Table 1 displays the overall construct ratings across sites. The IDDSI is a global standard for texture modification developed by an international committee and was adopted by New Zealand in 2018. Comprehensive IDDSI resources are available and accessible to the public. The IDDSI framework has detailed descriptions of definitions, test methods and food examples. Accordingly, intervention source and design quality and packaging had a strong positive influence on all sites. Trialability was also rated as a strong positive factor. As part of the implementation, three sites conducted IDDSI-compliant commercial TMD trials before moving on to a larger scale of commercial TMD, positive feedback was received from residents and staff. The other two sites indicated they did not make particular changes to TMD provision, so trialability did not apply to them.
With the exception of Site 1, where perception of the relative advantage was negative, the relative advantage had a favourable influence on the implementation. Compared to the previous terminologies, participants saw the benefits of having clearly defined levels and instructed testing methods for improving resident safety. According to the managers, TMDs have always been provided in ACFs and the various levels of TMDs were easily adaptable. Only Site 4 struggled to accommodate the minced and moist level due to the chef and kitchen manager’s lack of understanding and experience with TMD.
On the other hand, the evidence strength and quality showed a strong negative influence on all sites. Participants expressed that they wanted to know more about the IDDSI background 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.
Complexity was another common negative influence. The 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.’
The cost had a mixed rating with either, having a negligible or negative influence. Although the cost of implementation delivery and education sessions was less of a concern for the majority of the managers, Site 3 clinical manager stated that additional funding dedicated to 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).’ Twenty-three percent (n=7/30) of participants reported the higher cost to produce or purchase IDDSI–compliant meals was the most challenging change. The budget of food purchasing was mentioned by three kitchen managers who started purchasing commercial IDDSI–compliant meals. Though higher priced, commercial meals offer guaranteed texture and consistency while saving staff cooking time. These advantages were deemed to outweigh the price difference between freshly made and commercial meals. Two managers discussed the consumption of commercially fortified meals and clinical gains in nutrition and wound healing, reductions in hospital admissions, and cost savings for purchasing additional supplements.
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. Except for external policy and incentives, the other three constructs in the outer setting domain all had a favourable impact on implementation.
Both managers and staff acknowledged that IDDSI aims to enhance patient safety, which led to the motivation in IDDSI implementation. Choking incidents were mentioned by clinical managers at all sites except Site 1 which only had rest-home level of residents. Managers indicated the inconsistency they observed in freshly made TMD and powder-mixed thickened fluids before IDDSI was implemented. Sites that purchased commercial IDDSI–compliant meals found they were able to accommodate resident needs better with more suitable food options. 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 when only a few residents needed pureed diets due to the poor dentition. Therefore, the perception of patient needs and resources was only a positive impact on medium to larger sites. Cosmopolitanism and peer pressure acted as positive influencers to all sites. IDDSI implementation was considered a recommended project in healthcare. They all indicated having communicated with other clinicians or organisations during the initial implementation. Hospitals and commercial companies had all moved to use the IDDSI framework.
Structural characteristics and readiness for implementation constructs acted as positive factors to implementation outcomes. All sites reported a well-established foodservice and nutrition policy, including menu review by dietitians and individualizing ethnic food by preferences. Two types of foodservice systems were observed as described in 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 need 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].
Leadership engagement had a strong positive influence in three sites. Managers at some 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. Having available resources and access to knowledge and information also contributed to the positive effect of readiness for implementation. Although IDDSI offered adequate online learning material, no sites received additional resources to facilitate implementation, such as extra staff, space, or funds. Those sites that switched to commercial TMDs reported significant space and time savings. In contrast, due to IDDSI's stricter criteria, Site 4 stated that a shortage of kitchen staff and equipment hindered their capacity to supply all levels of TMDs.
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. All sites received IDDSI training from dietitians and commercial company support staff. However, of 84 staff surveyed, only 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 colour 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].
