UWL: Food, Appetite and Environment (2009)

Study Design:
- Click here for explanation of classification scheme.
Quality Rating:
Research Purpose:

To assess registered nurses', licensed practical nurses' and nursing assistants' perceived beliefs and views regarding the nutritional needs of nursing home residents.

Inclusion Criteria:

Nursing assistants, licensed practical nurses and registered nurses employed at one of five nursing homes in Washington state who responded to a flier soliciting participation. 

Exclusion Criteria:

None specified.

Description of Study Protocol:
  • Recruitment: A flier was prominently posted in each of five Washington state nursing homes
  • Design: Mail out survey to all who returned a flier with a name and mailing address. The first mailing was followed by a reminder, then a follow-up phone call three weeks later.  
  • Blinding Used: Unblinded although confidentiality was maintained
  • Statistical Analysis: Kendall's tau was used for correlations.
Data Collection Summary:

Timing of Measurements

A single survey with a stamped return envelope was mailed and followed at one week with a reminder postcard; non-responders received telephone follow-up three weeks later.   

Dependent Variables

Perceived beliefs and views regarding the nutritional needs of nursing home residents.

Independent Variables

Registered nurse, licensed practical nurse or nursing assistant.



Description of Actual Data Sample:
  • Initial N: 105 nurses; 225 nursing assistants
  • Attrition (final N): 44 nurses, 99 nursing assistants returned surveys
  • Location: Five proprietary nursing homes in Washington state. 
Summary of Results:

Other Findings

90% of nursing assistants and 93% of nurses identified "sometimes the residents do not like the food" as a barrier to nutrition care.

82% of nursing assistants and 79% of nurses reported that sometimes residents do not think the food looks good to eat. 

Significantly (P<0.05) more nurses (93%) than nursing assistants (73%) reported that when nursing assistants have to work short-staffed, residents do not get enough assistance with eating. 

Most nursing assistants (81%) believed they could not get everything done for their residents in the time allowed.

Many nurses (57%) agreed nursing assistants find it very difficult to feed all residents in a timely manner. 

Most nurses (96%) and nursing assistants (93%) agreed their facility gave residents sufficient amounts of food, and that residents who were assisted during meals received sufficient food. 

Only 55% of nurses and 57% of nursing assistants agreed that their facility menu provided a variety of foods to meet the individual needs of their residents. 

Most (84% of nurses and 88% of nursing assistants) agreed that residents who eat in their rooms do get assistance with eating. 






Author Conclusion:

Findings of the study suggest that management issues (e.g., lack of time, too many residents, working short-staffed, nurse-nursing assistant communication problems), food service concerns (e.g., possibly inadequate variety and quantity of food) and educational needs (e.g., non-certified nursing assistants, team-building/communication training needed for nurses and nursing assistants) are occurring in the nursing homes studied. 

Funding Source:
Reviewer Comments:

Validity of the questionnaires was addressed by using focus group data in developing measures and peer review by dietitians, nutritionists and a RN who made recommendations related to the content and complexity of items. Reliability was tested by nursing home staff not connected with the study during a pre-testing phase of the two instruments.

