Five ACFs participated in the study. All sites adopted the IDDSI in 2018-2019. A total of 15 managers were interviewed and 85 surveys were completed by the staff across the five sites. Sites ranged from 54-153 beds and all had access to a dietitian. Between 23-37% of residents were receiving TMDs including puree, minced and moist and soft and bite sized meals. Thickened drinks were much less frequent (range 5-12%). Details of sites and their meal services are displayed in Additional file 3.
Intervention Characteristics
Table 1 displays the overall contract ratings across sites.
1.1 Intervention source
The IDDSI is an externally developed initiative by an international committee and considered a global standard for texture modification. It was endorsed by New Zealand healthcare organizations in 2018. Positive perceptions of the source were found across all sites and was rated as a strong positive influencer of implementation.
1.2 Evidence strength and quality
IDDSI framework was developed by a multidisciplinary expert panel based on a systematic review that examined the impact of fluid viscosity and food texture on swallowing. The identification of IDDSI levels and descriptions were derived from both clinical evidence and expert opinions. Two facility managers expressed that they wanted to know more about the background of IDDSI suggesting a lack of awareness of the development process, which weakened their perception of the implementation needs: ‘I don't think it's been publicized enough maybe….They all know what soft, minced and moist and puree is. But, actually, the background behind that change’ Site 5 manager.
1.3 Relative advantages
With the exception of Site 1 which had a negative perception towards implementation, this construct showed a positive influence on the implementation. Compared to the previous terminologies, participants perceived advantages of having clearly defined levels and instructed testing methods for improving resident safety.
1.4 Adaptability
Managers confirmed TMDs have always been provided in ACFs and were aware of the various levels of TMDs. All sites were able to provide all levels of TMDs except for Site 4 where neither the chef nor kitchen manager had knowledge and experience of a minced and moist diet. Pureed diet was offered to residents who were prescribed on minced and moist diets. Other site managers found the changes were easily adaptable, though some sites made more changes than the others. Three sites started using IDDSI-complied commercial TMD after the implementation as it was more consistent and better compliant and presentation.
1.4 Trialability
Kitchen managers considered desserts as the hardest TMD to produce. Three sites conducted IDDSI-compliant commercial TMD trials with staff and residents during their implementation. Positive feedback was received from residents and staff before they moved on to a larger scale of commercial TMD. The other two sites indicated they did not make specific changes to the meals, so trialability did not apply to them.
1.5 Complexity
Though all managers were interviewed, three managers from three sites were either not aware of or involved in the implementation. Therefore, they were unable to give opinions on the rating of implementation difficulty and success. Mean range of implementation difficulty was 4.4 out of 10 (range 3-5). Four sites indicated the previous terminologies used to describe TMDs in New Zealand were very similar to IDDSI, but ‘it was hard getting the staff to adopt the new terminology and to understand what the new changes were and why we’re changing all these terminologies.’ Site 2 manager. Site 4 manager considered the process as relatively complex considering it as an ongoing process: ‘I would say that we're probably still going through the process. It's not like we're done with it. There're still some things that we need to regather.’
1.6 Design quality and packaging
Comprehensive IDDSI resources are readily accessed from the website, including written materials, posters, audit sheets, webinar and video links. The IDDSI framework has detailed descriptions of definition, test methods and food examples. Accordingly, the design quality of the IDDSI framework was rated as a strong enabler: ‘the information is easier to access. It wasn't online before. We would be lost, and we will assume.’ Site 2 kitchen manager.
1.7 Cost
Participants reported cost was not a major concern as the implementation was delivered by their full-time clinicians. Site 3 clinical manager pointed out extra funding dedicated to the IDDSI implementation would be beneficial :‘I think we need extra (funding) … at the moment, our suppliers would do it (education) or students would do it (education).’ Although the implementation project was not funded, two managers indicated their budget was able to cover the education delivered by contracted dietitians and they were willing to pay for more sessions in the future.
