Feeding Nursing Home Residents with Alzheimer's Disease People with Alzheimer's disease often require assistance in eating. Videotaped observations of meals show how to improve the mealtime experience and promote functional feeding. BY StrZAt~NF. VAN O R T / L I N D A
PHILLIPS
lzheimer's disease, the most common form of deentia, affects 10% of persons older than 65 years and approximately one half of those older than 85. l By the year 2000, it is predicted that one in every three American families will be coping with Alzheimer's disease; the number of patients is estimated to approach 14 million. 1 Elders with dementia are overrepresented in long-term care settings, comprising 70% to 90% of the nursing home population.2 Although other health professionals have episodic contact with cognitively impaired elderly persons, responsibility for most day-to-day care of these elders falls to nurses. Because a large majority of nursing home residents suffer from the cognitive impairments characteristic of senile dementia, nurses in that setting are constantly confronted with the challenges of caring for elders with dementia. Among this population, the minute-to-minute management of behavioral and functional aberrations challenges nurses. The symptoms of senile dementias (including Alzheimer's disease) include decreased memory, personality changes, mood changes, changes in the ability to communicate with others, and intellectual decline.2 From a functional standpoint, these symptoms interact to produce a progressive decline in ability to perform even the simplest of daily living activities, such as feeding, dressing, and grooming. The combination of impairments presents a tremendous challenge to nurses, who must assume responsibility for assisting or performing basic lifesustaining activities required by the patient)
SUZANNE VAN ORT, RN, PhD, FAAN, is a professor and associate dean for academic affairs, The University of Arizona College of Nursing, Tucson. LINDA PHILLIPS, RN, PhD, is a professor at the same institution. 34/1/39790
Although the focus of nursing practice is on the maintenance of function and the prevention of functional decline, the research-based knowledge available to guide nurses in these activities with cognitively impaired elderly persons is extremely limited. Because of the growing number of elders with senile dementia and the acuity of their management needs, it is imperative that nursing research efforts be directed toward determining the intervention strategies that are most effective with this population. Some nursing studies have suggested that deliberative intervention by the caregiver can increase functional behavior and decrease nonfunctional behavior during such activities as eating, even late in the disease course. Baltes and Zerbe 4 and Geiger and Johnsons showed that feeding behaviors and improved eating habits can be elicited through the use of social reinforcement and the manipulation of reinforcement contingencies and discriminative stimuli. Kolodny and Malek 6 developed a specific program to help nurses improve and refine their feeding techniques. Athlin and Norberg 7 showed that feeding behavior among patients with severe dementia can be improved through consistent interaction with the same feeder. These studies all focused on the effectiveness of a specific type of deliberative intervention. They suggest that (1) there is a range of equally effective actions and (2) these interventions are all rooted in the dynamics between an individual nurse and an individual resident during a specific self-care activity. Despite some research activity in this area, no systematic attempt has to date been made to identify and categorize the range of nursing activities that are effective for increasing functional feeding behavior and decreasing nonfunctional feeding behaviors during mealtime among elderly patients with dementia. The purposes of our study were therefore to characterize and describe (1) the range of nursing activities that
Geriatric Nursing September/October 1992 249
are effective and ineffective for increasing functional behavior and decreasing nonfunctional behaviors during feeding, (2) the range of resident behaviors during feeding, and (3) the nature of the interactions during feeding. Procedures An exploratory, descriptive design was used. This study was rooted in the operant social interaction paradigm, which assumes that behavior is learned and is the result of the dynamic interaction between at least two individuals within an environmental context. 8 Social learning theory also was a basis of the study. 9, Io Social learning theory assumes that behavior is elicited and sustained by reinforcement of trial and error attempts, as well as by vicarious methods. Data were videotaped. Analysis focused on (1) the antecedents and consequences of specific functional behaviors by the resident, in an attempt to identify the nurse behaviors that elicited, sustained, or extinguished behavior chains associated with successful eating, (2) the antecedents and consequences of nonfunctional behaviors by the residents, in an attempt to identify the nurse behaviors that elicited, sustained, or extinguished behavior chains counterproductive to eating, and (3) the environmental context in which the behaviors occurred. Videotape recording was used because it allows detailed systematic observations of events, observation not possible for those living the experience. The videotapes thus permitted second-by-second analysis of feeder and resident behaviors during mealtimes.
The feeding interactions between residents with cognitive impairments and their feeders during lunches and dinners were recorded. Only residents who routinely required feeding assistance were included in the sample. Because of the nature of staffing in this long-term care setting, feeders included nursing assistants, licensed practical nurses, and registered nurses. Although residents were also fed by family members and volunteers, these interactions were not videotaped. Data collection was intended to be as unobtrusive as possible, and no restrictions of any kind were imposed during videotaping. Usual unit activities, such as distribution of medications, occurred during videotaping without restriction. The feeders were instructed to proceed with feeding in their customary manner. Although the Hawthorne effect [awareness of scrutiny] likely influenced the feeder behaviors, the purpose of the study was to identify the range of feeder behaviors rather than to quantify the frequency these behaviors were used. Consequently, although behaviors perceived as "good" by the feeders were likely to outweigh those they perceived as "bad," the overall effect in the microlevel analysis was expected to be negligible. Specific feeding interactions were chosen for videotaping on the basis of convenience; that is, the feeder and resident were naturally positioned so that both were visible and audible to a hand-held camcorder. Data were collected from 29 different feeding sessions and included 10 residents and 1 1 feeders.
