food and fluid intake. Although the additional assistance did not result in a significant increase in intake, these findings suggest that strategies to encourage the involvement of family in mealtime assistance may have benefits not directly associated with meal consumption. Structured visits during mealtime may allow LTC staff more time to assist other residents and provide family members with a meaningful and purposeful activity that may increase their satisfaction with their visit and promote increased visitation.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was supported by VA Health Services Research and Development (HSR&D) Merit Grant IRR 07-250, “Prevention of Weight Loss in Long Term Care Veterans” and Agency for Healthcare Research and Quality (AHRQ) Grant 5R01HS018580-02, “Cost-Effectiveness of Weight Loss Prevention in Nursing Homes: A Controlled Trial.”

Author Biographies

Daniel W. Durkin, PhD, is an Assistant Professor in the Department of Social Work at the University of West Florida. His research interests include family caregiving, male caregivers, and dementia.

Matthew S. Shotwell, Ph.D. is Assistant Professor in the Department of Biostatistics at Vanderbilt University School of Medicine. He is active in collaborative and methodological research, and currently serves as Principal Investigator for the NIH-funded research project titled “Optimal Design of Challenge Response Experiments in Cardiac Electrophysiology”. Dr. Shotwell is interested in research design, mechanistic models, bootstrap, and other computational methodologies.

Sandra F. Simmons, PhD, is an Associate Professor of Medicine in the Division of General Internal Medicine and Public Health at Vanderbilt University. Her current clinical appointments include faculty member at the Vanderbilt Center for Quality Aging and Research Scientist in the Geriatric Research, Education and Clinical Center (GRECC), Veterans Administration. Her research foci include clinical interventions and staff training to improve care quality for older adults in a variety of healthcare settings including long-term care, acute care, post-acute care and assisted-living.

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