Bon Appetit! The Joy of Dining in Long-Term Care By Jitka Zgola, OT(C), and Gilbert Bordillon, BEH

Excerpted from the Chapter 1 and Chapter 12 of Bon Appetit! The Joy of Dining in Long-Term Care by Jitka Zgola and Gilbert Bordillon.

Copyright © 2001 by Health Professions Press, Inc. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.

OVERVIEW

The program described in this book aims to restore the joy of dining to people in long-term care. It is founded on the following premises:

• Meals are the single most consistently accessible, manageable, and effective health promoting activity that we can offer to residents.
• Failure to eat well is the single greatest threat to residents’ physical and emotional health.
• A major part of normal daily activity is centered around meals and their preparation, serving, sharing, and consumption. This preoccupation persists into old age and does not change with disability. Meals must, therefore, be given the attention they demand as significant activities of the day.

A meal does not start with the appearance of food on the table and end with the last mouthful. It is far more. It includes

• The preparation of the food
• The preparation of the dining room
• The invitation to the meal
• The greetings, conversations, and other social aspects of the occasion
• The taste, color, aroma, presentation, and texture of the food
• The actual consumption of the food and the dignity and pleasure that is associated with it
• The termination of the meal, which includes clearing the plates and washing up
• The wholesomeness, digestibility, and essential value of the food

The authors see meals and the events associated with meals as a potential source of exquisitely meaningful and gratifying activity, offering sensory and social stimulation, pleasure, and a sense of productivity and autonomy. All considered, meals are the most significant and meaningful activity of the day. Unless, of course, meals are offered in a context that is totally inconsistent with normal living and therefore unfamiliar, or unless the person is excluded from the activities that are associated with meals and is relegated to the role of passive recipient only. This is true for everyone but especially for people with dementia.

People with cognitive impairment usually depend on familiar, habitual activities and simple, social interaction for their continued function. What is more familiar than the sights, sounds, aromas, and actions associated with meals? These are the cues to which  people have learned to respond over a lifetime of experience. Then there are the habitual patterns of function, such as cooking, serving, being served, sharing, and clearing, that have been established over the years and that people with cognitive impairment can still call upon to experience those wonderful feelings of competence and productivity.

When this potential is squandered, productivity is blotted out. Autonomy, dignity, and pleasure are threatened. Appetite declines and behavior in the dining room deteriorates. The person’s nutritional status is placed in jeopardy. Action must be taken, so the diet is downgraded. Dignity, autonomy, and pleasure decline further still, as do appetite and interest in the meal, until, finally, the person is fed. This is the vicious cycle of excess disability. The proportion of nursing facility residents who are trapped in this cycle is astounding. Their true numbers are apparent only when appropriate interventions are implemented. Then, given the right circumstances and support, residents who were considered totally incapable of self-care almost miraculously regain their grace, dignity, and propriety. Some even regain their autonomy. The aim of the Bon Appetit! program is to give caregivers the tools with which they can offer the older people in their care a truly meaningful dining experience.

In a long-term care facility, a working dining enhancement program requires concrete, observable standards to which all staff commit themselves from the first day of their employment. The program also rests on a process of evaluation, monitoring, accountability, and feedback that ensures that these standards are maintained. These standards and the instruments to support them originate from an internal support structure, staff training, and ongoing supervision. The initiative is spearheaded by the Dining Enhancement Committee, which is made up of department heads. This committee

• Represents the facility’s commitment to enhanced dining for all of its residents
• Articulates the dining program mission in terms that are specific to the facility
• Ensures interdepartmental communication regarding dining program issues
• Represents the program on other facility committees
• Identifies and supports as many trainers as are required by the size and diversity of the facility’s programs
• Meets regularly to review recommendations that come from staff, volunteers, families, and residents through suggestion boxes, training sessions, or other means
• Provides feedback as to which changes will be implemented
• Coordinates the implementation of changes
• Provides an ongoing forum for review and evolution of the dining program
• Conducts initial and ongoing evaluations to ensure continued adherence to program standards
• Ensures program maintenance by coordinating ongoing education and awareness activities

These responsibilities may seem huge, but they represent a process that the committee is, or should already be, involved in on an ongoing basis. In the context of the Bon Appetit! program, this process is labeled, structured, and formalized.