Data Analysis
Videotape recording was used because it allows detailed systematic observation oF events, observation not possible For those living the experience. All data were collected in the special dementia-care unit of a long-term care facility. The particular setting was selected in part because of its excellent reputation for providing high-quality nursing care. Thirty residents with moderate to severe cognitive impairments lived on the unit. Although a few residents were fed in their rooms, most feeding occurred on the unit in a central area (a dayroom) located directly outside the residents' rooms. Data collection focused exclusively on the feeding interactions in the central area. Interactions in individual rooms were not recorded. Residents who needed individual feeding assistance were either escorted to a table where their trays were placed or had their trays brought to them where they were sitting in the cushioned chairs that lined the room. Usually there were about I0 residents in the dayroom who required the individual assistance of a feeder at each meal; these residents were the focus of the data collection.
250 GeriatricNursing September/October1992
Data were initially analyzed in two phases. First, the videotapes were watched in total to determine overall impressions and devise initial categories and definitions. Open coding I1 was used to devise the categories of behavior. During this phase, initial impressions and categories were used to devise a transcription method that made the data permanently accessible on paper. Second, the videotaped data were subjected to second-by-second analysis to identify antecedents and consequences of the behaviors of interest. Although both qualitative and quantitative analysis procedures were applied to the transcribed data, this article will focus exclusively on the initial qualitative analysis used to identify and categorize feeding behaviors. Although generalization to other samples or settings is not intended, there is no reason to suspect that the findings of this study are atypical of longterm care settings in general or setting specific to this one long-term care setting. Preliminary Findings Initial general impressions. The first viewing of the videotapes focused on discerning environmental, organizational, and interactional patterns that could serve as the basis for data analysis. The most important environmental pattern noted was that mealtimes consistently made an already chaotic environment even noisier and more active. There was a great deal of furniture in a confined
area, a high activity level, and a continual "hubbub" on the unit. Residents wandered around the unit, residents talked or yelled loudly, and visitors interrupted the feeders during mealtimes to ask questions or just chat. Noise came from noisy people and equipment. The television was on at a high volume and music was piped in overhead. Although the lighting on the unit was sufficient for the videotaping, the lighting was dim overall. The pattern that marked the beginning of mealtime was the delivery of the trays, which occurred at approximately the same time every day. Tray delivery was principally a visual cue, because little odor emanated from the food. When trays were delivered, the number of staff in the dayroom increased noticeably. At this point the orientation of the staff was to work together to complete the assigned feeding activities. Organizational patterns were especially difficult to discern. No clear pattern seemed to dictate the place of feeding for many residents. For some meals residents were at the table; for others they were in chairs against the wall; for still others they were fed in their rooms. There was also no clear "pattern to which feeder fed which resident. Feeders often fed different residents at each meal. Even for individual feeders, few patterns were discernible; each feeder fed multiple residents at each meal. Sometimes feeders moved from one resident to the next, feeding two or three residents simultaneously. Sometimes they fed one resident completely and then moved on to the next. Even if the feeder fed only one resident at a time, however, meals almost always involved interruptions. These interruptions stemmed from various sources, including other residents, other staff, and visitors. Placement of the food trays for residents sitting in the chairs against the wall also followed no pattern. Trays were often positioned close to the feeder but not to the resident. As a consequence, residents could not see their trays and were not "set-up" as expected during a meal. The organization of the feeding experience for individual residents also varied a great deal. There were few systematic attempts to elicit normal eating behavior from the residents, aside from prompting mouth opening. Finger foods were not used and residents were not coaxed to pick up spoons to feed themselves. Spoons were rarely placed in residents' hands, and no role modeling of "food scooping and spoon to mouth" was observed. The pace at which residents were fed, as well as how much food was given with each bite and during each meal, varied with residents and with feeders. With few exceptions (for example, if the resident spit food, the resident refused to open his or her mouth, or the food was gone), it was difficult to discern how feeders knew when to discontinue feeding; some meals were discontinued even though food remained on the tray. Food mixing was a consistent pattern all among feeders. Food mixing, an activity in which the feeder made circular stirring movements in the food with the spoon, occurred between almost every bite for almost every resident. Sometimes food mixing involved mixing one type of food on the tray. Sometimes it involved mixing several foods together, or mixing liquids with solid food. Food mixing produced audible clicking
PRELIMINARY BEHAVIORAL CATEGORIES Feeder
Resident
Fixing/mixing food Adjusting/maintaining contact Distracted/other-directed Privacy maintaining Connecting/touching
Rhythmic~random(rocking)
Distracted (staring) Feeding promotion (chewing) Food elicitotlon (reaching) Contact elicitatlon (leaning forward)
Attention-getting Role modeling Assessing Interpersonal etlcitcrtion Interaction control
