Why is it important for a nursing assistant to consider a residents cultural background when communicating with him?

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Barriers, Facilitators, Focus group, Qualitative, Social Ecological Model

Dementia is a growing public health concern in the United States and across the globe. In 2020, an estimated 5.8 million older adults are affected by Alzheimer’s disease, the most common form of dementia and the nation’s sixth leading cause of death (Alzheimer’s Association, 2020). Because of dementia’s negative impact on cognition and functional status, eating difficulties and weight loss are very common in those with dementia (Volkert et al., 2015). Mealtime difficulties may include trouble concentrating during meals, difficulty choosing what to eat, loss of ability to recognize food and utensils, difficulty eating independently, or refusal to eat (Volkert et al., 2015). Moreover, weight loss is an independent predictor of death in people with dementia (Hanson et al., 2013). Therefore, mealtime difficulties require special attention and necessitate preventative action. Specifically, current guidelines recommend providing adequate mealtime assistance to older adults with dementia, including supervision during meals, verbal prompting and encouragement, and feeding assistance (Volkert et al., 2015). For those with advanced dementia, “careful handfeeding” is recommended (Edward & David, 2015). Although more research is needed on providing optimal mealtime support, the time and attention required to provide mealtime assistance to these individuals substantially increases caregiver burden (Volkert et al., 2015).

In long-term care facilities in the United States, certified nursing assistants (CNAs) are primarily responsible for providing mealtime assistance to residents with dementia (Alzheimer’s Association, 2020). Unfortunately, there is a paucity of research exploring the barriers and facilitators that affect a CNA’s ability to provide mealtime assistance to residents with dementia, particularly in the United States. However, studies in Taiwan, Canada, and New Zealand suggest that CNAs in those countries lack training and support (Cammer et al., 2016; Chang & Roberts, 2008a; Nell et al., 2016). This may also contribute to CNA turnover rates as high as 53%, which affects the quality of care that is provided to residents (Castle et al., 2020). Given the number of Americans who will be affected by dementia in the coming years, the lack of research on mealtime experiences of CNA caregivers in the United States is an important gap in the literature.

Research suggests that many health-related problems are multifactorial, making it necessary to explore them using an ecological approach (McLeroy et al., 1988). The Social Ecological Model (SEM) consists of several levels of influence and can be used to explain health-related problems by starting with the individual at the center, and moving outward to investigate the influence of the relationships, environment, community, and policies where the individual is positioned, as seen in Figure 1 (Contento, 2016; McLeroy et al., 1988). The SEM has been effectively adopted in studies addressing many public health issues, including issues related to nutrition and eating (Contento, 2016). It should be noted that while the levels appear concrete and defined in the figure, there is actually an interplay between levels, allowing some overlap. In applying this theory to understand mealtime difficulties in individuals with dementia, it is important to first understand the various facets of the problem at different levels. Therefore, guided by the SEM, the aim of this qualitative study was to understand the factors that influence the ability of long-term care CNAs to assist residents with dementia during mealtimes. This manuscript details the findings from the individual and interpersonal levels of the SEM. The organizational and policy-level influencing factors have been published elsewhere (Douglas et al., 2020).

Method

Participants and Facilities

Purposive sampling was used to recruit CNAs from nursing homes in Alabama. The research team contacted nursing home administrators in Alabama, provided information about the study, and asked if they would allow the research team to conduct focus groups at their facility with their CNAs about their mealtime experiences with residents with dementia. With the administrator’s approval, recruitment flyers were posted at five facilities in areas where they would be visible to CNAs (near the time clock, on staff bulletin boards, etc.).

On the day of the scheduled focus group, the researchers provided potential participants with a verbal description of the project and reviewed the written informed consent document. Inclusion criteria specified that participants must (a) be a CNA in a long-term care facility, (b) have experience providing mealtime assistance to residents with dementia, and (c) usually assist residents with meals during their work shifts. CNAs who primarily work night shifts were excluded because they are not involved in providing mealtime assistance.

