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C H A P T E R
O N E

Introduction

MENU
Imagine
Losing It

Overview

Can It Be Done?
Beware of Red
Herrings!

IMAGINE LOSING IT
During your life youve enjoyed many meals, meals you have
fixed, served, and shared as well as meals that have been fixed
and served by others. Theyve been joyous, rowdy, quiet, intimate,
sophisticated, and primitive. Youve eaten at fine French restaurants and youve ripped into chicken just off the campfire grill.
Youve sat around the kitchen table with family and maybe
didnt even appreciate how wonderful that was because things
like that are just so easy to take for granted.
When your family noticed that you werent eating so
well on your own, they brought you to live in the nursing facility. It was nice to have your meals cooked for you, and usually the
food was pretty good. But does anyone at the facility know what
a good cook you are? There was something about bringing that
chicken to the table or taking the steaks off the grill steaming and
everyone exclaiming Ah! that you miss.
Every once in a while you enjoyed sitting down with a
sandwich and a good book or eating in front of the television, but
1

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eating alone was no fun all the time, so it was nice to have people around. Only you dont
really have much in common with the people that they seat you with at the facility. Youre
not great at conversation these days, so you just eat and look at your plate. When someone
does say something to you, theres usually so much noise in the place that you cant make
out what the person is saying, so you just nod and smile.
Theres something about the way they serve things here that you dont understand.
Is it a cafeteria? (When the meal is over, you look around to help clear or to pay, but everyone else is just leaving the room.) There are so many things on the tray that sometimes you
dont know where to start. Most of the time the things are a surprise. Is it all for you, or are
you supposed to share? What goes where and how? You get mixed up, and sometimes that
makes the food taste strange. Sometimes the things on the tray are hard to recognize. You
used to plan meals so that the plate was colorful, with red beets, green beans, mashed potatoes, and roast beef. Here, sometimes you get a plate with food thats all beige.
They make the food soft so its easy to chew, but you just want to feel something
crisp between your teeth. Your blood pressure has been up, so theres no salt added now, but
wheres the mustard, the garlic, the oregano? Sometimes you cant find the fork in all the stuff
on the tray, and so you put your hand in the plate. Its sticky, so you wipe it on your dress.
The other day you didnt remember quite how to handle that big piece of bony chicken,
so you picked it up in your fingers and, when you dropped it back into the plate, it made
a mess. The tables are so high (or have you shrunk?) that its hard to get the spoon of soup
all the way to your mouth without spilling it. Its a good thing they give you a bib, well,
sort of .
Lately the staff has started helping you more. Its nice to have the company, but you
wonder who is she talking to most of the time . Where did she go now? Things are getting so complicated and its just so much trouble, especially because your dentures make
your mouth sore. Now they feed you most of the time. Its hard to open your mouth when
you dont know whats on the spoon. You expect vanilla pudding and get mashed potatoes
instead. Sometimes theres someone who knows how you like things. Sometimes theres
someone new who pushes the food through your clenched teeth. Mostly, you just want to
eat the applesauce.
Now youre sitting at a table, by yourself, waiting, as more and more people come
into the room. Its getting busy. Are all these people here to eat dinner? You used to set a
fine table in your time. No one ever left your home hungry. Maybe youre supposed to be
helping. But what can you do? Theres so many of them now and they keep coming as you
sit there. What am I supposed to do with all these people here? you wonder. You are real-

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ly getting worried as still more come. Finally you shout, Tell them all to go home! I cant
help them all! A nurse comes by and tells you to be quiet. You are disturbing everybody!
With this happening to you, how do you feel?
What do you need?

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

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

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

The preparation of the food

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

The authors see meals and the events associated with meals as a potential source of exquisitely meaningful and gratifying activity, offering sensory and social stimulation, pleasure,
and a sense of productivity and autonomy. All considered, meals are the most significant and
meaningful activity of the day. Unless, of course, meals are offered in a context that is