sounds, which were sometimes mimicked by the selffeed!ng residents. Feeders also consistently offered few fluids during the meal. Before, after, and between meals, there was little consistency in the type of interaction initiated by the feeder. Some feeders were strictly verbal, even if the interaction was one-sided. Other care givers did not interact either verbally or nonverbally, even if the resident attempted to initiate interaction. Feeders appeared to use touch sporadically and intermittently. Sometimes touch preceded an offered bite, but usually there was no connection between touch and the offer of food. The interaction patterns of residents also varied widely. Some residents were totally self-absorbed; others made many overtures to their feeders. Some overtures were quite affectionate (for example, kissing the feeder's hand). On many occasions, residents reached for the feeder, rocked forward, or verbalized in apparent attempts to elicit more food. Initial categories. Preliminary analysis yielded the identification of 10 feeder behaviors and five resident behaviors that occurred repeatedly throughout meals (see "Preliminary Behavioral Categories"). Although these categories were initially useful for describing the types of behaviors that occurred during a meal, they were for several reasons only minimally useful in deriving answers to questions about eliciting and extinguishing functional behavior. In isolation, any particular behavior (such as an arm tap) could be categorized in many ways. Appropriately labeling the behavior as eliciting, sustaining, or extinguishing required knowledge of the relationship of the behavior to the resident's actual acceptance of a bite and to the resident's actual completion of a meal. Identifying antecedents and consequences required a method for sequencing mealtime activities and for discerning the relationship of specific behaviors with other behaviors within the sequence. Consequently, further analysis focused on identifying and defining events within each meal to allow the description of behavioral sequences associated with the resident's acceptance or rejection of food. Answering the research questions required devising a method for compartmentalizing the meal into meaningful subunits that could be measured in real time. These subunits were
Geriatric Nursing September/October 1992 251
EXAMPLES OF ELICITING BEHAVIORS Feeder Putting food on spoon Leaning toward resident Calling resident's name Touching resident
Resident Leaning forward Reaching for food Turning head upward Opening mouth to wait for bite Verbalizing short utterances
termed feeding cycles. Feeding cycles were conceived as consisting of two parts: feeding episodes and feeding intervals. On the basis of preliminary examination of feeder and resident behaviors, the following preliminary definitions were developed: 1. Feeding cycle: a sequence of feeding behaviors that includes preparatory feeder behaviors (cues) preceding a bite, the bite itself, and a noticeable letdown or relaxation by the feeder. 2. Feeding episode: an identifiable uninterrupted series of activities that begins with the feeder moving the hand toward the resident's mouth, proceeds through an attempt to give a bite or drink, and ends with a sign of letdown by the feeder. 3. Feeding interval: all activities that occur from the letdown by the feeder to the beginning of the next feeding episode. These definitions were used to develop categories to describe care giver and resident feeding behaviors. Feeder behaviors that elicit functional feeding (see "Eliciting Behaviors" box). Visual, tactile and verbal cues were the means used by feeders to prompt the acceptance of a bite. Cues occurred just before the beginning of a feeding episode. Preliminary examination of the videotapes suggested that although some feeders provided clear and consistent cues, most did not. Behaviors used by some feeders as consistent cues occurred randomly among other feeders, with no relationship to the offering of food. Sometimes behaviors that appeared to be cues were only distantly related in real time to the actual beginning of the feeding episode. Feeders appeared unaware that they were giving potential cues because of the randomness of cue occurrence and the time delay between cues and the beginning of the feeding episode. Resident behaviors that elicit functional feeding (see box). Visual, tactile, and verbal cues were used by residents to prompt the feeder to offer the next bite. Resident cues occurred during feeding intervals and, when recognized by the feeder as a cue, just before the beginning of the feeding episode. Residents' elicitation behaviors were often missed by feeders. At times a resident would turn the head in the direction of the feeder, open the mouth, and wait for a bite. Because no food was forthcoming, it can only be assumed that the feeder either did not see the cue or did not recognize it as a cue. Resident cues can be difficult to distinguish from other randomly occurring behaviors. Some residents reached for food and leaned for-
252 Geriatric Nursing September/October 1992
ward repeatedly while they were still chewing and not ready for more food. Feeder behaviors that sustain functional feeding (see box). Behaviors similar to normal social activities during meals fall into this category. An example of such behavior is watching and waiting for a cue from the resident that he or she wanted another bite. Sustaining behaviors often began in one feeding cycle and extended into the next. Sustaining behaviors should yield a relatively consistent pattern of feeding episodes and feeding intervals. However, many of the observed meals were characterized by feeding intervals that were extremely variable. Repeated interruptions and distractions during feeding intervals yielded sporadic patterns, which suggested that few actual sustaining behaviors occurred.
EXAMPLES OF SUSTAINING BEHAVIORS Feeder
Resident
Talking to resident Reorienting resident to meal Offering drink between bites Kissing or hugging resident Holding spoon ready for bite Touching resident continually
Verbalizing to feeder Maintaining touch Looking at feeder
Resident behaviors that sustain functional feeding (see box). Sustaining behaviors are those that provide continuous contact between the feeder and resident during a meal. Sustaining behaviors often extended over feeding cycles and involved interactive behavior over time. Most residents evidenced few sustaining behaviors.