All participants signed the informed consent document and were asked to keep others’ answers confidential. To enable participants to speak freely about their experiences without fear of reprimand, the researchers asked participants to reflect on experiences both in their current workplace, and in other facilities where they had provided mealtime assistance to residents with dementia. No facility administrators or supervisors were present during the focus groups.

Participants were invited to engage in member checking, where they provided a contact method where they could receive and provide feedback on the findings of the study. However, no participant information was tied to the audio or written transcripts. Participant demographic survey forms were anonymous. This study’s protocol was approved by each facility’s administration in addition to the University of Alabama’s Institutional Review Board.

Data Collection

Nursing home administrators at five long-term care facilities in Alabama agreed to allow the research team to hold focus groups at their facility. Focus groups were scheduled at times convenient for participants to attend, usually taking place at the end of a day shift, or just prior to the start of an evening shift. In order to better understand the influence of multiple factors on the mealtime experience of CNAs, focus groups were chosen for data collection. Unlike individual interviews, a focus group allows a group dynamic with a more comfortable atmosphere for participants, which supports the exchange of ideas and point–counterpoint discussions (Creswell & Poth, 2018). This method also stimulates participants’ thinking process through sharing and comparing; therefore, generating new ideas and richer perspectives that other methodologies could not provide (Brown, 1999). Using a semistructured guide, focus group sessions were moderated by the principal investigator. During each session, a member of the study team took field notes to document nonverbal responses and pauses in participant responses. These notes were used to support the interpretation of the session transcripts. The duration of the focus groups ranged from 31 to 69 min, with a mean of 50 min. Research team members—the principal investigator and a graduate research assistant—debriefed after each session, and discussed the impact of researcher bias on data collection. For example, when researcher bias was identified during debriefing, the entire research team met to further discuss the findings until they came to a consensus. All sessions were audio-recorded, transcribed verbatim by a professional transcriptionist, and checked for accuracy by the research team. Demographic data including gender, age, race, education level, duration of CNA certification, and employment classification (full-time, part-time, or per diem) were obtained from participants. As an incentive, each participant received $25 at the completion of the focus group.

Focus Group Guide

The SEM theoretical framework as described by Contento (2016) was used to develop the focus group guide and the probing questions. Guided by this framework, questions were developed using the existing literature on the topic and reviewed by the research team, which consists of experts in qualitative methods, the SEM, nursing home care, and older adults. Open-ended questions were written to provide participants with flexibility to describe their experiences, obtain their multiple perspectives, and reduce bias (Creswell & Poth, 2018). Participants were specifically asked about barriers and facilitators within the individual and interpersonal contexts that affect their ability to provide mealtime assistance. Probing questions were based on examples from each level of the model provided by Contento (2016), and were used to prompt participants to provide additional details to a response (Table 1).

Table 1.

Individual and Interpersonal Focus Group Questions

Description of Data Analysis

Transcripts were coded using NVivo 12 software (QSR International, 2018, Melbourne, Australia), and analyzed independently by two members of the research team. Analyses were guided by the directed content analysis approach, where the SEM framework served as a guide for organizing codes by level of the model (Hsieh & Shannon, 2005). Any disagreements in coding were resolved through discussion. For example, in an instance where a participant statement was coded differently by the researchers during independent coding, the researchers met to further clarify and discuss the statement. The entire research team met regularly to review the analyses, assist with resolution of disagreements, discuss the impact of researcher bias on the interpretation of the results, and to reorganize overlapping or similar codes (Graneheim & Lundman, 2004). Field notes were used to support the interpretation of the results. To enhance rigor, an audit trail and member checking were both employed to ensure the reliability of the data analyses (Lincoln & Guba, 1985). The audit trail consisted of researcher notes during coding and coding meetings, and meeting notes from each team meeting. Once data were analyzed, participants who agreed to member checking were sent a copy of the summarized results for their review, and were asked to provide clarification or feedback on the analyses. SPSS 24 was used to organize demographic data and generate descriptive statistics from participants (IBM, 2016, Armonk, NY).

