A systematic investigation of communication and mealtime management in residential aged care: Exploring perspectives and management across service providers

Abstract

Residents of Residential Aged Care Facilities (RACFs) represent one of the highest risk populations for communication and mealtime difficulties. Though past studies have examined these difficulties, most have taken a siloed approach exploring specific difficulties or interventions out of context and without consideration of residents’ holistic communication and mealtime needs. Further, few studies have investigated communication or mealtime management in RACFs from a multidisciplinary perspective. As specialists in the management of communication and mealtime difficulties there is potential for speech pathologists (SPs) to have an enhanced role in RACFs. Working in accordance with aged care policy service providers must work within a multidisciplinary and person-centered model of care (PCC) to provide individualised and tailored assessment and intervention, and to facilitate active ageing and subjective wellbeing. However, with vast gaps in literature exploring communication and mealtime management in RACFs there is limited evidence to guide service provision. Furthermore, though past research has identified broad barriers to care in RACFs, whether these barriers extend to communication or mealtime management and the potential consequences for speech pathology service provision is not known. Therefore, the aims of the current thesis were to: (1) obtain a more holistic and representative view of factors that influence optimal care in RACFs, identifying challenges and motivators to working in the setting for a range of service providers; (2) explore communication and mealtime management in RACFs examined in the context of daily care and considerate of documented, resident reported, and staff knowledge of residents’ communication and mealtime needs; and (3) explore the perspectives of a range of service providers involved in mealtime management in RACFs to identify shared and disparate issues influencing care. Four studies were conducted to address these aims. In Study 1, semi-structured in-depth individual and focus group interviews were conducted with 61 service providers including: care managers; nursing staff; assistants in nursing; care, domestic and support staff; and SPs, to explore challenges and motivators to working in RACFs. Content analysis revealed four themes: (1) working in RACFs is both personally rewarding and personally challenging; (2) relationships and philosophies of care directly impact service provision, staff morale, and resident quality of life; (3) a perceived lack of service specific education and professional support impacts service provision; and (4) service provision in RACFs should be seen as a specialist area. Themes 1 and 2 emphasised the importance of effective resident-staff communication to the completion of all care tasks and highlighted the challenges to care presented by resident cognitive and/or communication difficulties. Following this finding, Study 2 explored resident-staff communication and current communication management in RACFs. Data was triangulated using resident file reviews (n = 14), resident surveys (n = 14), staff surveys (n = 29), and 123 hours of observation. Results revealed limited documentation of residents’ communication needs insufficient to facilitate individualised or tailored intervention. Explicit management by RACF staff of residents’ communication needs was not observed. RACF staff surveys indicated staff knowledge of residents’ communication needs was also limited. In addition, observed resident-staff communication was largely task focused providing limited opportunity for residents to engage in meaningful conversation. With similar methodology to Study 2 and involving the same participants, Study 3 explored mealtime management triangulating data from resident file reviews (n = 14), resident surveys (n = 14), staff surveys (n = 29), and resident mealtime observations (n = 41). Results revealed inconsistencies in the communication and implementation of mealtime management recommendations at multiple levels and across all data sources. Observed mealtime management was limited in scope with a primary focus on the compensatory management of dysphagia, and was inadequate in considering residents’ psychosocial mealtime needs. In addition, little evidence of effective multidisciplinary care or care consistent with PCC was evident. Study 4 extended the findings of Study 3, further exploring service provider perspectives about mealtime management in RACFs. Data was obtained using qualitative methodology similar to that of Study 1 and including the same participants as Study 1. Four themes were identified: (1) mealtimes are highly valued; (2) service providers face common barriers to mealtime management; (3) communication among service providers is challenging; and (4) education in mealtime management is limited. These themes are similar to those found in Study 1 indicating broad challenges to service provision in RACFs also impact mealtime management. This thesis revealed, both communication and mealtime management in RACFs is hindered by numerous barriers to optimal care. Speech pathology involvement and multidisciplinary care in the setting is limited. Furthermore, current communication and mealtime management is inconsistent with PCC, the facilitation of active ageing, and consideration of residents’ psychosocial needs and subjective wellbeing. Future research and speech pathology management must aim to reconceptualise communication and mealtime management in RACFs, emphasising residents’ holistic needs, the complex nature of care in RACFs, and the need for increased training and support across service disciplines.