Feeder behaviors that extinguish functional feeding (see box). Discerning extinguishing behaviors required examining a series of feeding cycles to determine when feeding was extinguished and identify the behavior of the feeder that preceded refusal. Feeding episodes were extinguished when they were begun and aborted before food reached the mouth. For example, this occurred when the feeder was interrupted or distracted in the middle of the episode. After feeding is extinguished it can be re-
EXAMPLES OF EXTINGUISHING BEHAVIORS Feeder Failing to respond to resident
Resident Spitting out food
cues
Interrupting feeding multiple times Aborting feeding attempts Leaving to feed other residents Removing food tray
Refusing to open mouth Using hand to block offered spoon
established, but clear prompts and interactive negotiation may be required first. Events other than feeder behaviors directed at the resident also extinguished functional feeding. For example, interruptions of the meal by passersby, noise, and medication administration extinguished feeding. The feeder's leaving in the middle of the meal to serve another patient also extinguished feeding.
Resident behaviors that extinguish functional feeding (Table 4). Some resident behaviors extinguished all feeding attempts by the feeder. These included spitting food and repeatedly refusing to open the mouth. Discussion a n d Clinical Implications Feeding is a complex activity involving environmental and behavioral contexts that include individual feeder behaviors, individual resident behaviors, and synchronization of behaviors between feeders and residents in some form of interaction. The environmental context of feeding had few discernible or predictable patterns. The environment was chaotic and few attempts were made to focus activity directly on the feeding experience. For at least some residents, the sight and smell of food was not systematically linked with the offering of food. The environmental context was not arranged to elicit or support selffeeding attempts. Overall, meals consisted of numerous disrupted feeding cycles that were not systematically linked together. This suggests that one logical focus for nursing intervention would be to decrease environmental chaos and increase consistent patterning of mealtime events. For example, television and piped-in music could be omitted during mealtime. Staff could also be encouraged to emphasize mealtime as an event of importance to residents, rather than an activity to be completed as quickly as possible. Furthermore, the behavioral context of feeding was as problematic as the environmental context. Although it was possible to identify distinctive feeder and resident behaviors associated with various aspects of the feeding cycle, the continuity, pattern, and synchronization of behavior were poorly represented. Feeders' behaviors and interactive patterns were just as variable as residents' behaviors. Most likely, feeders emitted numerous randomly occurring cues that neither systematically elicited nor extinguished feeding behaviors. Residents evidenced numerous elicitation behaviors, but these were unrecognized and essentially random in their ability to actually elicit a response from a feeder. When meals are compartmentalized into identifiable behavior cycles, certain portions of the feeding cycle may be seen as more problematic than others. Feeding episodes, although sometimes interrupted, usually proceeded systematically. Feeding intervals, on the other hand, appeared to be a time during which many distractions, interruptions, and nonfeeding-related events occurred. The variability of feeding intervals may be a measure
of cycle disruption. The time between bites may be the critical intervention period for altering the structure, context, and functional outcome of the feeding episode. The feeding interval thus provides an opportune time for the implementation of nursing interventions to promote functional feeding. Consistent assignment of specific feeders, as staffing permits, for each resident and consistent use of cues by these feeders could improve patterning. Nursing interventions to modify the environment and to alter the behavioral context by patterning the feeding interactions could enhance mealtime for both resident and feeder. Specific protocols for promoting functional feeding for each resident could be developed and implemented. Summary The purpose of this exploratory, descriptive study was to identify and categorize the behaviors of caregivers and residents that elicit, sustain, or extinguish feeding. Although preliminary analysis yielded initial categories, mutually exclusive categories were difficult to distinguish. Relationships among identified cues and specific feeding behaviors are being examined in further analysis. The relationship between specific feeding behaviors and the environmental context of feeding is also being examined. The goals of studying feeding behaviors in nursing home residents with Alzheimer's disease are to enhance mealtime for both residents and caregivers and to encourage functional feeding behavior as much as possible. Identification of behaviors that elicit, sustain, and extinguish functional feeding can facilitate development of behavioral and environmental nursing interventions to promote functional feeding. • REFERENCES 1. Alzheimer's Association. What does the future hold? National program to conquer alzheimer's disease. Chicago: Alzheimer's Association; 1991. 2. Heacock P, Walton C, Beck C, Mercer S. Caring for the cognitively impaired: reconceptualizing disability and rehabilitation. J Gerontol Nurs 1991;17:22-6. 3. Burgener SC, Barton D. Nursing care of cognitively impaired, institutionalized elderly. J Gerontol Nurs 1991;17:37-43. 4. BaRes M, Zerbe M. Re-establishing self-feeding in a nursing home setting. Nurs Res 1976;25:24-6. 5. Geiger O, Johnson L. Positive education for elderly persons: correct eating through reinforcement. Gerontologist 1974;14:432-436. 6. Kolodny V, Malek A. Improving feeding skills. J Gerontol Nuts 1991;17:20-4. 7. Athlin E, Norberg A. Caregivers' attitudes to and interpretations of the behavior of severely demented patients during feeding in a patient assignment care system, lnt J Nurs Studies 1987;24:145-53. 8. Homans G. Social behavior: its elementary forms. New York: Harcourt, Brace, and World, 1960. 9. Bandura A. Principles of behavior modification. New York: Holt, Rinehart, and Winston, 1969. 10. Bandura A. Social learning theory. New York: General Learning Press, 1977. 11. Glaser B. Strauss A. The discovery of grounded theory: strategies for qualitative research. Chicago: Aldine Publishing, 1967.