Results

Nine focus groups were held, with 53 CNAs participating overall. As shown in Table 2, the majority of participants were female (98.1%) and employed full-time at their facility as a CNA (94.3%). Most study participants were Black/African American (66%), while 28.3% were White/Caucasian, and 1.9% were Hispanic/Latino. Educational backgrounds varied, as 30.2% of participants reported their highest level of education was graduating from high school, and 45.3% reported completing some college or technical school. Through directed content analysis in accordance with the SEM, there were three themes identified at the individual level and four themes identified at the interpersonal level (Table 3).

Table 2.

CNA Participant Characteristics (n = 53)

Table 3.

Individual- and Interpersonal-Level Themes Affecting the CNA’s Ability to Feed Residents With Dementia

Individual Level

At the individual level in the SEM, three themes were identified: individual skills, training, and personal characteristics. Within these themes, participants identified facilitators and/or barriers that influenced their abilities to provide mealtime assistance to residents with dementia.

Theme A: individual skills

Participants identified that their prior caregiving experiences were a facilitator in assisting residents with dementia during meals, in that caring for children or older family members in the past prepared them for their CNA training and work. For example, one participant commented, “But, it’s like feeding your babies. Like, you see how they eat, so it just comes back.” Another participant shared a similar statement by saying, “Well, I got a personal training, so my grandmother has dementia … So, you know, I had been around for years like with dementia and stuff like that.”

Effective communication skills emerged as an important facilitator that could directly affect the ability to assist residents with dementia. For example, one participant said, “Explain what’s on their tray so they know what they’re eating really helps.” Another participant also commented, “Talk them through it. Talking to them while you feed them also helps because sometimes, they don’t remember that they’re eating so you have to remind them, you gotta take a bite.”

Conversely, communication barriers often required that CNAs learn to interpret resident behaviors. One participant stated, “And some of them will tell you what they like and what they don’t like. Unless they can’t, you just kinda try it out and you’ll see if they do like it or not.” When asked how to respond to a nonverbal resident, one participant noted, “They tell you to go by their cues.” Ultimately, when a CNA had difficulty with assisting a resident during meals, they used their verbal communication skills to consult with another CNA or health care professional for help.

Theme B: training

Previous knowledge acquired through formal and informal training was frequently discussed as both a barrier and facilitator by study participants. Participants had positive opinions regarding their formal CNA training when there was time devoted to feeding residents, learning about dementia, and practicing hands-on techniques. For example, in reference to a dementia-sensitivity training, one participant stated, “All CNAs need to do that because it changed my whole mindset.” However, some participants stated that their training materials were outdated or inadequate, and overall, they did not feel adequately prepared to provide care to residents with dementia. For example, one participant expressed concern about the unrealistic training videos used in her training: “It shows you the perfect resident. The perfect angel. They don’t show you the one grabbing on you, scratching on you, pulling at your hair.”

Informal, on-the-job training was a consistent facilitator identified throughout the focus groups. Many felt that their formal training was inadequate in various ways; nevertheless, they developed skills by working directly with residents. For example, one participant stated, “Well, I learned a little bit in my class about feeding in general, but my knowledge came from actually feeding people with dementia.” Another participant responded, “CNA work is better learned hands on.” When asked about interest in continuing education beyond their training to become certified, many CNAs responded favorably, such as, “I think it would be helpful. Especially to new CNAs.”

Theme C: personal characteristics

Personal characteristics such as attitude, patience, and ability to learn were recognized as influencing CNAs’ ability to assist residents with dementia, both positively and negatively. One participant noted, “Yeah, well you have to have patience. Because you’ve got to have a heart to be in this line of work.” While patience and a positive attitude were identified as facilitators that could improve the mealtime experience, a negative attitude or approach from a CNA could hinder mealtimes. This was well captured in one participant’s remark, “Your attitude like, you have to have a positive attitude because it’s like, if you’re impatient, they sense that. They become impatient; they become irritated and frustrated …” As such, if a CNA had a negative attitude when providing mealtime assistance, the resident may respond by being less willing to eat for that CNA.