Quality Criteria Checklist: Primary Research
Relevance Questions
  1. Would implementing the studied intervention or procedure (if found successful) result in improved outcomes for the patients/clients/population group? (Not Applicable for some epidemiological studies) N/A
  2. Did the authors study an outcome (dependent variable) or topic that the patients/clients/population group would care about? Yes
  3. Is the focus of the intervention or procedure (independent variable) or topic of study a common issue of concern to dieteticspractice? Yes
  4. Is the intervention or procedure feasible? (NA for some epidemiological studies) N/A
Validity Questions
1. Was the research question clearly stated? Yes
  1.1. Was (were) the specific intervention(s) or procedure(s) [independent variable(s)] identified? Yes
  1.2. Was (were) the outcome(s) [dependent variable(s)] clearly indicated? Yes
  1.3. Were the target population and setting specified? Yes
2. Was the selection of study subjects/patients free from bias? ???
  2.1. Were inclusion/exclusion criteria specified (e.g., risk, point in disease progression, diagnostic or prognosis criteria), and with sufficient detail and without omitting criteria critical to the study? Yes
  2.2. Were criteria applied equally to all study groups? Yes
  2.3. Were health, demographics, and other characteristics of subjects described? ???
  2.4. Were the subjects/patients a representative sample of the relevant population? ???
3. Were study groups comparable? N/A
  3.1. Was the method of assigning subjects/patients to groups described and unbiased? (Method of randomization identified if RCT) N/A
  3.2. Were distribution of disease status, prognostic factors, and other factors (e.g., demographics) similar across study groups at baseline? N/A
  3.3. Were concurrent controls or comparisons used? (Concurrent preferred over historical control or comparison groups.) N/A
  3.4. If cohort study or cross-sectional study, were groups comparable on important confounding factors and/or were preexisting differences accounted for by using appropriate adjustments in statistical analysis? N/A
  3.5. If case control study, were potential confounding factors comparable for cases and controls? (If case series or trial with subjects serving as own control, this criterion is not applicable.) N/A
  3.6. If diagnostic test, was there an independent blind comparison with an appropriate reference standard (e.g., "gold standard")? N/A
4. Was method of handling withdrawals described? N/A
  4.1. Were follow-up methods described and the same for all groups? N/A
  4.2. Was the number, characteristics of withdrawals (i.e., dropouts, lost to follow up, attrition rate) and/or response rate (cross-sectional studies) described for each group? (Follow up goal for a strong study is 80%.) N/A
  4.3. Were all enrolled subjects/patients (in the original sample) accounted for? N/A
  4.4. Were reasons for withdrawals similar across groups? N/A
  4.5. If diagnostic test, was decision to perform reference test not dependent on results of test under study? N/A
5. Was blinding used to prevent introduction of bias? No
  5.1. In intervention study, were subjects, clinicians/practitioners, and investigators blinded to treatment group, as appropriate? N/A
  5.2. Were data collectors blinded for outcomes assessment? (If outcome is measured using an objective test, such as a lab value, this criterion is assumed to be met.) No
  5.3. In cohort study or cross-sectional study, were measurements of outcomes and risk factors blinded? N/A
  5.4. In case control study, was case definition explicit and case ascertainment not influenced by exposure status? N/A
  5.5. In diagnostic study, were test results blinded to patient history and other test results? N/A
6. Were intervention/therapeutic regimens/exposure factor or procedure and any comparison(s) described in detail? Were interveningfactors described? N/A
  6.1. In RCT or other intervention trial, were protocols described for all regimens studied? N/A
  6.2. In observational study, were interventions, study settings, and clinicians/provider described? N/A
  6.3. Was the intensity and duration of the intervention or exposure factor sufficient to produce a meaningful effect? N/A
  6.4. Was the amount of exposure and, if relevant, subject/patient compliance measured? N/A
  6.5. Were co-interventions (e.g., ancillary treatments, other therapies) described? N/A
  6.6. Were extra or unplanned treatments described? N/A
  6.7. Was the information for 6.4, 6.5, and 6.6 assessed the same way for all groups? N/A
  6.8. In diagnostic study, were details of test administration and replication sufficient? N/A
7. Were outcomes clearly defined and the measurements valid and reliable? Yes
  7.1. Were primary and secondary endpoints described and relevant to the question? Yes
  7.2. Were nutrition measures appropriate to question and outcomes of concern? Yes
  7.3. Was the period of follow-up long enough for important outcome(s) to occur? N/A
  7.4. Were the observations and measurements based on standard, valid, and reliable data collection instruments/tests/procedures? Yes
  7.5. Was the measurement of effect at an appropriate level of precision? Yes
  7.6. Were other factors accounted for (measured) that could affect outcomes? Yes
  7.7. Were the measurements conducted consistently across groups? N/A
8. Was the statistical analysis appropriate for the study design and type of outcome indicators? Yes
  8.1. Were statistical analyses adequately described and the results reported appropriately? ???
  8.2. Were correct statistical tests used and assumptions of test not violated? Yes
  8.3. Were statistics reported with levels of significance and/or confidence intervals? Yes
  8.4. Was "intent to treat" analysis of outcomes done (and as appropriate, was there an analysis of outcomes for those maximally exposed or a dose-response analysis)? N/A
  8.5. Were adequate adjustments made for effects of confounding factors that might have affected the outcomes (e.g., multivariate analyses)? N/A
  8.6. Was clinical significance as well as statistical significance reported? N/A
  8.7. If negative findings, was a power calculation reported to address type 2 error? N/A
9. Are conclusions supported by results with biases and limitations taken into consideration? Yes
  9.1. Is there a discussion of findings? Yes
  9.2. Are biases and study limitations identified and discussed? Yes
10. Is bias due to study's funding or sponsorship unlikely? Yes
  10.1. Were sources of funding and investigators' affiliations described? Yes
  10.2. Was the study free from apparent conflict of interest? Yes