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totally inconsistent with normal living and therefore unfamiliar, or unless the person is
excluded from the activities that are associated with meals and is relegated to the role of passive recipient only. This is true for everyone but especially for people with dementia.
People with cognitive impairment usually depend on familiar, habitual activities
and simple, social interaction for their continued function. What is more familiar than the
sights, sounds, aromas, and actions associated with meals? These are the cues to which
people have learned to respond over a lifetime of experience. Then there are the habitual
patterns of function, such as cooking, serving, being served, sharing, and clearing, that have
been established over the years and that people with cognitive impairment can still call upon
to experience those wonderful feelings of competence and productivity.
When this potential is squandered, productivity is blotted out. Autonomy, dignity,
and pleasure are threatened. Appetite declines and behavior in the dining room deteriorates. The persons nutritional status is placed in jeopardy. Action must be taken, so the diet
is downgraded. Dignity, autonomy, and pleasure decline further still, as do appetite and
interest in the meal, until, finally, the person is fed. This is the vicious cycle of excess disability. The proportion of nursing facility residents who are trapped in this cycle is
astounding. Their true numbers are apparent only when appropriate interventions are
implemented. Then, given the right circumstances and support, residents who were considered totally incapable of self-care almost miraculously regain their grace, dignity, and
propriety. Some even regain their autonomy. The aim of the Bon Appetit! program is to
give caregivers the tools with which they can offer the older people in their care a truly
meaningful dining experience.
In a long-term care facility, a working dining enhancement program requires concrete, observable standards to which all staff commit themselves from the first day of their
employment. The program also rests on a process of evaluation, monitoring, accountability,
and feedback that ensures that these standards are maintained. These standards and the
instruments to support them originate from an internal support structure, staff training, and
ongoing supervision. The initiative is spearheaded by the Dining Enhancement Committee,
which is made up of department heads. This committee

Represents the facilitys commitment to enhanced dining for all of its residents
Articulates the dining program mission in terms that are specific to the facility
Ensures interdepartmental communication regarding dining program issues
Represents the program on other facility committees
Identifies and supports as many trainers as are required by the size and diversity of
the facilitys programs

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Meets regularly to review recommendations that come from staff, volunteers, families, and residents through suggestion boxes, training sessions, or other means
Provides feedback as to which changes will be implemented
Coordinates the implementation of changes
Provides an ongoing forum for review and evolution of the dining program
Conducts initial and ongoing evaluations to ensure continued adherence to program standards
Ensures program maintenance by coordinating ongoing education and awareness
activities

These responsibilities may seem huge, but they represent a process that the committee is, or
should already be, involved in on an ongoing basis. In the context of the Bon Appetit! program, this process is labeled, structured, and formalized.
Another vital component of the infrastructure consists of Dining Enhancement Teams
on each unit. These are frontline staff who assume responsibility for the maintenance of
standards on their unit. At Villa Providence, in Shediac, New Brunswick, Canada, for
example, the staff decided to call these teams quipes daction, or action teams. These teams
are an important part of the program and a key to its success. Team members receive special training so that each is familiar with the program as a whole and is able to

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

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

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

To ensure that all staff share the same basic information about dementia and the
objectives of the dining program so that they can offer a consistent and positive
experience to residents
To consolidate and confirm knowledge that staff have acquired through other inservice training sessions as well as their own experience and intuition and give them
the confidence to do their jobs with satisfaction
To give staff a forum in which to share what they know with others, especially
with new and replacement staff
To establish a process of communication by which staff can express ideas and concerns about what they are doing and can also receive feedback about how they are
doing
Finally, ongoing supervision ensures that

Staff members are doing what they should be doing to keep the operation running
well and offer consumer satisfaction.
Small problems are identified and rectified before they become big problems.
Staff have the confidence that they are doing well and continue learning, promoting a feeling of security.
Supervisors remain constantly in control of their operations, thus ensuring consistency and their own job satisfaction.

In a restaurant, such supervision is the responsibility of the matre dhtel; the authors
call ongoing supervision the matre d model. The matre d is the person who approaches a
waiter who has just dealt well with a difficult client and says, Good job! or takes aside a
waiter who has overlooked a service and explains immediately what went wrong and how
it should have been done. This person also spots a waiter who is struggling and steps in to
lend a hand, and later helps to solve the problem so that it does not recur. At no time does
the supervisor assume that things are being done and done correctly. It is this persons
responsibility to be constantly alert and to follow up on each occurrence of a problem. That
kind of supervision also is vital in a Bon Appetit! setting.
The continued success of any program depends on consistent support from its
leaders. In this case, those leaders are the department heads and unit supervisors. They

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must understand the dining enhancement program, be committed to the benefits that it will
bring to the residents and the facility staff, and understand their role in supporting the program. This support comes in several ways:

Keeping everyone on board once a consensus has been achieved

Advocating strongly for needed changes to the environment and processes affecting the program
Recognizing standards of deportment and service among their staff
Acknowledging the efforts of staff who meet those standards and correcting staff
who do not do so in a consistent and positive manner (the matre d model)
Committing themselves to their own ongoing learning and to that of their staff
Sharing responsibility by supporting the Dining Enhancement Teams

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

CAN IT BE DONE? BEWARE OF RED HERRINGS!