There were distinguishing differences in networks and communications between sites. One site reported a close working relationship between dietitians, kitchen and clinical staff, whereas two sites implied a 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. Site 4 clinical managers. The fact that none of the sites assembled an interdisciplinary project team was regarded as a hurdle. Meanwhile, rather than having a team coordinator on-site, the majority of the locations relied on an off-site dietitian to act as the implementation coordinator. 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. A lack of input from speech pathology 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. 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.
The culture construct was evaluated from interviews, surveys and direct observations. All sites had a friendly but intense working environment. Most of the managers implied they have adequate staff producing meals and assisting residents. Routine staff were familiar with resident dietary preferences and were able to accommodate cultural requirements. 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. Staff were asked to rate their satisfaction with TMD provided in the facility (Figure 1). Site 2 and 4 had lower satisfaction ratings compared to other sites (average below 4 out of 5).
There were a few implementation climate constructs that were not applied to Sites 2 and 3 where the implementation was provided by their central office. They did not have time to ponder the necessity at the time. However, choking incidents were brought up by two sites.
In two sites, 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 in small organisation 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.
Compatibility was rated as a strong influencer for Site 4 and 5 because they both had IDDSI quality improvement projects in progress. IDDSI was compatible with all sites goals of quality improvement and resident safety, however, IDDSI terms were incompatible with medical software from an Australian business that some sites were using, which still utilised Australian terms for TMDs. Staff could only select from the options presented on the software, and the resulting confusion was a negative contributor to compatibility.
The relative priority construct was only rated for Site 4, which was a self-directed implementation project. Other sites were led as a mandated project by the main office. As a result, none of the sites offered any incentives or prizes; all sites were rated as neutral in terms of organisational incentives and rewards.
Except for site 1, which was rated negative in goals and feedback, all sites had some form of monitoring in place. Site 2 and 3 monitored the terminologies used and managers would correct staff when they used the wrong name. 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.
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.
Characteristics of Individuals
Results from this domain were interpreted indirectly from staff self-reported surveys as we did not directly assess individual attitudes at the time of implementation. We were unable to assess individual staff belief in their ability to succeed in IDDSI practice or staff readiness for change. As a result, the individual stage of change construct was inapplicable. The other three constructs: knowledge and beliefs about the intervention, self-efficacy and individual identification with organisation were all considered as positive influences towards the implementation.
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 reason 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. Nonetheless, all managers expressed a high confidence level in staff performance and knowledge development in the future training (rated from 8-10 out of 10) and were satisfied with staff performance.
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 only 18% reporting IDDSI hard to understand and comply with (Table 2).
Four sites said that having a dietitian who could assist them comprehend and address problems regularly made them feel supported: ‘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.
Missing an organized structural plan was rated as a barrier in two sites. Though four sites received the plan from their headquarters, it was not tailored to each of them. There was no comprehensive plan encompassing pre-implementation gap analysis. Internal training was given for all sites at the time of implementation but without follow-up. The other site rolled out the implementation by an allied health coordinator. Site 5 indicted that the rollout could have been better developed.
The absence of influential opinion leaders, formally appointed internal implementation leaders and champions 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 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 the meals that we serve and what should the texture be. She did some education training’ Site 4 clinical manager.
Three sites gained compelling support from commercial companies, which offered resources and staff training. The introduction of IDDSI–compliant products (thickener and TMD) resulted in a reported improvement in service quality. Therefore, external change agents brought strong positive influence to the implementation outcomes.
The absence of key stakeholder involvement, as well as the lack of reflection and evaluation, both had a negative impact on implementation. 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 4], inconsistent use of IDDSI terminologies from observations and inaccurate terminologies used by managers in interviews. Every site held regular team meetings, but none of them mandated IDDSI on the agenda. All sites lacked an evaluation. 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. Because the residents were not involved in the implementation and the absence of precise planning, the intervention participants and executing constructs were inapplicable.