As demonstrated in Tables 1 and 2, the 137 included articles yielded literature prominently from Western countries, that were most frequently cross-sectional studies reflecting diverse methods and methodologies. All articles were published between 1975 and 2021. Categorisation according to decade of publication identified that 59.1% were published after 2011, 29.9% were published between 2001 – 2010, and 10.9% were published ≤2000. Only two included studies were published prior to 1990 (Benedict 1975, Kayser-Jones 1982).
The included articles used diverse terminology due to the different language that countries use to refer to RACFs, as demonstrated in Table 3, which charts the study settings. Full-text reviews confirmed that these terminologies were equivalent. Table 4 demonstrates the range of mealtime interventions and the research populations in the included literature.
Major themes derived from each domain are described in order of their prominence in the data, illustrated by quotes and article citations. Policy information was used to interpret the themes, and was most prominent in the Legitimation and Domination domains that are more reflective of organisational practices than the Signification domain that explored the meanings residents attribute to mealtimes.
Domain 1: Signification
Four themes were captured in the Signification domain that related to the residents’ understandings and interpretations of RACF mealtimes and regulations.
Theme 1: Mealtime experience. The most prominent theme identified, mealtime experience reflected the meanings that residents ascribed to mealtimes. These meanings were unique, formed from combined factors related to each resident’s experience. Factors included staff (Pelletier 2005, Caspar, Berg et al. 2020, Caspar, Davis et al. 2021); social interactions (Bennett, Ward et al. 2014, Shune and Linville 2019, Morrison-Koechl, Wu et al. 2021), personhood (Gastmans 1998, Reimer and Keller 2009), food service (Evans, Crogan et al. 2003) and environment (Kenkmann and Hooper 2012, Maluf, Cheater et al. 2020) that each shape their mealtime experiences.
Mealtimes contribute to the broader RACF social environment as meanings are formed through dining interactions with staff and other residents (Watkins, Goodwin et al. 2017). The literature often referred to mealtimes as opportunities for social interaction that are shaped by “interactive efforts to create an appropriate version of a meal situation” (Harnett and Jönsson 2017 p839). The mealtime meanings that residents construct are therefore influenced by how social interactions are facilitated. “The social element, meaning conversing with residents, sharing stories and feeling a sense of community, defined the meal for some residents” (Simon 2015 p35), and is associated with improved nutritional outcomes (Morrison-Koechl, Wu et al. 2021). Staff permit residents’ capacity to engage in meaningful social interactions with others during mealtimes through actions that facilitate, or do not facilitate residents’ preferences and meaningful socialisation (Shune and Linville 2019, Trinca, Chaudhury et al. 2021). Staff also perceive a “good meal” according to their own nutritional knowledge, training in mealtime management and personal beliefs and values (Pelletier 2005, Reimer and Keller 2009). Thus, staff understanding of mealtime purposes and processes, influence how a resident interprets and makes meaning from mealtimes.
“Staff interpreted mealtimes in different ways. In some care homes there was little staff interaction with residents observed other than delivering the meals to the tables or rooms.” (Holmes 2019 p125)
Meal delivery methods and the dining environment also influence how residents interpret and understand mealtimes (Keller, Beck et al. 2015), including interventions targeting food production and meal delivery (Abbey 2015), modifications to the environment, mealtime ambience and food service (Evans and Crogan 2005, Byles, Perry et al. 2009, Chaudhury, Hung et al. 2013, Keller, Beck et al. 2015, Matwiejczyk, Roberts et al. 2018), and improving staff ratios and access to education (Kayser-Jones and Schell 1997, Simmons, Bertrand et al. 2007, Bertrand, Porchak et al. 2011, Stone 2014). Additionally, moulded TMDs may improve mealtime experiences for residents with dysphagia as meaning is enhanced when food is recognisable and describable (Ullrich, Buckley et al. 2014). Interventions that combine environmental modifications with staff education improve mealtime experiences with greater impact than changing the physical dining space alone (Perivolaris, Leclerc et al. 2006).
Theme 2: Meaning of mealtimes.
Residents bring life experiences to the RACF that inform their values and preferences. Residents with choice and control perceive mealtimes as more successful, as they can attend to their preferences about when, where and what to eat (Evans, Crogan et al. 2003). Opportunities and barriers for RACFs to promote independence and personalisation thus contribute to the mealtime meanings that residents construct (Caspar, Davis et al. 2021, Trinca, Chaudhury et al. 2021). However, when their mealtime preferences do not align with RACF processes, residents may experience feelings of powerlessness and lost autonomy.