Geriatric Nursing September/October 1992 253
PHILLIPS
lzheimer's disease, the most common form of deentia, affects 10% of persons older than 65 years and approximately one half of those older than 85. l By the year 2000, it is predicted that one in every three American families will be coping with Alzheimer's disease; the number of patients is estimated to approach 14 million. 1 Elders with dementia are overrepresented in long-term care settings, comprising 70% to 90% of the nursing home population.2 Although other health professionals have episodic contact with cognitively impaired elderly persons, responsibility for most day-to-day care of these elders falls to nurses. Because a large majority of nursing home residents suffer from the cognitive impairments characteristic of senile dementia, nurses in that setting are constantly confronted with the challenges of caring for elders with dementia. Among this population, the minute-to-minute management of behavioral and functional aberrations challenges nurses. The symptoms of senile dementias (including Alzheimer's disease) include decreased memory, personality changes, mood changes, changes in the ability to communicate with others, and intellectual decline.2 From a functional standpoint, these symptoms interact to produce a progressive decline in ability to perform even the simplest of daily living activities, such as feeding, dressing, and grooming. The combination of impairments presents a tremendous challenge to nurses, who must assume responsibility for assisting or performing basic lifesustaining activities required by the patient)
SUZANNE VAN ORT, RN, PhD, FAAN, is a professor and associate dean for academic affairs, The University of Arizona College of Nursing, Tucson. LINDA PHILLIPS, RN, PhD, is a professor at the same institution. 34/1/39790
Although the focus of nursing practice is on the maintenance of function and the prevention of functional decline, the research-based knowledge available to guide nurses in these activities with cognitively impaired elderly persons is extremely limited. Because of the growing number of elders with senile dementia and the acuity of their management needs, it is imperative that nursing research efforts be directed toward determining the intervention strategies that are most effective with this population. Some nursing studies have suggested that deliberative intervention by the caregiver can increase functional behavior and decrease nonfunctional behavior during such activities as eating, even late in the disease course. Baltes and Zerbe 4 and Geiger and Johnsons showed that feeding behaviors and improved eating habits can be elicited through the use of social reinforcement and the manipulation of reinforcement contingencies and discriminative stimuli. Kolodny and Malek 6 developed a specific program to help nurses improve and refine their feeding techniques. Athlin and Norberg 7 showed that feeding behavior among patients with severe dementia can be improved through consistent interaction with the same feeder. These studies all focused on the effectiveness of a specific type of deliberative intervention. They suggest that (1) there is a range of equally effective actions and (2) these interventions are all rooted in the dynamics between an individual nurse and an individual resident during a specific self-care activity. Despite some research activity in this area, no systematic attempt has to date been made to identify and categorize the range of nursing activities that are effective for increasing functional feeding behavior and decreasing nonfunctional feeding behaviors during mealtime among elderly patients with dementia. The purposes of our study were therefore to characterize and describe (1) the range of nursing activities that
Geriatric Nursing September/October 1992 249
are effective and ineffective for increasing functional behavior and decreasing nonfunctional behaviors during feeding, (2) the range of resident behaviors during feeding, and (3) the nature of the interactions during feeding. Procedures An exploratory, descriptive design was used. This study was rooted in the operant social interaction paradigm, which assumes that behavior is learned and is the result of the dynamic interaction between at least two individuals within an environmental context. 8 Social learning theory also was a basis of the study. 9, Io Social learning theory assumes that behavior is elicited and sustained by reinforcement of trial and error attempts, as well as by vicarious methods. Data were videotaped. Analysis focused on (1) the antecedents and consequences of specific functional behaviors by the resident, in an attempt to identify the nurse behaviors that elicited, sustained, or extinguished behavior chains associated with successful eating, (2) the antecedents and consequences of nonfunctional behaviors by the residents, in an attempt to identify the nurse behaviors that elicited, sustained, or extinguished behavior chains counterproductive to eating, and (3) the environmental context in which the behaviors occurred. Videotape recording was used because it allows detailed systematic observations of events, observation not possible for those living the experience. The videotapes thus permitted second-by-second analysis of feeder and resident behaviors during mealtimes.
The feeding interactions between residents with cognitive impairments and their feeders during lunches and dinners were recorded. Only residents who routinely required feeding assistance were included in the sample. Because of the nature of staffing in this long-term care setting, feeders included nursing assistants, licensed practical nurses, and registered nurses. Although residents were also fed by family members and volunteers, these interactions were not videotaped. Data collection was intended to be as unobtrusive as possible, and no restrictions of any kind were imposed during videotaping. Usual unit activities, such as distribution of medications, occurred during videotaping without restriction. The feeders were instructed to proceed with feeding in their customary manner. Although the Hawthorne effect [awareness of scrutiny] likely influenced the feeder behaviors, the purpose of the study was to identify the range of feeder behaviors rather than to quantify the frequency these behaviors were used. Consequently, although behaviors perceived as "good" by the feeders were likely to outweigh those they perceived as "bad," the overall effect in the microlevel analysis was expected to be negligible. Specific feeding interactions were chosen for videotaping on the basis of convenience; that is, the feeder and resident were naturally positioned so that both were visible and audible to a hand-held camcorder. Data were collected from 29 different feeding sessions and included 10 residents and 1 1 feeders.