That is really great if you have the time and the staff.
We would do that if we had the money.
Sounds lovely, but regulations would not permit it.
If we promote autonomy, acuity levels will go down, and reimbursement will also
go down. Then we will have even less money and fewer staff.

Are these comments familiar to you? They could be a response to just about any new idea.
The authors hear them often in reaction to workshops and conference sessions about programs that improve the quality of life for long-term care residents with dementia, programs
such as enhancing the dining experience; managing behavior with psychosocial, nonpharmaceutical means; or handling bathing as a pleasant, life-enriching activity. Anyone contemplating a new program or a change of any kind should be prepared to face these comments
head on. That means understanding where such comments come from. They indicate the
presence of red herrings.

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Although they may seem realistic at first, such remarks are disturbing for a number
of reasons. They make it seem as though nothing can change without additional funds,
staffing, and endorsement from regulators, as well as altered reimbursement levels. They are
the signs of an immobilizing frustration among facility operators, who see their resources
already stressed and see no possibility for change. They produce a sense of futility among
staff, who feel taunted by ideals that seem out of their reach. Most of all, these comments
perpetuate existing methods and defeat the possibility of ever implementing programs such
as those presented.
Such remarks, however, skirt the real issue. The real issue is that change, although
it is usually perceived as an additional burden on an already-overloaded system, is necessary
and must start from within. Fear of change must not be allowed to divert attention from
the true challenge facing long-term care: to create an optimum quality of life for everyone
living and working in the facility.
This is not the kind of change that happens with the simple infusion of resources.
In fact, there is a serious likelihood that, when additional funds and resources become available to the agencies that have resisted change, they will only perpetuate more of the old system. It requires a change from within the core of the organization. Starting the process
requires identifying real priorities and reassigning resources in accordance with those priorities. That usually means moving away from the standard medical model of care and creating a setting that is homelike and relationship based and promotes a normal lifestyle. In this
way, the care setting respects the individual needs of residents and their right to enjoy life.
An exciting movement in that direction is already underway. Since the mid-1980s, we have
seen a remarkable turnaround with the implementation of numerous person-centered care
models. The main impetus has come from dementia care, but the movement is spreading
through the caregiving community.
We must beware of the kippers. A kipper, a red herring, drawn across the fox trail
diverts the attention of hounds from the desired course. Money, staffing/time, and regulations may be such red herrings. They seek to redirect the forces of change because they
spring from resistance to and fear of change. Lets look at each one.

MONEY
It does not cost any more to do things differently. A smile is priceless yet costs nothing.
Training and the staff support that goes into producing it is costly, but so is staff turnover
when facilities do not spend money on training and support. One of the greatest costs in
long-term care is staff turnover. Staff who are directly engaged in a positive contribution,

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who feel that they know what they are doing and that they have the power to control
the direction of their efforts, are loyal to the program. Research indicates that job satisfaction ranks above salary in factors that affect staff retention.
Food that is thrown away represents waste, not only in terms of provisions but also
in terms of staff time, effort, and morale. Therefore, any program that consistently reduces
the amount of food that is discarded represents a savings in all of these resources. When the
dining program advocates special foods that are tasty, manageable, and presented in an
appealing way, the up-front cost is real, but so are the savings on reduced food wastage and
lowered reliance on supplements to compensate for refused meals.
When behavior management techniques that demand staff attention and environmental changes are implemented, there is an initial cost in staff training and capital costs.
However, the savings in pharmaceuticals to calm residents and in staff absenteeism related
to poor morale are also considerable. In other words, we can spend it and keep spending it,
or we can spend it now and save it later.

TIME
Time is a limited commodity. It must not be wasted fixing problems that should have been
prevented. Much staff time goes into dealing with challenging behavior that would have
been averted had time been spent attending to the needs that precipitated the behavior. A
good deal of time is also spent doing things that were priorities under the medical model,
for example, bathing people in supertubs or making them adhere to schedules that have
little or no relation to real-life activities. Doing things for people may go faster than helping them do for themselves, but it costs more in the long run as learned dependency
becomes entrenched.

