Mixed methods developmental evaluation of the CHOICE program: a relationship-centred mealtime intervention for long-term care

The concept of the CHOICE Program was developed over several years of research that identified the potential for dining in LTC to be more relationship-focused. Early research by this team identified the role meals played in the family home for persons living with dementia and their family care partners [16]. As families moved into residential environments, the understanding that these meals did not live up to expectations was identified [17]. Observations in a variety of residential environments demonstrated the social engagement and potential for building of relationships for residents and staff [6] and finally the concept of relational dining which encapsulates RCC and person-centred care practices was formed [18]. It was believed that the overall experience of a mealtime that captured physical, social and relationship-centred components could be measured and thus the Mealtime Scan (MTS) was developed and used in a large multi-site study [19]. The way that care was provided, and specifically more person- and relationship-centred was found to be associated with improved food intake [19]. This team then embarked on a journey to develop the CHOICE Program based on this acquired knowledge and experience with mealtimes in LTC settings.

The first step in development of the training program was to articulate more fully what relationship-centred and relational care could look like in the dining room and draw upon important principles from a substantive theory developed in a previous study with persons living with dementia and their care partners on the meaning of mealtimes [17]. This lead to the development of the CHOICE Principles which stand for Connecting, Honouring dignity, Offering support, supporting Identity, Creating opportunities and Enjoyment (Table 1). These principles were discussed at a variety of provider conferences and decision-maker discussion groups to see whether they resonated with those outside of the research program. In line with RCC, the program needed to enhance the mealtime experiences for residents and team members (i.e., Personal Support Workers and Dietary Aids) by changing team member attitudes, knowledge, and behaviour in order to promote and re-emphasize the importance of meaningful social interactions with residents. To be effective and responsive to the changing needs of residents and team members, the CHOICE Program needed to be tailored to the individual home area based on the priorities identified by the team members. Thus, the focus of training was on the principles and how they could be enacted within a specific care setting. Training materials for the CHOICE Program were developed based on models typically utilized by LTC home chains, and where this developmental evaluation was to be conducted. This included: a) a presentation that described each CHOICE Principle, b) scenarios on each principle for staff huddles (i.e., brief direct care staff meetings), c) brainstorming ideas for making specific improvements in physical, social and relationship-centred care, and d) verbal and visual reminders to enact identified ideas for mealtime improvements. The physical dining room and the team members within it were the targets for the intervention.

This study describes the developmental evaluation of the CHOICE Program for LTC staff delivered in a single pilot site. The aim of this study is to determine: a) if the mealtime experience (e.g. physical, social and RCC practices) could be modified with the CHOICE Program, and b) how program components needed to be adapted and/or if new components were required.

Developmental evaluation is used in the early stages of an intervention or program to understand what works and what does not, especially in multi-component programs designed for complex environments [20]. A key purpose of such an evaluation is to learn and adapt the intervention as it is being delivered, and thus a ‘bottom-up’ approach is needed [20]. This form of evaluation is especially relevant for complex interventions that involve coordination of diverse staff and attempts to change their social interactions with others. As a result, components of CHOICE were revised or discarded and new components developed during the course of this evaluation. An explanatory sequential mixed methods (QUANTITATIVE ➔ qualitative) pre-test post-test time series design was used to evaluate the CHOICE Program. This evaluation began with the collection of quantitative data using the observational tool, the Mealtime Scan for Long-Term Care (MTS), at four time points during a 24-week period. Quantitative results informed the subsequent qualitative data collection using semi-structured interviews [21]. Findings were merged to address study objectives. Ethical clearance was obtained from the University of Waterloo Office of Research Ethics (#21413).

It was anticipated that learnings would be enhanced and strengthened if two home areas (sometimes referred to as "care units") - Parker and Wellesley (pseudonyms) - in a single LTC were included, as resident differences with respect to eating capacity would likely influence types of team member activities undertaken to make improvements. The LTC home was located in Southern Ontario, Canada, and is part of an Ontario chain of for-profit homes. The Schlegel-University of Waterloo Research Institute for Aging (RIA) facilitated the incubation of this innovation in a research-friendly home so that the learnings from this work could contribute to the acceleration and eventual mobilization of the innovation to the broader LTC sector. The participating home has a total of 192 beds within 6 home areas and was also selected based on a self-identified need to refocus team member efforts on resident mealtimes. As well, this home had minimal prior exposure to external mealtime-focused research initiatives. As the quantitative data collection procedure was based on dining room-level observations, written consent was not required as per the University of Waterloo Office of Research Ethics from individual team members and residents, as only global aspects of the mealtime experience were being assessed. Informational posters and newsletters were provided to residents, families, and team members prior to the start of implementation to ensure that everyone who lived and worked in this home area was aware of the initiative and the use of observations to measure potential changes. Signs were posted advising the home areas when meal observations were to occur. Those care team members and home management who played critical roles in the implementation of the CHOICE Program were invited to participate in interviews in the qualitative phase; informed written consent was provided.