Many CNAs demonstrated pride in their work, specifically when providing mealtime assistance. For example, one participant stated, “This is more than a job. This is a mission. Everybody has a mission in this.” Similarly, another participant remarked, “Knowing they eat. No weight loss. Makes you proud to see that.” They also acknowledged that successfully assisting a resident to eat could lead to clinically significant results, such as improvement in food intake and weight gain. This was portrayed in one participant’s comment: “And when they go from eating nothing to eating maybe 50%. That’s great, you know, they’re making progress. Even if they gained a pound, it still makes you smile.”

CNAs also discussed how the challenges they face during mealtimes can be discouraging. For example, one participant shared, “Or if they just won’t eat anything at all and you feel bad, like, hey, am I doing something wrong?” Another CNA described “the spitting, the fighting” they experience from some residents to be particularly difficult. While this is an aspect that CNAs did not enjoy when working with these residents, they expressed that they still felt satisfied when they were able to see improvements, as conveyed by the statement: “It’s always satisfying to see them when they accomplish their goals.”

Interpersonal Level

Four themes were identified at the interpersonal level: relationships with residents, relationships with fellow CNAs, relationships with other health care professionals, and relationships with residents’ families (Table 3).

Theme D: relationships with residents

Establishing relationships with residents emerged as a facilitator because knowing the residents can result in an improved dining experience. For example, one participant offered, “We’re around them every day. We know their likes, their dislikes, what they do, what they want to do.” Another mentioned, “Like I know one lady that won’t eat unless you give her her cranberry juice before she can take a bite. But if you don’t, she won’t eat.” Another participant also remarked, “Having a good relationship and knowing the resident is a big help, it makes it a whole lot easier.”

CNAs also explained that their bond with their residents positively affected their ability to provide mealtime assistance. Participants explained that a bond could be initiated when the resident becomes familiar with the CNA and appreciates how that CNA treats them, creating trust between the pair. By establishing this trust with a resident, participants said that it improved the likelihood that the resident would eat for them. For example, one participant stated, “When you’re humble and sweet, you can feed them and talk to them. That’s how you form your bond with them.” On the other hand, CNAs noted that if a resident was either unfamiliar or had not established trust with CNAs, the lack of a bond was a barrier. To this end, one participant stated, “If they don’t like you, they are not going to eat for you.”

Participants also emphasized the importance of communicating with residents as a successful mealtime strategy. For example, one participant noted, “You tell them what’s on their tray. And then when you say what’s on their tray, you can ask them what would they like to have.” Another participant mentioned, “If you’re talking about their family, or whatever, they’ll continue eating and drinking without even realizing.”

Participants again discussed how adverse resident behaviors could impede their ability to assist them at mealtimes, a theme that also emerged at the individual level. At times, residents may be distracted by other items on the table, or they may not comply with what the CNAs were asking of them. For example, one participant mentioned, “But you get a lot of them like when you put the spoon to their mouth, they won’t open.” Another participant stated as follows:

You have to be careful because there have been times they’re drinking syrup or eating jelly or the salt so, we kind of have to put them [condiments] on the side and so, you know with certain patients with dementia because when they get hungry they’re trying to eat the table cloth and anything close by.

Thus, even with the bond between the CNA and the resident, there are times that the resident exhibits behaviors that make mealtimes challenging.

Theme E: relationships with fellow CNAs

Teamwork was a consistent facilitator that emerged when participants discussed their relationships with their fellow CNAs. CNAs shared that when they worked effectively as a team, their high resident caseload seemed more manageable. For example, one participant noted, “But when we work together, 8 [residents] seems like 3.” Participants also discussed sharing strategies with one another: “Especially if someone is not used to feeding that resident, say ‘You might want to try this, that, and the other in order to, you know, get them to eat.’” Participants also perceived that trying again with a different staff member could be another effective strategy, especially when a CNA was struggling to assist a specific resident, such as, “And if at first you can’t feed them, you rotate, you try somebody else.”