Twenty-three percent (n=7/30) of staff who completed the survey question ‘the hardest changes for you using IDDSI’ found the cost was higher to produce or purchase IDDSI–compliant meals. The budget of food purchasing was mentioned by three kitchen managers who started purchasing commercial IDDSI–compliant meals. Though higher priced, the commercial meals offer guaranteed texture and consistency, while also saving staff cooking time. Such benefits were deemed to outweigh the cost difference between freshly made and commercial meals. Managers from Site 2 and 5 reflected on the consumption of commercial fortified TMD and clinical improvements in nutrition and wound healing, reductions in hospital admissions, and saving the cost for purchasing additional supplements: ‘yes, providing [commercial packaged TMD] has been an issue, because when we started, we were always over budget by $4-5,000 a month. And I had to work with my kitchen manager to understand how to reduce other products to allow for these 12 people being catered for..it's a slightly higher cost overall. Although the price per resident per day is ok, it's about $1.80 I think, for the modified meals.’ Site 2 manager. ‘Cost-effective versus the time it takes us to do it otherwise. So, it is cost-effective. Also, it's already pre-fortified, so comes with all the additional supplements that we need too.’ Site 5 manager.
Outer Setting
2.1 Patient needs and resources
Most of the staff were aware of the level of TMD their residents were prescribed but had limited knowledge regarding the appropriate food for each level. Seventy-eight percent (n=28/36) of the staff surveyed agreed the TMD should be tested daily. Managers acknowledged that IDDSI aims to enhance patient safety, which led to the motivation of the IDDSI implementation. Choking incidents were mentioned by clinical managers in all sites except Site 1 which only had rest-home level of residents: ‘when I first started, we had a resident who choked, eventually was sent to the hospital and died in hospital…the resident was on a soft diet and .. supervision from the staff was poor.’ Clinical manager. ‘After the main choking incident that we had, we also did an investigation, one of the findings was that not all of our staff was aware of the choking guideline ..So, we implemented.’ Clinical manager.
Managers indicated the inconsistency they observed of freshly made TMD and powder-mixed thickened fluids before IDDSI was implemented. Sites purchased commercial IDDSI–compliant meals found they were able to accommodate resident needs better with more suitable food options: ‘so, the reason that we went with [commercial packaged TMD] was about my kitchen… minced and moist, it might be good one day and the next day it might be slightly runny or might be too thick… it was very hard for them to get the consistency correct every day.’ Site 2 manager.
Upgrading resident dining experience was another incentive for ACFs to implement IDDSI: ‘we want to make sure that everyone … engaging dining experience.’; ‘we just started a new quality goal for this year. And one of them is foodservice, including texture modification and flavours and things like that.’ Site 3 manager and Site 5 clinical manager. On the other hand, managers in the smallest site were not enthused about the changes. They only had a few residents on pureed diets and the residents on soft diets were mostly due to the poor dentition, so they did not perceive the needs to improve their current practice.
2.2 Cosmopolitanism
All sites indicated they had communicated with others during initial implementation: ‘I met [the speech-language therapist] from Greenlane clinic, the head SLT. Because there was a lot of confusion about the information that we got into the practice that we were doing.’ Site 4 clinical manager.
2.3 Peer Pressure
Peer pressure had a positive impact on sites. IDDSI implementation was considered a recommended project in healthcare. Hospitals and commercial companies had moved to the IDDSI framework.
2.4 External Policy and Incentives
Despite IDDSI being endorsed by the New Zealand Speech-language Therapists’ Association and the Dietitians Association, there was a lack of mandatory performance measurement or evaluation. While it was incorporated into the New Zealand Dietitian Menu Audit Tool, this was not mandated.
Inner Setting
3.1 Structural characteristics
Two types of foodservice systems were observed. Minced and moist and pureed diets were moulded by three sites using commercial TMD (Site 2, 3 and 5) while the other two sites served freshly made TMD with ice cream scoops. Suitable snacks and desserts were provided to TMD residents in all sites except Site 1 who did not modify dessert. All sites reported a well-established foodservice and nutrition policy, including menu review by dietitians and individualizing ethnic food by preferences [Additional file 3]. IDDSI labels were only used at Site 2. The kitchen manager and chefs with advanced experience working in ACFs and producing TMD demonstrated a better understanding of the needs to improve TMD and comply with IDDSI. Surveys indicated that half of the staff had 1-5yrs of work experience and a third had <1yr of experience [Additional file 4].