“Mealtimes are important opportunities to support residents’ personhood; a pleasurable dining experience affects residents’ perception of well-being and is inextricably linked with their quality of life.” (Chaudhury, Hung et al. 2013 p492)
Beyond nutrition, food is associated with meanings, traditions, memories and personhood, constructed across a lifetime of interactions and contexts, that shape residents’ expectations of mealtimes in the RACF (Bernoth, Dietsch et al. 2014, Abbey 2015, Fjellström and Sydner 2017). For example, some residents see food as a symbol of security resulting from wartime austerity (Chou, Boldy et al. 2002). Their past experiences, social associations and food memories combine to structure mealtime expectations and meaning.
“Food provides more than just a way to meet the physical nutritional requirements of the body, but can also be associated with memory, social occasions, and emotions, and provide a source of enjoyment, socialisation, nurturing and dignity.” (Milte, Shulver et al. 2017 p52)
Theme 3: Meaning of residential aged care. The literature briefly described how residents’ mealtime experiences connect with their broader understanding of their residential care experience (Watkins 2018). A duality of structure exists, where a resident’s interpretation of mealtimes influences their RACF experience; and residing in RACFs influences the meaning they assign to mealtimes experiences. Traditionally, RACFs follow a bio-medical model (Davis, Byers et al. 2009, Milte, Ratcliffe et al. 2018), but changing public expectations, evidence and the marketization of residential care have directed more RACFs to provide home-like environments (Hogden, Greenfield et al. 2017). However,, many RACFs continue to view residents as care-dependent consumers with structures that institutionalise residents’ understanding of mealtimes, including mealtime schedules, menus and seating arrangements that privilege routine, standardisation and dependence (Abbey 2015, Fjellström and Sydner 2017, Maluf, Cheater et al. 2020).
“When a resident moves in they find the menu already set and organised and then have to adjust to being told when to eat, what meals are served and who they will be sharing a meal with in the dining room.” (Abbey 2015 p36)
Acknowledging this shift from traditional biomedical approaches, the final report of the Royal Commission into Aged Care Quality and Safety (Commonwealth of Australia 2021) recommends future policy that incentivises the use home-like residential care environments, and a regulatory focus on PCC practices, including mealtime practices. The final report also references the integral relationship between residents’ perceptions of quality aged care and the quality of food, the dining experience, and the implications for those who lack choice and control (Commonwealth of Australia 2020, Commonwealth of Australia 2020).
Theme 4: Interpretation of regulations. Loose interpretation and different understandings of organisations and aged care accreditors about mealtime regulations were commonly reported. In the Australian context, the Australian Aged Care Quality Standards that provide the regulatory standards that all Australian RACFs comply with, operate on an outcome-based rather than process-oriented approach (Aged Care Quality and Safety Commission 2020, Commonwealth of Australia 2020). Outcomes for food and nutrition care are measured using ‘unplanned weight loss’ as a single measure. Similarly, regarding meal provision, the Standards state that “where meals are provided, they are varied and of suitable quantity and quality” (Aged Care Quality and Safety Commission 2020 Requirement 3f), however, outcome measures related to this standard are lacking.
Consequently, regulators and aged care providers are permitted to variably interpret the Standards (Abbey 2015). Whilst these are purported to “[provide] a mechanism by which stakeholders achieve minimum standards of quality” (Hogden, Greenfield et al. 2017 p140), individualised interpretations form signification structures for assessors, RACF staff and other stakeholders that influence how RACFs are rated, and how particular resident activities or care processes, such as mealtimes, are ranked for accreditation purposes. Similarly, how RACFs understand the intent of the Standards translates to the structures that guide how facilities manage and enact mealtimes, which ultimately impacts residents’ experience and their own interpretation of mealtimes (Hogden, Greenfield et al. 2017).
Domain 2: Legitimation
The domain of legitimation captured four themes that identified the rules, processes and routines that produce structures to guide a resident’s mealtime experience.
Theme 1: Care approaches. Care approaches in RACFs set expectations and procedures that form legitimation structures that guide the resident’s mealtime experience. PCC approaches (Hogden, Greenfield et al. 2017, Holmes 2019, Jones and Ismail 2019, Caspar, Berg et al. 2020), or a social model of care (Henkusens, Keller et al. 2014) guide mealtime processes that “[provide] choices and preferences, supporting independence, showing respect and promoting social interaction” (Reimer and Keller 2009 p327).
“In recent years, the model for long-term care settings has gone through a major paradigm shift from the traditional institutional, medical environment to more interactive communities that focus on quality of life, individual choice, and a more person-centered, home-like culture.” (Dorner 2010 p1556)
Where RACFs operate under a biomedical model of care that lacks incorporation of PCC, staff may adopt a care approach that is more task-oriented than resident-focused, which impacts the mealtime experience (Watkins, Goodwin et al. 2019). Ultimately, the approach adopted by RACFs form structures that guide how mealtime care is enacted.