Theme F: relationships with other health care professionals

Relationships with other health care professionals (nurses, therapy staff, administrators, and dietitians) appeared as both a facilitator and barrier that influenced CNAs’ capabilities when assisting residents with dementia. A key facilitator identified was the support provided by other health care professionals during mealtimes. To illustrate this, one participant commented as follows regarding staff members from across the facility coming to help distribute meal trays:

Certain facilities I’ve been to where it’s—when this [meal] cart comes on this hall, we all get to this hall and we get it done. By the time other [meal] cart comes, you almost got all the rest of the hands back on to that [meal] cart and that just works better anywhere you go, from my opinion. Everybody does it, it’s not this staff and then next hall and next hall, and that just works better to me, from my experience.

When support was lacking, CNAs felt like it negatively affected their ability to perform their job. Moreover, some participants felt like their opinions regarding resident care were not valued, even though CNAs provide a significant amount of hands-on care. This was portrayed in one participant’s comment:

And a lot of people don’t realize that they feel like we’re bottom of the barrel, but we’re the ones holding this facility together, because if we do not do what is needed and required from these residents, who’s gonna do it?

However, participants also offered solutions to this issue. One participant noted, “But I think they [administrators and other healthcare professionals] should connect, some way, like I think they should ask for our opinions.” Another CNA remarked, “I think they [CNAs] should be able to go to morning meetings, and voice our opinions.”

Theme G: relationships with residents’ families

CNAs explained that developing relationships with the residents’ families could be an integral part in connecting with residents, and family members could provide helpful information, such as a resident’s likes and dislikes. For example, one participant stated about obtaining information from the family members of residents, “The one who spend the most time with them and who knows them best, normally they can give the best info.” However, they also indicated that communication with family members may not always lead to positive results, especially when family members make requests or suggestions that are not in line with what the residents want or what the CNA can provide. To this end, one participant remarked:

With the family, a lot of times they want things done a certain way. Like they may say, that they want them [the resident] to be fed a certain way, you know, just saying different stuff they want done. But, a lot of times that does not work for you or the resident … If they—I feel like they [family members] should at least try to ask them [CNAs], “well what you think is best” because we are the ones who have got to be here and take good care of them.

Furthermore, regarding the presence of family members during mealtimes, one participant made the following statement:

Being in the way like instead of helping, you know and if they would try to feed their family members, it’d be a lot more helpful than just, you know, like they already said it was crowded. So being there kind of makes it harder.

On the other hand, some family members are helpful during mealtimes, as indicated by another participant stating, “Well, sometimes they can get them to eat a little more than we can.”

Discussion

Guided by the SEM, the purpose of this study was to identify factors that influence the ability of CNAs to provide mealtime assistance to nursing home residents with dementia. Across nine focus group sessions, 53 participants provided a wealth of information, identifying influencers at multiple levels including the individual and interpersonal levels.

Individual Level

Individual skills

The CNAs in this study discussed the importance of communication skills when caring for residents with dementia, including both verbal and nonverbal communication. CNAs gave examples of verbal communication by describing how they cued and prompted residents during mealtimes. CNAs noted that communicating with residents while providing mealtime assistance could improve their meal intake, which has been supported in the literature (Liu et al., 2015).

For nonverbal residents, CNAs reported the need to evaluate the nonverbal communication to interpret the needs of the resident. Similar findings were reported in a study of staff members in nursing homes in Canada, where researchers identified 12 general communication and care strategies that staff used in caring for their residents, including verbal task-based strategies and interpreting resident behaviors (Wilson et al., 2012). According to Wilson et al., staff members reported using individualized communication strategies that would match each resident’s cognitive ability.