STAFFING
The division of labor among facility departments and the division of staffing times into shifts
that do not reflect normal life patterns contribute a great deal to staffing inadequacy. These
issues demand serious examination. In facilities where staff roles are fluid, the lines among
nursing, administration, activities, housekeeping, and dietary staff are blurred. When all
staff interact actively with residents and contribute to their lifestyles, suddenly real resident/
staff ratios are dramatically reduced. If maintenance staff engage residents in chores, if secretaries come in to feed dependent residents, if activities staff give baths that are sensorystimulation experiences, or if nursing staff supervise meals that are social groups, then all
need training. This is a valuable expenditure that pays off in multitudinous ways.

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REGULATIONS
Regulations exist to protect residents and staff, not to impose a diminished quality of life.
Therefore, when a program that seems to contradict existing regulations, such as permitting
residents to participate in food preparation, is being considered, it is a good idea to write it
up, itemizing goals, objectives, methods, and precautions, and submit the proposal to the
regulator for approval before implementing it. This process serves three purposes: 1) it forces
practitioners to think through their programs, 2) it informs regulators of advances in care
practices, and 3) it ensures security for the program in the event that it is questioned by an
uninformed regulatory reviewer.

REIMBURSEMENT LEVELS
Reimbursement levels are the most frightening red herring of all in that they seem to defeat
the purpose of programming. If reimbursement is reliant on keeping residents in a dependent conditionand the system actually penalizes facilities that invest precious resources into
promoting the dignity and autonomy of their residentsthen this is not really a red herring,
it is a monster, and it needs to be addressed immediately. Effort and resources that are spent
in promoting autonomy among people with dementia must be recognized and counted in
the equation when care levels are assessed. Such programs must be seen in the same light as
are other necessary services that maintain biological functions. A person who needs medication to control a seizure disorder would not be removed from a drug plan just because his
or her seizures ceased while on medication. The person with dementia has an illness that requires the implementation of special psychosocial and environmental circumstances that control and prevent problematic behavior and foster autonomy. These circumstances are essential to the persons care and, therefore, must be calculated. The staffing and resources that are
needed to feed three meals daily to 10 residents with cognitive impairment are obvious and
easily counted. Staffing and environmental resources that create and maintain circumstances
that enable these 10 residents to feed themselves must also be made part of reimbursement
calculations.

A VISION

FOR IMPLEMENTATION

Very often the notion of implementing a person-oriented program within the existing system is difficult to envision because the system, as it is, is not set up to accept such programs.
It is often rooted in a model of care that prizes efficiency, accuracy, and sterile conditions
over human values. A real change does not start with physical alterations on the units or the

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launch of new programs. Such change demands, first and foremost, the creation of an
infrastructure to accommodate it. Creating this infrastructure requires a master plan that is
guided by a vision of how the total system should operate, which may mean relinquishing
standards and practices that have been in place for many years and have lost their meaning
and starting with fresh ones.
As mentioned, the commitment to person-oriented care and the issue of qualityof-life standards overriding medical standards in long-term care is growing. The success of
such programs in many facilities has proven that they can work, providing that they start
with the facilitys management and staff s identifying their mission and stating it in terms
that reflect actual practice. The program then needs follow-through with a clearly charted
action plan, delineating each step of the process precisely in actions to be taken, projected
costs, person or people responsible, and target date. Only by implementing this process will
the proposed changes stay on track. This is the model on which the Bon Appetit! program
is based. Without this structure behind them, so many efforts prove futile. Programs implemented as isolated entities usually flounder and succeed only in proving that they were
unrealistic in the first place. In other words, they become self-fulfilling prophecies and the
spawning grounds for more red herrings.
How can we protect ourselves against the swarm of red herrings, when our resources
are already spread so thin and we feel so vulnerable? We can take one slice of cake at a time.
Tremendous relief comes from the realization that the whole thing need not be done at
once. We can still make progress toward our vision, step by step, as resources become available. When we allow ourselves to be overwhelmed with the size of the entire project and
the enormous change that it represents, there is little chance that our difficulties will ever
be resolved and that change will ever begin.
There is a beautiful mountain behind our house. The view from the top is breathtaking, and the fresh air is invigorating. Some days, though, it just seems so far away. We
say, It would be nice, but we just cant muster all the energy it would take to climb up
there. However, we do have enough for the first step. Well, then, shall we go?