3.2 Networks and Communications
There were distinguishing differences between sites. One site reported a close working relationship between dietitians, kitchen and clinical staff: ‘they come straight to me when we have a new resident, they hand me a nutritional profile. The clinical manager is fully on to it, she does her part, and basically, the RNs communicate on the daily basis. If there's any issue, we have meetings … and resolve it as quickly as possible.’ ‘[me and the dietitian] work by .. If there's anything that needs to be implemented, she comes on-site, has a meeting with the village manager and myself’ Site 2 kitchen manager.
Two sites implied the need to improve communication between staff and dietitians: ‘it's a good relationship between clinical staff and kitchen, but there's a lot of work in progress’; ‘Sometimes I hear from the kitchen manager that the staff are not telling her everything... The communication should be better.’ Site 4 and 5 clinical managers.
None of the sites formed an interdisciplinary project team which was considered as a barrier. The staff received a one-time training and did not have a further meeting to discuss the challenges or problems they experienced. Meanwhile, the majority of the sites depended on the off-site dietitian acting as the coordinator for the implementation rather than having a team coordinator on site. All sites used online systems or electronic documents regarding dietary requirements. Clinical and kitchen managers were in charge of documenting. However, limited staff had access to up-to-date information. Foodservice preferred using paper format displaying the updated dietary requirements, and verbally delivered to healthcare assistants at the mealtime.
The private funding system means that facilities have access to ‘free’ community speech pathologists for one-off resident referrals only, but they are obligated to pay for education or training needs. A lack of input from speech-language therapy was indicated at all sites: ‘because if the resident is not high in the priority with the healthcare service, then it is a matter of between 6 weeks to 3 months, or even longer, the waiting period.’ Site 4 clinical manager.
3.3 Culture
This construct was evaluated from interviews, surveys and direct observations. All sites had a friendly but intense working environment. Most of the managers indicated they have adequate staff producing meals and assisting residents. The kitchen manager from Site 4 indicated short staffing to prepare TMDs was one of the reasons they did not serve minced and moist diets. Routine staff were familiar with resident dietary preferences and were able to accommodate cultural requirements. Site 3 had a high ratio of residents who required feeding assistance against the number of staff available (n=7:3) while staff had limited interactions with residents at mealtime. Managers were satisfied with staff performance and valued good quality of nutritional care and safety for the residents. A mix of positive and negative comments about TMD was received: ‘the thickener that we use in here tastes awful. We use the guar gum. With pureed, I would say that it put me off just because of how it looked. I really didn't think of the taste. I wouldn't be able to rate it properly. I didn't taste all of it. And the texture in my mouth also weirded me out.’ Site 1 and 4 clinical managers.
Staff were asked to rate their satisfaction with TMD provided in the facility (Figure 1). Site 2 and 4 had lower satisfaction rating compared to other sites (average below 4 out of 5).
3.4 Implementation Climate
3.4.1 Tension for change
Concerns for resident safety empowered tension for change: ‘I doubt (the current thickener gives the right consistency) because in the previous facility we used liquid water, the pump. And that was such a quality improvement. It was consistent and the taste was good, there are no lumps. I would really like us to start using that here as well.’ Site 5 clinical manager. The need for change was not felt to be urgent at a low implementation site: ‘we are not there yet, maybe we need it more when we move to a bigger site and having more patients [on TMDs].’ Site 1 clinical manager. The Tension for Change construct was not applied to Site 2 and 3 where the implementation was brought by their head office. They did not have the chance to consider whether it was needed at the time. However, choking incidents were brought up by two sites.
3.4.2 Compatibility
IDDSI was compatible with all sites goal of quality improvement and resident safety. IDDSI terms were not compatible with medical software some sites were using from an Australian company, which still used the Australian terms for TMDs. Staff could only choose the options listed on the software, and it confused them from adapting the IDDSI levels. Compatibility was rated as a strong influencer for Site 4 and 5 because they both had quality IDDSI improvement projects in progress.