Another vital component of the infrastructure consists of Dining Enhancement Teams on each unit. These are frontline staff who assume responsibility for the maintenance of standards on their unit. At Villa Providence, in Shediac, New Brunswick, Canada, for example, the staff decided to call these teams équipes d’action, or action teams. These teams are an important part of the program and a key to its success. Team members receive special training so that each is familiar with the program as a whole and is able to

• Monitor program application on his or her unit and give feedback for action to the Dining Enhancement Committee regarding the environment, the methods of service, the quality of the food, and the residents’ reactions to meals in general
• Help other staff to remember the principles of the Dining Enhancement Program
• Maintain a constructive and direct line of communication with the dietary department supervisor in charge of the unit

To do these things effectively, the members of each team need to learn to work as a team and to use methods of good communication. This is an opportunity to learn valuable skills and make an important contribution to this exciting project. At Villa Providence, the administration was skeptical as to whether the frontline staff would have the courage and desire to fulfill this demanding role. To the administration’s surprise, staff welcomed the opportunity and the accompanying sense of empowerment. They took pride in having been entrusted with such responsibility. Communication and collaboration between these teams ensures ongoing review and monitoring, innovations, and documentation of a healthy program.

For a dining enhancement program such as Bon Appetit! to work, staff training is essential. That is why it is given such a prominent place in this book. The aims of the training sessions are as follows:

• To ensure that all staff share the same basic information about dementia and the objectives of the dining program so that they can offer a consistent and positive experience to residents
• To consolidate and confirm knowledge that staff have acquired through other inservice training sessions as well as their own experience and intuition and give them the confidence to do their jobs with satisfaction
• To give staff a forum in which to share what they know with others, especially with new and replacement staff
• To establish a process of communication by which staff can express ideas and concerns about what they are doing and can also receive feedback about how they are doing Finally, ongoing supervision ensures that
• Staff members are doing what they should be doing to keep the operation running well and offer consumer satisfaction.
• Small problems are identified and rectified before they become big problems.
• Staff have the confidence that they are doing well and continue learning, promoting a feeling of security.
• Supervisors remain constantly in control of their operations, thus ensuring consistency and their own job satisfaction.

In a restaurant, such supervision is the responsibility of the maitre d’hotel; the authors call ongoing supervision the maitre d’ model. The maitre d’ is the person who approaches a waiter who has just dealt well with a difficult client and says, “Good job!” or takes aside a waiter who has overlooked a service and explains immediately what went wrong and how it should have been done. This person also spots a waiter who is struggling and steps in to lend a hand, and later helps to solve the problem so that it does not recur. At no time does the supervisor assume that things are being done and done correctly. It is this person’s responsibility to be constantly alert and to follow up on each occurrence of a problem. That kind of supervision also is vital in a Bon Appetit! setting.

The continued success of any program depends on consistent support from its  leaders. In this case, those leaders are the department heads and unit supervisors. They must understand the dining enhancement program, be committed to the benefits that it will bring to the residents and the facility staff, and understand their role in supporting the program. This support comes in several ways:

• Keeping everyone on board once a consensus has been achieved
• Advocating strongly for needed changes to the environment and processes affecting the program
• Recognizing standards of deportment and service among their staff
• Acknowledging the efforts of staff who meet those standards and correcting staff who do not do so in a consistent and positive manner (the maitre d’ model)
• Committing themselves to their own ongoing learning and to that of their staff
• Sharing responsibility by supporting the Dining Enhancement Teams

The amazing thing is that an effective dining program does not stop in the dining room. Lessons learned through dining are applicable to other aspects of care. The authors’ experience shows that staff who learned effective communication and problem-solving techniques while implementing the dining program continued to use these skills in other aspects of their job. Overall communication, attention, and, consequently, care improve. Thus, good dining is truly at the core of good care.

Sample Recipe
Omelet Rolls                

Instructions

1. In a bowl, lightly whip the eggs. Add bacon and chives.
2. Pour the mixture into a large round frying pan. Cook the omelet mixture in butter over high heat. Flip it over with a spatula. Do not overcook. Remove from heat and allow to cool.
3. Roll the omelet tightly. Wrap the rolled omelet in aluminum foil and refrigerate.
4. Before serving, allow the omelet to warm to room temperature and cut the rolled omelet into bite size slices.
5. Serve on a dark plate with carrot dollars and stuffed mushrooms.

Remarks: The variety of omelet ingredients are endless. Bacon can be replaced with, for example, seafood, ham, mushrooms, or eggplant.