The ability to effectively communicate with coworkers was also emphasized by CNAs in this study, where they reported that it may take several CNAs working together to provide appropriate mealtime assistance to a resident. Other studies have also described the importance of this communication between CNAs, and noted that breakdowns in communication can be a barrier to providing adequate care, as verbal communication is often the primary source of information for CNAs (Hansson et al., 2018; Kolanowski et al., 2015). Studies indicate that these communication skills are important in developing the interpersonal relationships between residents and staff members, and that communication training programs may be effective at equipping care staff with these skills (Howe, 2014; Wilson et al., 2012). As such, the development and mastery of verbal and nonverbal communication skills is an important facilitator in providing mealtime assistance to residents.

Training

Another key factor at the individual level that could help or hinder the CNA providing mealtime assistance to nursing home residents with dementia was the training the CNA had received, including both formal and informal training. Many participants in this study indicated that they needed more formal training on caring for residents with dementia. Not surprisingly, a number of studies of nursing assistants and other health care team members have highlighted the importance of adequate staff training and the need for dementia-specific training to address knowledge gaps and improve care (Blumberg et al., 2018; Chang & Roberts, 2008a; Cook et al., 2012; Furåker & Nilsson, 2009; Leson et al., 2014). Encouragingly, training programs have shown promise at improving knowledge and care skills. In a study by Chang and colleagues, caregiver knowledge of dementia and use of appropriate feeding skills improved after a hands-on training (Chang et al., 2006). Another study by Pimentel and colleagues highlights how formative evaluation can enhance the quality of training in addition to front-line worker responsiveness to changes in the long-term care setting (Pimentel et al., 2020).

Additional research is needed to determine a training curriculum that is best-suited to the learning styles of CNAs in the United States. To this end, the training method is as important as the content of the training. In this study, CNAs consistently reported that they learned by doing, or by taking an experiential, “hands-on” approach. This is supported in a recent systematic review of training methods for dementia care, where authors noted that training is most likely to be effective when it includes active participation by the learners (Surr et al., 2017). As such, the development of curricula focused on improving the mealtime experiences of CNAs and their residents with dementia should include hands-on practice and active participation.

Personal characteristics

Aside from the training provided to caregivers and the skills developed as a result of training and experience, CNAs in this study mentioned several key personal characteristics that were needed in providing mealtime assistance to those with dementia, including patience and a positive attitude. In a study by De Bellis et al. (2003), researchers also noted that the attitude and approach of staff members made a meaningful difference in mealtime situations, as CNAs with a positive approach were able to assist their residents to consume more during mealtimes. Conversely, residents ate markedly less when paired with a task-focused CNA who did not provide verbal cues and interaction.

It is important to note that these personal characteristics can be developed in CNAs. In a meta-ethnography of CNAs’ perspectives on their jobs, authors reported that negative feelings and frustration among CNAs may be due to lack of adequate training, and that this may lead CNAs to feel unequipped to manage challenging situations with residents (Cook et al., 2012). On the other hand, they reported that CNAs who receive adequate training and knowledge on dementia may be able to handle difficult situations more appropriately. These findings further highlight the need for adequate CNA training, as it may affect the attitude and approach of the CNA.

Several participants in this study reported experiencing positive feelings when they helped a resident achieve a goal or make progress, a sense of “pride” in what they do. Similarly, in other studies, CNAs have also indicated the importance of doing meaningful work that makes a difference for their patients (Cook et al., 2012). This indicates that CNAs not only value their work as a form of income, but also as something they personally take pride in.

Interpersonal Level

Relationships with residents

CNAs believed that creating a relationship with residents and understanding their preferences could improve their efficacy in providing mealtime assistance. This is supported in the literature, where knowing a resident’s preferences and creating an individualized plan of care have been used to improve food intake (De Bellis et al., 2003; Nell et al., 2016; Volkert et al., 2015). In a qualitative study of CNAs, researchers identified the theme of “Knowing What Makes Them Tick,” which explains the importance of CNAs understanding the history of the person they are caring for (Galik et al., 2009). Fostering this relationship may help the CNA gain the trust of the resident, and may help the CNA to interpret resident behaviors more effectively. The individual communication skills and personal characteristics of the CNA are inherent to developing this interpersonal relationship between the CNA and the resident. In situations where staff find it challenging to assist a resident during mealtimes, it may be beneficial to focus first on fostering the relationship between the resident and the CNA. This transition from task-focused care to resident-centered care may improve the mealtime experience (De Bellis et al., 2003).