3.4.3 Relative priority
The relative priority construct was only rated for Site 4, which was a self-directed implementation project. Other sites were led by the head office as a required project, where the priority was not applied.
3.4.4 Organisational incentives and rewards
All sites were rated as neutral with regards to incentives and rewards. Though one site held monthly meetings to reward dedicated staff nominated by their colleagues, residents or family members for outstanding performance. None of the sites offered any incentives or rewards for this particular implementation.
3.4.5 Goals and feedback
Managers did not receive any feedback from staff after IDDSI implementation. Site 2 and 3 monitored the terminologies used. Managers would correct staff: ‘a lot of staff still refer to the old terminology, and if I hear and I just say, oh what's that?’ Site 2 manager. Both Site 4 and 5 started ongoing TMD auditing using IDDSI audit sheets. Site 4 had monthly TMD testing sessions and collected staff feedback on the texture and taste of the food, staff would also point out and send back the inappropriate TMD to the kitchen when noticed.
3.4.6 Learning climate
There were no potential risks related to the learning climate. All sites had a positive rating as a result of the collaborative working climate. Managers indicated chefs and kitchen managers as key players. Clinical staff reported they were able to communicate efficiently with the kitchen managers with the exception of Site 2, where 18-25% of the clinical staff (nurses and healthcare assistants) surveyed had limited involvement with TMDs, which could lead to a negative perception of them being less motivated and involved in the changes.
3.5 Readiness for implementation
3.5.1 Leadership engagement
Managers at some sites were highly engaged in monitoring performance, delivering training and actively seeking necessary input, whereas some leaders had conflicting opinions regarding the priority of the project: ‘as a clinical manager, obviously I need to make sure firstly my staff does understand what it means. And then they need to understand what the different levels are, especially for the thickened fluids, and for the diets as well. And then make sure they are serving the right type of food to the right person’ Site 2 clinical manager. Site 5 delivered by cascaded approach, where leaders played a critical role: ‘…cascade it to the other leaders, so the unit coordinators. Because we’re large, for each floor, the structure of this home, each community has its leader, but we have to start at the top.’ Site 5 manager.
3.5.2 Available resources
IDDSI provided sufficient resources online for individual access. Other resources such as extra staff, space or funding were not provided to any sites for the implementation. Using packaged TMD saved space for cooking and time. Because IDDSI has more strict standards, Site 4 mentioned the lack of kitchen staff and equipment limited their ability to provide all levels of TMDs.
3.5.3 Access to knowledge and information
All sites received IDDSI training from dietitians and commercial company support staff: ‘…(dietitian) would also bring [commercial TMD products] for the staff to taste. So that they would know what the food tastes like. We have done 3 training in the past about texture modification, IDDSI.’ Site 3 clinical manager. Managers mentioned staff need more training to reinforce the knowledge, in particular, for new staff. IDDSI framework posters were displayed in Site 2 and 4. Chefs felt it was challenging to achieve the IDDSI standards due to the limited training on cooking TMD: ‘I know that nutrition is important to me in the aged-care area. And I personally have no training in nutrition or dietary thing.’ Site 4 kitchen manager.
Of 84 staff surveyed, 25% (n=21) were aware of IDDSI. A limited knowledge level of IDDSI was found in all sites, with only 12% (n=10) able to match the terminologies with the correct number and color coding. Of the staff who reported being aware of IDDSI implementation, Site 2 and 4 had 75% of staff (n=3/4) and 45% (n=5/11) respectively felt they received sufficient information to understand IDDSI [Additional file 3].
Characteristics of Individuals
Results from this domain were interpreted indirectly from staff self-reported survey as we did not directly assess individual attitude at the time of implementation.
4.1 Knowledge and beliefs about the intervention
Managers had mixed beliefs and understanding of the importance and implication of IDDSI mainly due to their background and job responsibility. Fifty-three percent (n=8) of managers considered meals had improved since IDDSI roll-out, 27% (n=4) expressed few changes were seen, and the other 20% (n=3) indicated that TMDs still required improvements at their site. Despite the agreement on improving clinical safety, some managers pointed out the confusion staff had regarding the reasons for implementing IDDSI: ‘make sure that everybody understands the differences between the different textures and the reasons why someone might be on them and the risks of what could happen if they don't deliver alright‘ Site 5 clinical manager. Site 1 manager indicated the relevance of IDDSI was insignificant to their site considering their limited use of TMD.