Theme 2: Norms and routines. Mealtimes in RACFs legitimise structures related to time, place, social interactions and normality each day (Bundgaard 2005, Philpin, Merrell et al. 2014). Mealtimes provide staff with an action repertoire that also form social rituals (Harnett and Jönsson 2017). For staff and residents, the daily routine of mealtimes often follows “an institutional script with established roles and a sequential order of action” (Harnett and Jönsson 2017 p839), involving set timings, predetermined menus and designated resident seating (Henkusens, Keller et al. 2014, Maluf, Cheater et al. 2020). However, these routines provide a sense of normality and structure to the day that also benefits resident health (Bundgaard 2005, Simon 2015). For example, saying grace is associated with initiating mealtimes (Ullrich, Buckley et al. 2014). Regular set menus are reported to be “imprinted into the olfactory memory” (Wang, Everett et al. 2020 p630) of residents and their meal choices reflect comfort in familiarity and routine.
Similarly, residents’ rules and routines enacted whilst sharing food, space, company and interactions contribute to RACF mealtime structures (Palacios-Ceña, Losa-Iglesias et al. 2013). For example, when residents deviate from the ‘code of conduct’ that directs the rules of their table, they may face admonishment from others (Milte, Shulver et al. 2017). Conversely, conventions and manners are part of proxemic behaviour that facilitate residents with dementia to participate in mealtimes (Curtis 2008). Through mealtime habits and routines, residents can make sense of the broader experience of living in RACFs (Roberts 2011, Maluf, Cheater et al. 2020). These mealtime norms and routines provide structure for the daily activities for residents (Philpin, Merrell et al. 2014).
Theme 3: Best practice. In RACFs best practice is grounded in the evidence for PCC, which informs practice guidelines and norms that form legitimation structures (Bailey, Bailey et al. 2017). The literature identified some evidence supporting the assessment of mealtime needs, interventions and strategies. The FoodEx-LTC assessment tool successfully identified and incorporated resident perspectives in mealtime service delivery (Evans and Crogan 2005). Assessments including the Dining Environment Assessment Protocol (Chaudhury, Keller et al. 2017) for evaluating the physical environment and Making the Most of Mealtimes framework (Keller, Carrier et al. 2017) assist to develop and evaluate best practice mealtime interventions. Best practice assessment also requires multidisciplinary team input to develop appropriate care plans that generate new mealtime rules (Bennett, Ward et al. 2015). Additionally, open and regular communication with residents provide staff direct feedback and gauge resident expectations and experiences of meals (Wang, Everett et al. 2020).
Best practice menu guidelines for resident nutrition have been developed in Australia, but these are not mandated, and do not provide guidance about improving mealtime experiences (Williams 2012, Abbey 2015). For example, whilst studies have recommended policy that protects mealtimes and deters non-mealtime related tasks during meals (Ullman 2009, Ullrich, Buckley et al. 2014), these are not policy measures. A submission to The Productivity Commission Public Inquiry into the Care of Older Australians recommended best practice guidelines to inform organisational processes and funding to improve RACF mealtimes (Wilson, Wright et al. 2010, Productivity Commission 2011), and similar recommendations are provided in the Final report of the Royal Commission into Aged Care Quality and Safety (Commonwealth of Australia 2021). Best practice recommendations form benchmarks that should set legitimation structures that underpin RACF mealtime practices, routines and actions.
Theme 4: Policies and regulations. Policies and regulations form legitimation structures that set norms for mealtime processes and routines for staff and residents but differ between and within countries. This review most prominently derived policy guiding mealtimes from the Aged Care Quality Standards, which contain regulatory standards related to nutrition and hydration, choice and decision making, and catering, cleaning and laundry services (Aged Care Quality and Safety Commission 2020, Aged Care Quality and Safety Commission 2020), but do not directly reference or measure quality mealtime practices (Wang, Everett et al. 2018).
Global regulations that direct minimum staff qualifications and care hours are lacking (Abbey 2015), and there are not standardised protocols or guidelines for feeding assistance, despite the relationship between eating dependency, malnutrition and complications of dysphagia (Milte, Shulver et al. 2017). Local organisational policies that govern the budget for food, staffing and time allocated for eating, vary between organisations (Lowndes, Daly et al. 2018, Wang, Everett et al. 2020). These rules and regulations direct local management and organisation of mealtimes, forming legitimation structures that translate to the practices that staff and residents enact during mealtime routines.
Domain 3: Domination
The four themes identified in the Domination domain related to power and resources individuals use to accomplish mealtime actions. These themes reflected resident, staff, organisational and government power over mealtimes.