Data Analysis
Videotape recording was used because it allows detailed systematic observation oF events, observation not possible For those living the experience. All data were collected in the special dementia-care unit of a long-term care facility. The particular setting was selected in part because of its excellent reputation for providing high-quality nursing care. Thirty residents with moderate to severe cognitive impairments lived on the unit. Although a few residents were fed in their rooms, most feeding occurred on the unit in a central area (a dayroom) located directly outside the residents' rooms. Data collection focused exclusively on the feeding interactions in the central area. Interactions in individual rooms were not recorded. Residents who needed individual feeding assistance were either escorted to a table where their trays were placed or had their trays brought to them where they were sitting in the cushioned chairs that lined the room. Usually there were about I0 residents in the dayroom who required the individual assistance of a feeder at each meal; these residents were the focus of the data collection.
250 GeriatricNursing September/October1992
Data were initially analyzed in two phases. First, the videotapes were watched in total to determine overall impressions and devise initial categories and definitions. Open coding I1 was used to devise the categories of behavior. During this phase, initial impressions and categories were used to devise a transcription method that made the data permanently accessible on paper. Second, the videotaped data were subjected to second-by-second analysis to identify antecedents and consequences of the behaviors of interest. Although both qualitative and quantitative analysis procedures were applied to the transcribed data, this article will focus exclusively on the initial qualitative analysis used to identify and categorize feeding behaviors. Although generalization to other samples or settings is not intended, there is no reason to suspect that the findings of this study are atypical of longterm care settings in general or setting specific to this one long-term care setting. Preliminary Findings Initial general impressions. The first viewing of the videotapes focused on discerning environmental, organizational, and interactional patterns that could serve as the basis for data analysis. The most important environmental pattern noted was that mealtimes consistently made an already chaotic environment even noisier and more active. There was a great deal of furniture in a confined
area, a high activity level, and a continual "hubbub" on the unit. Residents wandered around the unit, residents talked or yelled loudly, and visitors interrupted the feeders during mealtimes to ask questions or just chat. Noise came from noisy people and equipment. The television was on at a high volume and music was piped in overhead. Although the lighting on the unit was sufficient for the videotaping, the lighting was dim overall. The pattern that marked the beginning of mealtime was the delivery of the trays, which occurred at approximately the same time every day. Tray delivery was principally a visual cue, because little odor emanated from the food. When trays were delivered, the number of staff in the dayroom increased noticeably. At this point the orientation of the staff was to work together to complete the assigned feeding activities. Organizational patterns were especially difficult to discern. No clear pattern seemed to dictate the place of feeding for many residents. For some meals residents were at the table; for others they were in chairs against the wall; for still others they were fed in their rooms. There was also no clear "pattern to which feeder fed which resident. Feeders often fed different residents at each meal. Even for individual feeders, few patterns were discernible; each feeder fed multiple residents at each meal. Sometimes feeders moved from one resident to the next, feeding two or three residents simultaneously. Sometimes they fed one resident completely and then moved on to the next. Even if the feeder fed only one resident at a time, however, meals almost always involved interruptions. These interruptions stemmed from various sources, including other residents, other staff, and visitors. Placement of the food trays for residents sitting in the chairs against the wall also followed no pattern. Trays were often positioned close to the feeder but not to the resident. As a consequence, residents could not see their trays and were not "set-up" as expected during a meal. The organization of the feeding experience for individual residents also varied a great deal. There were few systematic attempts to elicit normal eating behavior from the residents, aside from prompting mouth opening. Finger foods were not used and residents were not coaxed to pick up spoons to feed themselves. Spoons were rarely placed in residents' hands, and no role modeling of "food scooping and spoon to mouth" was observed. The pace at which residents were fed, as well as how much food was given with each bite and during each meal, varied with residents and with feeders. With few exceptions (for example, if the resident spit food, the resident refused to open his or her mouth, or the food was gone), it was difficult to discern how feeders knew when to discontinue feeding; some meals were discontinued even though food remained on the tray. Food mixing was a consistent pattern all among feeders. Food mixing, an activity in which the feeder made circular stirring movements in the food with the spoon, occurred between almost every bite for almost every resident. Sometimes food mixing involved mixing one type of food on the tray. Sometimes it involved mixing several foods together, or mixing liquids with solid food. Food mixing produced audible clicking
PRELIMINARY BEHAVIORAL CATEGORIES Feeder
Resident
Fixing/mixing food Adjusting/maintaining contact Distracted/other-directed Privacy maintaining Connecting/touching
Rhythmic~random(rocking)
Distracted (staring) Feeding promotion (chewing) Food elicitotlon (reaching) Contact elicitatlon (leaning forward)
Attention-getting Role modeling Assessing Interpersonal etlcitcrtion Interaction control