Staff demonstrated positive attitudes towards learning IDDSI, 94% (n=79) wished to receive more information. Workshops (n=43), training courses (n=38) online resources (n=33), seminars (n=30) and hard copy handouts (n=25) were the most popular choices of learning. Site 1 showed a poor response rate as evidenced by only 29% of staff (n=2/7) completing all sections of the survey. Most staff showed positive beliefs of IDDSI with 18% pointing out IDDSI was hard to understand and comply with (Table 2).
4.2 Self-efficacy & 4.3 Individual stage of change
We were unable to assess individual staff belief in their ability to succeed in practising under IDDSI nor staff readiness for the changes. All managers expressed a high confidence level in staff performance and knowledge development in a future training (rated from 8-10 out of 10) and were satisfied with staff performance: ‘I think everybody is ok. I often .. wander through in the mealtimes and everybody seems fine. No concerns’ Site 1 manager.
4.4 Individual identification with organisation
Four sites reported they felt supported by having a dietitian who could help them understand and solve problems on regular basis: ‘the dietitian comes in every month, we're in touch almost every 2 weeks .. she came to train us for the moulding part twice, which was going on pretty smoothly’ Site 2 kitchen manager. Managers demonstrated strong existing relationships: ‘the dietitian comes here often and makes sure things are working well’ Site 3 manager.
Process
5.1 Planning
Though four sites received the plan from their head office, it was not individualized for each of the sites. None of the sites had a comprehensive plan covering pre-implementation assessments or gap analysis. Internal training was given for all sites at the time of implementation but without follow-up. Three sites received the education and materials from their national organizational dietitian. One site received the implementation material through head office online resources and received the education from their contracted dietitian. The implementation was generalized based on the organization rather than individual sites. The other site rolled out the implementation by an allied health coordinator. Missing an organized structural plan was a barrier. Site 5 indicted that the roll out could have been better developed.
5.2 Engaging
5.2.1 Opinion leaders, 5.2.2 Formally appointed internal implementation leaders and 5.2.3 Champions
The absence of influential leaders and appointed champions in this project was considered as a major barrier for all sites. None of the leaders had a working team engaging in the implementation. Only site 4 had an allied health coordinator who acted as a formally appointed internal leader to lead the implementation: ‘she has a project called 'Dining with dignity'. She came into IDDSI and we worked alongside the kitchen, then we've invited a dietitian. Then she reviewed our meals that we serve and what should the texture be. She did some education training’ Site 4 clinical manager. The leaderships and coordinator roles were vacant in other sites.
5.2.4 External change agents
This construct significantly influenced the implementation effectiveness. Some sites received better support from commercial companies who provided resources and training to staff. Introducing the IDDSI–compliant products (thickener and TMD) led to a perceived improved quality of service.
5.2.5 Key stakeholders
One of the significant changes of IDDSI was the detailed instructions on TMD preparation and testing. Food particle size, consistency and texture should be tested for each level of TMDs. Only kitchen managers received information on TMD preparation and testing. Other kitchen staff and clinical staff had minimal involvement and were lacking awareness of IDDSI evidenced by the unsatisfactory IDDSI knowledge level from the surveys [Additional file 3], inconsistent use of IDDSI terminologies from observations and inaccurate terminologies used by managers in interviews.
5.2.6 Intervention participants
Residents were not participants in the implementation, therefore, it was not applicable.
5.3 Executing
Executing was not coded due to the lack of detailed planning and few procedures were developed by the sites.
5.4 Reflecting and evaluating
All sites had regular team meetings, but none of them tabled IDDSI on the agenda. Evaluation was missing in all sites. Participation in this study was voluntarily and sites were willing to receive formal feedback and reinforce implementation. A positive attitude was shown towards evaluation and improvement.