Serving culture change at mealtimes

The nutritional status of nursing home residents typically is poor and often results in negative health outcomes such as increased illness, disability, and psychological complaints, as well as unintended weight loss and dehydration, all of which are central issues of concern in many nursing homes. Estimates indicate that as many as 85% of long-term care residents are at risk of malnutrition, which can lead to increased mortality and morbidity.

A major reason for the prevalence of resident malnutrition is food refusal. Furthermore, dissatisfaction with food and the dining experience is a significant driver of overall resident unhappiness. Food is one of the few remaining pleasures for many residents. The choices related to eating, such as whom to eat with and what to eat, are reflective of lifelong habits and preferences.

The idea of providing residents with more control is at the forefront of the culture change movement. Residents who value autonomy, self-determination, freedom, and voice achieve them through decision-making. In the archetypal institution-directed culture, the resident must comply with schedules and routines preset by the organization. Through culture change, residents and staff design schedules that reflect the residents’ personal needs and desires. For example, within reason, residents can decide whether they prefer a shower or a bath in the morning or in the evening.

A study by the Parker Jewish Institute strived to integrate the basic tenets of culture change with mealtime activities in an effort to yield positive changes and outcomes for its nursing home residents. The program shifted meals from a typical tray service to a buffet-style dining room, giving residents choices regarding meals and their eating companions.


A buffet-style dining program (BSDP) was implemented, offering a sample of residents freedom of choice, eating independence, and dining room ambience in an attempt to increase each resident’s appetite. Each person received a tray and plate and was able to select from a variety of entrées, vegetables, and side dishes. Those with eating problems, such as messy eaters, and those who had difficulties chewing and were considered disruptive or inappropriate at mealtimes ate in a smaller lunchroom adjacent to the main cafeteria to re-create an enjoyable atmosphere similar to one encountered at home or in a restaurant.

Staff implemented BSDP on one floor of the nursing home. On another floor, staff continued to deliver dinner trays to each control group resident’s room. Staff obtained residents’ weights from several months before the study via archival records and administered surveys, with assistance as needed.

The intervention group receiving the BSDP consisted of 44 residents. Staff excluded those on severely restricted diets, such as pureed foods only, and those tube-fed. At pretest, intervention group resident weights ranged from 73 to 252 pounds. The control group consisted of 62 residents weighing 80 to 329 pounds at pretest and excluded those who were on restricted diets and tube-fed.


No statistically significant differences between the intervention and control groups were seen over time (see table). At time one, weights ranged from 77 to 245 pounds in the intervention group and 73 to 326 pounds in the control group, and at time two from 88 to 253 pounds and 72 to 332 pounds, respectively.

Between groups t-test results for weights over time

Intervention Group

Control Group









t (df)











Time 1










Time 2










Looking more closely at the intervention group, differences in weight from the pretest to time one (one month later) ranged from a weight loss of 7 pounds to a gain of 13 pounds, whereas weights ranged from a loss of 26 pounds to a gain of 17 pounds in the control group. Weight differences from pretest to time two weights (two months later) ranged from a loss of 11 pounds to a gain of 15 pounds in the intervention group and a loss of 26 pounds to a gain of 20 pounds in the control group.

While none of these results were statistically significant, these trends reflect clinical significance. The differences in weight loss across all three time points were considerable: at pretest, 7 and 26 pounds; at time one, 11 and 26 pounds; and at time two, 8 and 17 pounds for the intervention and control groups, respectively. Additionally, during the first month, on average, participants gained one pound and sustained the gain throughout the second month of the program, whereas the control group continued to lose weight through the second month.

Forty-four participants (11 men and 33 women) in the intervention group completed the satisfaction survey and had an average age of 82. Additionally, 37% of these individuals were on a special diet, such as low salt, diabetic, or renal. Thirty-one control group participants (7 men and 24 women) completed the survey and had an average age of 80; 48% of these individuals were on a special diet. As compared with the control group, the intervention group was significantly more satisfied with the food’s quality, taste, temperature, and appearance, as well as the overall dining experience (see figure).

Differences in satisfaction between intervention and control groups. *Indicates significant differences


This small study showed that by improving the dining experience by allowing choice, independence, and increased ambience, both psychological and medical outcomes could improve in residents. Dining may seem to play a small role in the life of residents, but it remains an integral part of the nursing home culture. Offering residents the opportunity to socialize with other residents and the power to make decisions regarding their meals restores a sense of independence and freedom. Those who are eating more and maintaining weight stand a better chance of remaining healthy and evading additional illness. This increased satisfaction not only has countless benefits on the residents’ health, but also makes their domicile a happier place.

Nicole A. Andreoli, MS, is a contributing author.

Lorraine Breuer, MA, is the Assistant Vice-President for Research at the Parker Jewish Institute, a 527-bed facility offering a constellation of inpatient short-term rehabilitation/sub-acute care and long-term care/skilled nursing programs. Breuer is responsible for the development and conduct of research studies to improve quality of life for seniors through a range of clinical and health services investigations.

Diane Marbury, BA, is a Program Coordinator in the Nerken Center for Research at the Parker Jewish Institute.

Sylvia Williams, RN, MA, is the Vice-President for Patient Care Services at the Parker Jewish Institute and is responsible for administration of nursing services, physical medicine and rehabilitation, and therapeutic recreation.

Michael N. Rosenblut, MBA, LNHA, is the President and CEO of the Parker Jewish Institute. He is involved with advocacy for post-acute care with the New York Association of Homes and Services for the Aging and is a Board Member with the Continuing Care Leadership Coalition, the post-acute arm of the Greater New York Hospital Association.

For more information, phone (718) 289-2100, ext. 4980, or visit To send comments to the authors and editors, please e-mail

Topics: Articles , Nutrition , Operations