sounds, which were sometimes mimicked by the selffeed!ng residents. Feeders also consistently offered few fluids during the meal. Before, after, and between meals, there was little consistency in the type of interaction initiated by the feeder. Some feeders were strictly verbal, even if the interaction was one-sided. Other care givers did not interact either verbally or nonverbally, even if the resident attempted to initiate interaction. Feeders appeared to use touch sporadically and intermittently. Sometimes touch preceded an offered bite, but usually there was no connection between touch and the offer of food. The interaction patterns of residents also varied widely. Some residents were totally self-absorbed; others made many overtures to their feeders. Some overtures were quite affectionate (for example, kissing the feeder's hand). On many occasions, residents reached for the feeder, rocked forward, or verbalized in apparent attempts to elicit more food. Initial categories. Preliminary analysis yielded the identification of 10 feeder behaviors and five resident behaviors that occurred repeatedly throughout meals (see "Preliminary Behavioral Categories"). Although these categories were initially useful for describing the types of behaviors that occurred during a meal, they were for several reasons only minimally useful in deriving answers to questions about eliciting and extinguishing functional behavior. In isolation, any particular behavior (such as an arm tap) could be categorized in many ways. Appropriately labeling the behavior as eliciting, sustaining, or extinguishing required knowledge of the relationship of the behavior to the resident's actual acceptance of a bite and to the resident's actual completion of a meal. Identifying antecedents and consequences required a method for sequencing mealtime activities and for discerning the relationship of specific behaviors with other behaviors within the sequence. Consequently, further analysis focused on identifying and defining events within each meal to allow the description of behavioral sequences associated with the resident's acceptance or rejection of food. Answering the research questions required devising a method for compartmentalizing the meal into meaningful subunits that could be measured in real time. These subunits were
Geriatric Nursing September/October 1992 251
EXAMPLES OF ELICITING BEHAVIORS Feeder Putting food on spoon Leaning toward resident Calling resident's name Touching resident
Resident Leaning forward Reaching for food Turning head upward Opening mouth to wait for bite Verbalizing short utterances
termed feeding cycles. Feeding cycles were conceived as consisting of two parts: feeding episodes and feeding intervals. On the basis of preliminary examination of feeder and resident behaviors, the following preliminary definitions were developed: 1. Feeding cycle: a sequence of feeding behaviors that includes preparatory feeder behaviors (cues) preceding a bite, the bite itself, and a noticeable letdown or relaxation by the feeder. 2. Feeding episode: an identifiable uninterrupted series of activities that begins with the feeder moving the hand toward the resident's mouth, proceeds through an attempt to give a bite or drink, and ends with a sign of letdown by the feeder. 3. Feeding interval: all activities that occur from the letdown by the feeder to the beginning of the next feeding episode. These definitions were used to develop categories to describe care giver and resident feeding behaviors. Feeder behaviors that elicit functional feeding (see "Eliciting Behaviors" box). Visual, tactile and verbal cues were the means used by feeders to prompt the acceptance of a bite. Cues occurred just before the beginning of a feeding episode. Preliminary examination of the videotapes suggested that although some feeders provided clear and consistent cues, most did not. Behaviors used by some feeders as consistent cues occurred randomly among other feeders, with no relationship to the offering of food. Sometimes behaviors that appeared to be cues were only distantly related in real time to the actual beginning of the feeding episode. Feeders appeared unaware that they were giving potential cues because of the randomness of cue occurrence and the time delay between cues and the beginning of the feeding episode. Resident behaviors that elicit functional feeding (see box). Visual, tactile, and verbal cues were used by residents to prompt the feeder to offer the next bite. Resident cues occurred during feeding intervals and, when recognized by the feeder as a cue, just before the beginning of the feeding episode. Residents' elicitation behaviors were often missed by feeders. At times a resident would turn the head in the direction of the feeder, open the mouth, and wait for a bite. Because no food was forthcoming, it can only be assumed that the feeder either did not see the cue or did not recognize it as a cue. Resident cues can be difficult to distinguish from other randomly occurring behaviors. Some residents reached for food and leaned for-
252 Geriatric Nursing September/October 1992
ward repeatedly while they were still chewing and not ready for more food. Feeder behaviors that sustain functional feeding (see box). Behaviors similar to normal social activities during meals fall into this category. An example of such behavior is watching and waiting for a cue from the resident that he or she wanted another bite. Sustaining behaviors often began in one feeding cycle and extended into the next. Sustaining behaviors should yield a relatively consistent pattern of feeding episodes and feeding intervals. However, many of the observed meals were characterized by feeding intervals that were extremely variable. Repeated interruptions and distractions during feeding intervals yielded sporadic patterns, which suggested that few actual sustaining behaviors occurred.
EXAMPLES OF SUSTAINING BEHAVIORS Feeder
Resident
Talking to resident Reorienting resident to meal Offering drink between bites Kissing or hugging resident Holding spoon ready for bite Touching resident continually
Verbalizing to feeder Maintaining touch Looking at feeder
Resident behaviors that sustain functional feeding (see box). Sustaining behaviors are those that provide continuous contact between the feeder and resident during a meal. Sustaining behaviors often extended over feeding cycles and involved interactive behavior over time. Most residents evidenced few sustaining behaviors.