In addition to allowing the CNA to better care for the resident with dementia, the bond between CNAs and their residents may provide meaningful relationships for CNAs. As in other studies (Blumberg et al., 2018), CNAs in this study referred to their nursing home residents as family. In other studies, CNAs have reported that their relationships with residents were a key factor in job continuity (Brady, 2016; Sung et al., 2005). Thus, the CNA–resident bond may be an important component of CNA job satisfaction.

One of the challenges expressed by CNAs during mealtimes was adverse and unpredictable resident behaviors. Not surprisingly, these behaviors can make it difficult for CNAs to provide assistance (Chang & Roberts, 2008b). Kolanowski et al. (2015) interviewed nursing home staff who voiced similar concerns, and participants in their study stated that more education on managing resident behaviors would be helpful. For instance, training CNAs on how to redirect distracted residents could be an intervention that improves oral intake. Research by Cook et al. (2012) mirrors these recommendations for more training on managing challenging behaviors as a strategy to help CNAs to depersonalize the behaviors, thereby improving the CNA’s approach to the resident, which then improves the resident–CNA relationship.

Relationships with health care staff

CNAs consistently expressed that forming relationships with fellow CNAs in addition to effectively working as a team was a vital component in providing mealtime assistance to residents with dementia. It has been previously documented that teamwork among CNAs is a helpful and necessary element of their job (Brady, 2016; Cook et al., 2012). Fostering a helpful and collaborative environment in the long-term care setting has the potential to improve patient care and mealtime assistance.

In line with teamwork, both facilitators and barriers were shared when describing relationships with other health care professionals in the long-term care setting. When teamwork was implemented among various disciplines and CNAs, the resident dining experience improved. Not surprisingly, other studies have shown that interdisciplinary teamwork can facilitate quality care (Galik et al., 2009). Conversely, the lack of support from other disciplines could hinder CNAs’ productivity. Multiple participants in this study indicated that they did not feel like they were included by the health care team in making care decisions for residents. Some participants conveyed that they could provide solutions to help their residents eat more and gain weight, but their opinions were not valued in comparison to staff of other disciplines. This concept has also been indicated in the literature, where CNAs have reported that they felt “overlooked and not listened to by nurses” (Brady, 2016). Likewise, the disparity between CNAs’ limited role in decision making and their provision of the most hands-on care has been documented previously, and it should be considered an area of improvement among management staff (Blumberg et al., 2018).

Relationships with residents’ families

There were varying reports regarding the relationships with residents’ family members by participants. Some CNAs stated that family members could be helpful when they were supportive during mealtimes, or family members could sometimes impede the process. CNAs reported conflict with the family members of those residents unable to verbalize their wants and needs. Furthermore, family members at times disagreed with CNAs on the types of foods to provide to the resident. A potential explanation of the underlying cause of this conflict could be the dementia disease process itself (Papachristou et al., 2013). As dementia progresses, food preferences shift over time, and family members may not understand that their loved ones do not prefer the same foods as they previously had. Improved communication among CNAs, other disciplines, and family members could rectify this issue. Additionally, CNAs could encourage family members to engage in mealtimes with their loved one, as previous research indicates that family participation during mealtimes can improve intake and the social experience for the residents (De Bellis et al., 2003).