Prior to pilot implementation, the research team (i.e., Principal Investigator HK, HD Study Coordinator, and doctoral student, SW) met with the home’s administrators to discuss program components, implementation process, and potential barriers and facilitators of care team behaviour change during mealtimes (Table 2). A mutual agreement was reached on study timeline (i.e., 8-month involvement of care staff implementation process and evaluation), time commitments (i.e., time dedicated to staff huddles and coaching phone calls), support resources (i.e., informational resources on care delivery, program print materials), and outcome goals (i.e., what was feasible for each home area to achieve in this program). The home’s administrators identified two Mealtime Champions (MT Champions) per home area to act as leaders to guide fellow team members through the implementation process. MT Champions play a critical role as point of contact for the interventionists as a way to give and receive feedback during implementation. The MT Champions were selected based on: a) their interest and dedication to care improvement, b) their positive social influence among their colleagues and reciprocated respect they received, and c) full-time employment to ensure their knowledge of the home area. Each home area attempted to work on one CHOICE Principle at a time to raise awareness and identify areas for improvement. Flexibility in the program allowed home areas to spend as much time as needed on a principle. The Director of Food Services (DFS), acted as both an internal resource and CHOICE advocate to hold the team members within each home area accountable to their goals each week. It became apparent immediately that the MT Champions and DFS needed further support post training to stimulate change among the care team. The research team took on this role collectively; the PI provided support on techniques and theory to make change; the study coordinator who was an employee of the RIA facilitated communications among home management, the dining team and the researchers, while the doctoral student visited the site, initially with the study coordinator, and took on the role of ‘CHOICE Coach’ on-site as the implementation progressed. The Coach visited the study site twice per month for 5 months, spending 1 day in each home area to attend team member huddles, support the completion of the huddle diary, observe mealtimes, gain feedback from team members and residents, and strategize and problem-solve with the MT Champions. She also took this time to meet with the DFS to review progress reports generated by the research team using MTS results in order to strategize on ways to support team members in areas identified as needing improvement. Over the last 3 months of implementation, the Coach reduced in-person presence in order to promote capacity and independence among the MT Champions and team members; however, bi-weekly coaching teleconference meetings continued with the research team.

As the MT Champions and the DFS started to consider how to make improvements, it was recognized that they needed coaching on change management. The Theoretical Domains Framework was chosen as a basis for coaching on strategies to make change [22, 23]. In this framework, fourteen domains (i.e., knowledge, skill, beliefs about capabilities, intentions, goals, etc.) can be condensed into three core components in relation to behaviour change: capability, opportunity, and motivation (e.g. COM-B; [24]). The COM-B model was selected specifically for this LTC intervention as it places emphasis on the importance of context (i.e., opportunity) when looking to change behaviour, which is critical when designing feasible and acceptable interventions for health care environments. Without explicitly educating team members on this framework, coaching was provided by the research team to support the adoption, uptake and execution of the program components. For example, celebrating success was an incentive to further motivate team members to complete a specific care activity.

The intervention evolved over the course of the pilot, as is typical of developmental evaluation [20]. It ultimately included 8 components that supported team members in their change efforts, as outlined in Table 2. Team members and the research team worked to tailor these components over the course of the implementation process to meet specific needs of the individual home areas. For example, the in-person educational session on CHOICE Principles was translated into an online education module and made available on the home’s intranet training platform for those team members and administrators who were not present for the in-person sessions, as well as new team member hires.

Nine interviews were conducted with four PSWs (two of whom were MT Champions), two DAs, two home management members (HM), and one registered nurse (RN). Six themes emerged from the analysis. In addition, we provide key learnings and/or materials developed in response to the needs of each dining room identified during the implementation process for each theme (Table 6).

Results from this developmental evaluation demonstrate the potential for the CHOICE Program to improve some aspects of the mealtime experience, namely physical and overall quality of the dining environment. It is important to note however, that these changes were not necessarily experienced in both home areas to the same extent. For example, although there was a significant time by dining room change noted in the social summative scale, there was a decrease in performance for one area (Wellesley = 5.4 to 5.2) over time. From baseline, one home area improved the overall quality of the environment significantly more than the other, demonstrating that comparisons across neighbourhoods can be challenging, as they are not equivalent with respect to their capacity for improvement. In areas where residents have significant dementia, social interactions are likely to never be high due to their limited verbal capacity. Relationship-centred care may also be challenging due to the higher demands for hands-on care. The physical and overall quality of the mealtime experience, which significantly improved in both areas included in this pilot, appear to be more readily changeable with the CHOICE program. These findings not only reinforce the need to account for contextual differences between environments, but also to temper expectations as to what can realistically be achieved within a short-period of time based on staffing and team member skills as well as the capacity of residents. Making improvements to an organization’s care culture and social environment has been noted to be a challenging task [42] that requires additional time and effort when compared to making improvements to the physical dining environment [11]. Often such cultural changes require targeting roles and responsibilities with added quality supervision on the part of home leadership [36]. Thus, it is recommended that the feasible changes to the built environment be targeted in the initial stages of the implementation process, as altering the physical dining environment (i.e., clock on wall, decorations on table, music playing) provides visible improvements that change-making is underway.

Future evaluation of CHOICE should consider the use of a wait list control through a stepped-wedge design rather than a randomized control trial, as this pilot clearly demonstrated that the context of units greatly influences uptake and discernible change. Methodological limitations of this study include the MTS potentially being too insensitive, with too few observations, to capture the gradual improvements that team members and leadership referred to during interviews [25]. The issue of social desirability from interview participants may have led to responses, which may not have been entirely reflective of their experiences implementing the program. As well, there is the potential for confirmation bias, as the interventionist was the interviewer. Other forms of quantitative assessment to capture improvements should include team members’ perspectives on mealtimes and dyads of the resident and family members. Furthermore, it should be noted that because of an illness outbreak at the LTC home, we were unable to capture the last point of data collection at 32 weeks, which may have indicated further improvements in the dining environment. Staff turnover was a barrier to continuity with initial study participants; most notably, a key individual from the home’s management team was unable to participate in the interview process due to extenuating circumstances, which would have undoubtedly revealed critical insights into the feasibility and acceptability of the program. The research team appreciates the importance of the inclusion of family and residents in a relationship-centred intervention, however, these perspectives were not attained in this evaluation. Future development of the CHOICE Program will extend qualitative data collection to family and residents as well.