Feeder behaviors that extinguish functional feeding (see box). Discerning extinguishing behaviors required examining a series of feeding cycles to determine when feeding was extinguished and identify the behavior of the feeder that preceded refusal. Feeding episodes were extinguished when they were begun and aborted before food reached the mouth. For example, this occurred when the feeder was interrupted or distracted in the middle of the episode. After feeding is extinguished it can be re-
EXAMPLES OF EXTINGUISHING BEHAVIORS Feeder Failing to respond to resident
Resident Spitting out food
cues
Interrupting feeding multiple times Aborting feeding attempts Leaving to feed other residents Removing food tray
Refusing to open mouth Using hand to block offered spoon
established, but clear prompts and interactive negotiation may be required first. Events other than feeder behaviors directed at the resident also extinguished functional feeding. For example, interruptions of the meal by passersby, noise, and medication administration extinguished feeding. The feeder's leaving in the middle of the meal to serve another patient also extinguished feeding.
Resident behaviors that extinguish functional feeding (Table 4). Some resident behaviors extinguished all feeding attempts by the feeder. These included spitting food and repeatedly refusing to open the mouth. Discussion a n d Clinical Implications Feeding is a complex activity involving environmental and behavioral contexts that include individual feeder behaviors, individual resident behaviors, and synchronization of behaviors between feeders and residents in some form of interaction. The environmental context of feeding had few discernible or predictable patterns. The environment was chaotic and few attempts were made to focus activity directly on the feeding experience. For at least some residents, the sight and smell of food was not systematically linked with the offering of food. The environmental context was not arranged to elicit or support selffeeding attempts. Overall, meals consisted of numerous disrupted feeding cycles that were not systematically linked together. This suggests that one logical focus for nursing intervention would be to decrease environmental chaos and increase consistent patterning of mealtime events. For example, television and piped-in music could be omitted during mealtime. Staff could also be encouraged to emphasize mealtime as an event of importance to residents, rather than an activity to be completed as quickly as possible. Furthermore, the behavioral context of feeding was as problematic as the environmental context. Although it was possible to identify distinctive feeder and resident behaviors associated with various aspects of the feeding cycle, the continuity, pattern, and synchronization of behavior were poorly represented. Feeders' behaviors and interactive patterns were just as variable as residents' behaviors. Most likely, feeders emitted numerous randomly occurring cues that neither systematically elicited nor extinguished feeding behaviors. Residents evidenced numerous elicitation behaviors, but these were unrecognized and essentially random in their ability to actually elicit a response from a feeder. When meals are compartmentalized into identifiable behavior cycles, certain portions of the feeding cycle may be seen as more problematic than others. Feeding episodes, although sometimes interrupted, usually proceeded systematically. Feeding intervals, on the other hand, appeared to be a time during which many distractions, interruptions, and nonfeeding-related events occurred. The variability of feeding intervals may be a measure
of cycle disruption. The time between bites may be the critical intervention period for altering the structure, context, and functional outcome of the feeding episode. The feeding interval thus provides an opportune time for the implementation of nursing interventions to promote functional feeding. Consistent assignment of specific feeders, as staffing permits, for each resident and consistent use of cues by these feeders could improve patterning. Nursing interventions to modify the environment and to alter the behavioral context by patterning the feeding interactions could enhance mealtime for both resident and feeder. Specific protocols for promoting functional feeding for each resident could be developed and implemented. Summary The purpose of this exploratory, descriptive study was to identify and categorize the behaviors of caregivers and residents that elicit, sustain, or extinguish feeding. Although preliminary analysis yielded initial categories, mutually exclusive categories were difficult to distinguish. Relationships among identified cues and specific feeding behaviors are being examined in further analysis. The relationship between specific feeding behaviors and the environmental context of feeding is also being examined. The goals of studying feeding behaviors in nursing home residents with Alzheimer's disease are to enhance mealtime for both residents and caregivers and to encourage functional feeding behavior as much as possible. Identification of behaviors that elicit, sustain, and extinguish functional feeding can facilitate development of behavioral and environmental nursing interventions to promote functional feeding. • REFERENCES 1. Alzheimer's Association. What does the future hold? National program to conquer alzheimer's disease. Chicago: Alzheimer's Association; 1991. 2. Heacock P, Walton C, Beck C, Mercer S. Caring for the cognitively impaired: reconceptualizing disability and rehabilitation. J Gerontol Nurs 1991;17:22-6. 3. Burgener SC, Barton D. Nursing care of cognitively impaired, institutionalized elderly. J Gerontol Nurs 1991;17:37-43. 4. BaRes M, Zerbe M. Re-establishing self-feeding in a nursing home setting. Nurs Res 1976;25:24-6. 5. Geiger O, Johnson L. Positive education for elderly persons: correct eating through reinforcement. Gerontologist 1974;14:432-436. 6. Kolodny V, Malek A. Improving feeding skills. J Gerontol Nuts 1991;17:20-4. 7. Athlin E, Norberg A. Caregivers' attitudes to and interpretations of the behavior of severely demented patients during feeding in a patient assignment care system, lnt J Nurs Studies 1987;24:145-53. 8. Homans G. Social behavior: its elementary forms. New York: Harcourt, Brace, and World, 1960. 9. Bandura A. Principles of behavior modification. New York: Holt, Rinehart, and Winston, 1969. 10. Bandura A. Social learning theory. New York: General Learning Press, 1977. 11. Glaser B. Strauss A. The discovery of grounded theory: strategies for qualitative research. Chicago: Aldine Publishing, 1967.
Geriatric Nursing September/October 1992 253