Limitations

While the results of this study provide evidence of the complex role of the CNA in providing mealtime assistance to nursing home residents with dementia, it is not without limitations. The probing questions and examples provided to participants were based on the SEM as described by Contento (2016), and may have been leading to participants. Additionally, it is possible that the research team did not accurately interpret the information provided by the CNAs during the focus groups. However, the research team members were trained in qualitative research methods, and engaged in debriefing, member checking, and created an audit trail to improve rigor and ensure representativeness. No participants who participated in member checking voiced disagreement with any findings of the study. It is possible that the concepts that emerged from the focus groups are unique only to the facilities where the focus groups took place, and not generalizable to other CNAs at other facilities in the United States. However, the facilities were strategically chosen to represent both for-profit and not-for-profit structures, independent and part of a larger corporation, and rural and urban locations. Furthermore, most of the concepts identified in this study were mirrored in other studies with CNAs.

Appropriateness of the SEM

In this study, CNAs identified multiple factors at the individual and interpersonal levels that affect their ability to provide mealtime assistance to residents with dementia. As previously published by Douglas et al., CNAs in this study also identified barriers at the organizational and policy levels that influence mealtimes. These barriers include lacking the right dining equipment and utensils to meet resident needs, facing inadequate CNA staffing, being excluded from the interdisciplinary team, and struggling to comply with regulations (Douglas et al., 2020). Taken together, the number and variety of these themes generated by the focus groups clearly reflect that there are multiple barriers and facilitators in providing mealtime assistance to nursing home residents with dementia. This is also supported in the literature across the globe, where researchers have reported on the “complex and interrelated” (Nell et al., 2016) factors that influence the mealtime experiences of residents with dementia and their caregivers (Chang & Roberts, 2008a; Furåker & Nilsson, 2009; Gibbs-Ward & Keller, 2005; Nell et al., 2016).

Together, these findings provide evidence that the SEM is a sound theoretical framework from which to investigate the mealtime experiences of CNAs who provide assistance to residents with dementia. As proposed in the model, several of the themes identified were not limited to just one level; in fact, themes in several instances overlapped other levels of the model. For example, communication was mentioned as both an individual skill and an interpersonal asset in the relationships that CNAs have with both their residents and other CNAs. As such, this indicates the need for multipronged interventions that target multiple influencing factors (Chang & Roberts, 2008a; Gibbs-Ward & Keller, 2005; Liu et al., 2015).

Implications/Conclusions

The goal of this study was to identify individual and interpersonal factors that affect the ability of CNAs to provide mealtime assistance to nursing home residents with dementia. Based on the tenets of the SEM, it was expected that multiple factors would be identified, and some influencing factors would span across multiple levels of the model. As a result of this study, several strategies are suggested to improve mealtime experiences of CNAs and residents with dementia (Figure 2). First, it is important to acknowledge that CNAs play a vital role in caring for nursing home residents. CNAs have a unique understanding of the residents in their care, and they can provide valuable insights to other members of the health care team.

CNAs need communication skills, both verbal and nonverbal. Communication served as an interpersonal skill, and as a mechanism to foster relationships with residents, other health care team members, and residents’ family members. CNAs also need adequate training on providing dementia-specific care, which can in turn affect their approach to caring for their residents. This yields a domino effect, where a change in their approach can strengthen the relationship between the CNA and resident, and thereby improve the mealtime experience. The interpersonal relationships between the CNAs and residents, other staff, and family members of residents are also important. Structuring activities and opportunities for fostering relationships between CNAs and their residents may be particularly important. Developing these relationships is an integral component in the care provided to residents by CNAs and may even serve to improve job satisfaction among CNAs. These findings can inform comprehensive quality improvement programs targeted to the unique needs of CNAs.

While this study provides important findings regarding individual and interpersonal factors, future research is certainly needed. The other levels of the SEM should be explored, particularly in relation to the findings from this study. Future research should also evaluate interventions that seek to improve communication and relationships to determine their impact on the mealtime experience. Still yet, additional research is needed to evaluate how the mealtime experience influences the nutritional status of nursing home residents with dementia.

Funding

This work was funded by the Research Grants Committee at The University of Alabama.

Conflict of Interest

The authors have no conflicts of interest to disclose.

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This work is written by (a) US Government employee(s) and is in the public domain in the US.

Special Issue: Workforce Issues in Long-Term Care