Theme 1: Resident power. RACFs contain domination structures that often limit the power of residents to enact control over mealtimes, and position power with the staff and institution. For example, residents lose some independence and control on entry to an RACF, including reduced access to familiar foods (Abbey 2015, Wang, Everett et al. 2020). Residents value opportunities to exercise agency and have autonomy over preferred foods, location and timing of meals, and tablemates (Bailey, Bailey et al. 2017), and to participate in preparing food (Grøndahl and Aagaard 2016).
“When asked to rate the importance of control and choice over certain areas of their everyday life in a home, residents prioritised having choice over their foods as the most important.” (Abbey, Wright et al. 2015 p7581)
However, paternalistic mealtime care approaches create domination structures that result in fewer opportunities for residents to make routine or participatory decisions (Schell and Kayser-Jones 1999, Henkusens, Keller et al. 2014), and residents are almost entirely dependent on the facility for nourishment (Hotaling 1990, Evans, Crogan et al. 2003). Many residents are also aware of government policies and RACF processes that direct the extent of their choice and control at mealtimes (Evans and Crogan 2005), and feel resigned to having limited control (Watkins, Goodwin et al. 2017), or are less inclined to raise concerns for fear of retribution (Pearson, Fitzgerald et al. 2003, Reimer and Keller 2009). This pertains particularly to dependent residents, such as those with cognitive impairment or dysphagia, where domination structures related to care further compromise control and dignity over mealtime situations, routines and practices (Grøndahl and Aagaard 2016, Milte, Shulver et al. 2017, Ballesteros-Pomar, Cherubini et al. 2020).
Theme 2: Staff power. RACF staff, including nurses, nursing assistants, dietitians, speech-language pathologists, occupational therapists and general practitioners, are directly involved in mealtime management and their interventions influence the extent that residents can exert power (Bennett, Ward et al. 2015). Staff responsibilities that include offering support to residents, fostering independence, facilitating social interactions and creating opportunities for residents to exercise autonomy can positively influence mealtime experiences (Barnes, Wasielewska et al. 2013, Holmes 2019). Whilst RACF staff have reported having little control in how RACFs operate (Gibson and Barsade 2003), when they are empowered and “invested, aware, and knowledgeable, residents… have more individualised and ultimately, successful experiences” (Shune and Linville 2019 p149). Shifting power from staff to resident requires staff access to quality education and training and organisational resources that sanction practices that enable residents to enact autonomy during mealtimes (Keller, Wu et al. 2021).
Theme 3: Organisational powers. How RACFs allocate and manage resources for mealtimes affects resident agency, mealtime culture and experience (Watkins, Goodwin et al. 2017). This includes fiscal and staffing constraints, such as food budget, staff workload and education (Beattie, O'Reilly et al. 2014, Lowndes, Daly et al. 2018, Matwiejczyk, Roberts et al. 2018). Resource allocation strategies that relate to poor-quality mealtime experiences for residents include staff attending to non-meal tasks during mealtimes, foodservice time limitations, and cost containment schemes such as menu cycling (Lowndes, Daly et al. 2018, Wang, Everett et al. 2018). Local organisational policy further impacts on mealtime experience as this directs how the dining environment is physically managed (Bundgaard 2005). RACFs report difficulty in balancing residents’ individual needs with organisational constraints and often prioritise the organisation’s needs (Bailey, Bailey et al. 2017). Consequently, these organisational structures can impact how residents can access positive mealtimes.
Organisational support structures may enable staff to build knowledge and learn together to implement best practice and new ideas, but hierarchical staffing structures also pose barriers to staff who have ideas for improvement (Lea, Goldberg et al. 2017). Organisational processes inform whether PCC is prioritised (Keller, Wu et al. 2021), and how staff enact teamwork to manage mealtimes (Byles, Perry et al. 2009), but a lack of clarity about RACF responsibilities to enact best practice has increased recommendations for multidisciplinary mealtime management to be explicitly regulated (Hotaling 1990, Bennett, Ward et al. 2014, Holmes 2019). Thus, RACF organisational and resource allocation strategies generate domination structures related to the rules, procedures and routines that are enacted during mealtimes that impact residents’ ability to exert power and control.
Theme 4: Government and regulatory powers. Cultural, political and economic contexts influence professional knowledge and theories on ageing which affect how RACFs are organised (Bundgaard 2005). Governments serve as regulatory bodies to organise aged care provision by mandating regulatory policies that are tied to government funding for providers (e.g. Australian Government 2018, Aged Care Quality and Safety Commission 2020). As such, through funding linked with compliance requirements, governments generate domination structures that direct the implementation of care and daily activity routines according to their priorities for funding and outcomes. However, Australian aged care policy contains no standards related to foodservice provision, mealtime quality, care or practice. There lack compliance measures that generate domination structures for minimum quality mealtime practices that would directly impact residents’ mealtime experiences (Commonwealth of Australia 2021).